Shoulder stiffness when reaching overhead

How to fit in different types of exercise within your week

Wed, 03 Dec 2025 04:05:23 GMT

What is the most effective way to fit different types of exercise in across a given week?

Your workout week - when to train

Figure out when you like exercising, as in what time of day works for you and fits with your schedule. There is no right or wrong. It is important to book it into your schedule, like you would a work meeting, or social meeting with a friend, so that it is non-negotiable. Waiting until you feel like it almost never works.

Ideally, you should try to do a full body resistance workout at least twice per week. These sessions should not be on consecutive days if you are just doing the 2 sessions per week. If you do 3 days per week, full body, ideally you should have a day of rest between each.

For those of you that are more active, it is possible to resistance train 4 or even 5 days per week, however the structure of your workouts is likely to be very different. Remember that quality is really important and coming into workouts fresh, matters. People who lift weights 5 days a week likely structure their programs so that they are relatively resting one whole body part while training another (e.g. they do upper body one day and lower body the next). This is outside the scope of FKB programs, which are a maximum of 3 days per week.

Training full body 3 days a week is a great choice. There will be similar movement patterns trained during each session, e.g. a barbell back squat in one and a goblet squat in another, but the exact same exercises are unlikely to be repeated within a week unless you are training for something specific (e.g. powerlifters often barbell bench press 3-4x per week). You can do these sessions without a rest day in between, however your muscles recover when you arent exercising, and it probably is more effective to have at least a day in between each session if you can.

Your workout week - for people who do lots of exercise

If you do other forms of exercise too, like pilates or yoga or cardio, the priority is maximising your performance in the exercise you care most about, or are prioritising results from. For example if you are trying to get a 5k PB, it would not make sense to lift weights before going for a run on the same day, or doing a heavy legs session the day before a fast run. If you are doing two exercise sessions in one day, you should do the priority exercise first.

Ideally, having time (hours) in between same-day sessions is important, depending how hard each session is. For example, if you are doing a heavy strength training session, you might be able to do something like pilates straight afterwards without too much dificulty. On the other hand, doing a pilates session directly before lifting weights might compromise your strength performance, so probably isnt advised. Splitting the sessions up with multiple hours in between (e.g. morning and evening sessions) is easier to manage.

Figure out what causes fatigue that runs into the next day and structure your week accordingly, e.g. you may prefer to allow 48 hours in between a heavy squat session and a long run.

It is important to have at least one complete rest day per week (light forms of exercise like walking and yoga are ok to do on rest days). If you are finding it hard to find time to have a rest day around the type of training you need to do, try to put two sessions on one day. Some suggest doing high intensity sessions on the same day, having a few ‘very hard’ days in a week, so you can have some very easy days in a week, instead of having lots of ‘moderately to pretty hard’ most days of the week.

Rest days and recovery are important to reduce risk of injury & can require careful tinkering to get right!

How to structure a strength training session

Wed, 03 Dec 2025 04:03:01 GMT

How to design a strength training session that makes sense

Compound vs isolated exercises

A strength workout will be made up of a variety of different exercises.

Compound exercises are those that involve lots of muscle groups at once. They are big, tiring movements, and are done early on in the workout when you are fresh to make sure you can do them well. These are things such as deadlifts, squats and bench presses. Exercises such as rows and leg press are also compound exercises but they are slightly less effortful, in that some body parts are more fixed. I.e. doing a barbell deadlift, you are pushing with your legs, loading your hips and lower back, controlling through your upper body, and lifting very heavy weights. Doing a leg press, you are using your large hip and knee muscles, but your upper body and back are fixed and supported by the machine. A knee extension or bicep curl is isolated, in that it is only using one joint at once - the knee extension simply loads one side of the knee joint muscles (quads), a bicep curl loads one side of the elbow joint muscles (biceps).

Compound barbell exercises, squats, deadlifts, and bench press, are often referred to as primary lifts or main lifts on a given day. The other exercises are known as accessories.

How a session is structured

Generally, it makes sense to start off with larger compound exercises when you are fresh, as they require the most energy and technique. Often doing these exercises by themselves, so you can recover effectively in between sets, is a good idea.

You could then move onto compound exercises that are less intense (eg leg press) that still require lots of power and energy but a little less than the unsupported movements. It can be efficient to combine these exercises into groups to maximise time efficiency, e.g. an upper body exercise with a lower body exercise, so one body part works while the other body part rests. This enables shorter overall rest beaks (discussed in more detail later).

Finally you can add isolated exercises which do not require as much technical focus and are not as fatiguing towards the end of the workout. It is ok to do these exercises when the muscles have already been used in the workout elsewhere. In our classes this is often when we add core and impact exercises, again which can be done with a degree of fatigue without it compromising performance.

Why are rest breaks important?

Rest breaks in weight lifting are there to help you to continue to lift heavy enough. You may not feel out of breath after lifting weights, particularly if you are fit, but your muscles should feel temporarily fatigued. If you are lifting heavy enough, i.e. to 2 reps in reserve, you wouldnt be able to do another set of the prescribed reps immediately after finishing the first set. The higher the intensity of the lifts, the longer the rest break is likely to need to be to be able to repeat the effort. For high intensity lifts, e.g. your compound lifts done at low reps, you need the longest break. For people doing 1RM lifts, for example, they may take 5 minutes rest before trying again.

In our FKB programs, as we do not lift to this intensity, the maximum rest required is probably closer to 2-3 minutes. We often program a lighter accessory exercise with our compound lifts at the start of the workout that wont compromise the performance on the compound lift. This is because most people find total rest boring (!) and it also means you get more total exercise in a given timeframe. As we are not going for max, max efforts, we find this doesn’t compromise performance on the main lift.

What to include in each workout

If you are training 1-3 times per week, it probably makes the most sense to do a full body workout each time. This is to make sure you are training the most important movements (e.g. squats, hinges, presses) multiple times per week. If you are training any more frequently, you might like to try splitting your workout up differently, e.g. into upper and lower body days.

There is a matter of personal preference here and probably the most important consideration is how well you recover. You might find doing an entire upper body session is very tiring within the session and your performance drops as the session goes on. Or, you might find if you try and do a full body session 4 days per week, you cant recover from it well and performance drops across the week. A degree of trial and error is necessary to figure out what works.

A full body workout should include a squat, hinge, split squat, upper body vertical push and pull, upper body horizontal push and pull, and something for core and calves. These movements should each be trained more than once per week, ideally.

How to warm up for lifting weights

Wed, 03 Dec 2025 03:54:32 GMT

How (and why) to warm up for resistance training

Warming up for weight lifting should be specific to the task at hand.

In general, it is enough to warm up by doing the intended exercise at a lower intensity before progressively adding weight. In an exercise session, usually, you will do large, multi-joint, compound exercises first, when you are fresh. For example, a squat or a deadlift. How light you need to go in your warm up will depend on how heavy you are going in your workout, as well as your experience level, preference, and personal requirements.

The goal is effectively warm up to doing an exercise without getting so fatigued warming up that you impact your performance at it. When you do a big compound lift, you need to recruit lots of muscle fibres. Warming up helps your body to fire up these pathways and get your muscles primed and ready. Even the most experienced lifter cannot turn up cold to lift their heaviest ever weight without warming up first. However, you don't want to warm up so much that you actually start building fatigue that then prevents you performing at your best. So, it is a bit of a balancing act that takes practice.

In our programs, we refer to ‘warm up weight’ and ‘working weight’. We usually only list warm up weights for the primary compound lifts (barbell squats, deadlifts, and bench press). Lower reps will require more warm up sets, as it means you are lifting to a higher intensity. Again, experience level will dictate how much warm up you need to do.

For example, if you are currently lifting 40kg deadlift for 5 reps, but are still learning, while this may be the heaviest you have lifted so far, it may not actually all that hard for you. In this case, you might do just one warm up set at 30kg (deadlifts usually need to be about 20kg at a minimum using the lightest possible bar and bumper plate combo (15kg + 2x2.5kgs), so we often don’t start people on the bar until they can lift at least this much), then go into your working sets at 40kg.

For someone who is going for a very heavy 1 or 2 reps, lets say at 60kg, and this weight is very hard and near maximal for them, they might need to do warm ups at 40k, 50kg, and 55kg. To avoid getting too tired doing these warm ups, it can be useful to do decreasing reps as the weight gets heavier. For example, 5 reps at 40kg, 3 reps at 50kg, 1 rep at 55kg - the point of this last rep to give them a ‘feel’ of the heavier weight so they are not shocked by how heavy the top weight feels. Again this comes down to experience and how confident you are lifting different weights. As time goes on, generally the warm up weight can become heavier, the jumps to heavier weights larger, and the number of reps less.

In general, you don’t need to rest between warm up sets, unless you have done quite a few, or gone close to working weight, and can feel you are fatigued - especially if you are lifting the weights to change them, that in itself can be tiring! Remember that the main goal is to lift as much as you can, and perform at your best in your working sets, particularly in your first working exercise.

For accessory exercises, you might use your first set of an accessory exercise as a kind of warm up, going slightly lighter and then working towards your working weight in the 2nd set. For e.g. if you are able to do 10 reps of chest press at 6kg and just managed to get to 7kg last week, it can be good to do 6kgs for your first set then progress to the 7kgs for the second.

If you are starting at a moderate intensity, I.e. doing 10-12 reps, you may not need much of a warm up, as the exercise itself at that intensity may count as a warm up. You might find you need to work up to your working weight still, for example if you are doing the leg press, 100kgs, for 12 reps, you might do 6 reps at 50kgs before increasing to 100kgs and doing 12. If the exercise is later in the workout, you might find you don’t need to warm up at all and can go straight to your working weight (if your legs are already warmed up).

Again - it depends a bit, and comes down to personal preference and experience. You will figure out what works over time. You might find you work better doing some cardio first as a bit of a warm up, but again avoid getting too fatigued before starting - keep it short and light (5-10 minutes).

What makes FKB Bone Density/ Strong for life classes different?

Wed, 19 Nov 2025 07:42:39 GMT

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Pain in the hip: FAI/ femoroacetabular impingement and what to do about it

Sat, 18 Oct 2025 04:34:30 GMT

Hip pain? You’re not FAI-king it!

What is FAI?

First of all, let’s take a look at your hip and what exactly it is. The hip joint is a ball-and-socket joint. This means that it consists of one “ball” part (the head of your femur/thigh bone), and a “socket”, which is the deep recess (acetabulum) in your pelvis that allows the “ball” to sit in. Most of the time, this ball-and-socket joint moves smoothly through your full range of movement. However, in some situations, you may get pain due to various hip conditions.

In this blog post, we will be discussing a common condition named femoroacetabular impingement (FAI) syndrome. FAI syndrome is a symptomatic condition caused by abnormal contact between the femur and acetabulum, which can present as hip pain. FAI can present in three patterns: cam, pincer and mixed.

Cam morphology is the irregular formation of the femoral neck, which increases the area available for contact with the “socket” of the hip joint.

Pincer morphology occurs where there is overcoverage of the “socket” over the “ball”. Some hips may present with a combination of both cam and pincer morphologies, and are termed as a mixed pattern.

Source: https://orthoinfo.aaos.org/en/diseases--conditions/femoroacetabular-impingement/

How is it diagnosed?

In order for FAI syndrome to be diagnosed, there has to be a combination of symptoms, objective assessment findings and radiological findings. Some people may have incidental findings on a scan of their hips without experiencing pain or symptoms, and this would not be diagnosed as FAI syndrome.

What are the symptoms?

The clinical presentation of FAI is usually hip pain, which may be accompanied by clicking, catching, locking, giving way or stiffness (Griffin et al, 2016). In combination with a detailed subjective interview, practitioners may perform a few tests, such as the FADIR test which involves moving the hip into certain positions to elicit symptoms.

Pain from FAI syndrome is diverse in its location, nature and severity. Most patients report pain in the groin and/or hip, but pain can also be located in the lateral hip, glute, knee, lower back, or in various parts of the thigh (Griffin et al, 2016).

Reproduction of pain is usually movement related or due to sustained postures. This can look like symptoms during or after high intensity activity, or pain with movement going through a larger than normal range of motion (such as dance and gymnastics), or symptoms due to prolonged or sustained positions such as sitting for long periods of time.

Patients with FAI often have pain especially at the end of their available range of motion. For example, sitting in deep chairs, or high kicking. These types of activities bring the hip joint into the end of its available range, where the impingement occurs, thus leading to symptoms.

High kicks (Left) bring the hip into its end-range position. Soccer players or dancers may do this repetitively during training. Deep or low seats cause more hip flexion in sitting (right), which can cause irritation in the hip joint if prolonged.

How is it managed?

The common approaches to managing FAI are conservative interventions such as various types of injections and physiotherapy management or more invasive interventions such as surgery (hip arthroscopy).

The symptomatic hip often has reduced strength in hip and core musculature, particularly in hip adduction and flexion (Diamond et al, 2015). However, this varies with the individual, with some studies showing that male and females have strength deficits in different muscle groups (Freke et al, 2018). Thus, each patient should be carefully assessed to identify specific deficits, and provided a tailored strengthening program of these muscles to reduce symptoms and maintain joint health in the long term. Additionally, aggressive and painful stretching into the end of available range is not recommended as this may put the hip joint in positions that expose the cartilage to damage (Wall et al, 2016).

Studies have also shown that people with FAI also tend to have altered control of hip and pelvis movement when compared to populations without FAI syndrome (Lewis et al. 2018; Bagwell and Powers, 2019). This may present as a reduced ability to tilt the pelvis backwards in movement. Hence, neuromuscular control with unilateral exercises such as step ups with a focus on reduced trunk and hip flexion and more posterior pelvic tilt could be included to re-train movement of the joint in a less aggravating position.

Comparison of step up technique. Left: Step up with less trunk flexion which may be less irritable for FAI. Right: Step up with more hip and trunk flexion which may increase irritation of FAI.

Other than building strength in the symptomatic hip to reduce deficits for better long term outcomes, it is also important to have strategies for short-term relief. Individuals with FAI can be recommended non-steroidal anti-inflammatories to reduce acute inflammation and pain. As an adjunct to pain relief, patients can also be taught activity and lifestyle modification to reduce irritation of the hip and reduce aggravating activities. For example, people with FAI can be encouraged to lean backward when sitting for prolonged periods. This is so that the hip is not in sustained hip flexion, which is an aggravating factor.

The same principle can be applied to exercise prescription where individuals can be recommended to avoid end of range positions in squats and leg press, or to alter leg positioning to reduce impingement positions.

Narrow squat with feet and knees parallel which may be less comfortable due contact in hip joint vs 2. wide stance squat with feet and knees pointed outwards which may be more comfortable. 3. End of range deep squat which may be aggravating vs 4. shallow squat (right) which may be more tolerable.

In certain situations, physiotherapy alone may not be sufficient to reduce symptoms. In these cases, injections may be a suitable adjunct to physiotherapy treatment. Injections available for treatment of FAI syndrome include corticosteroid, hyaluronic acid, platelet rich plasma (PRP), or bone marrow aspirate concentrate (BMAC) injections. Of these injections, studies have shown that hyaluronic acid and corticosteroid injections (CSI) demonstrate short-term benefit. However, CSI is associated with possibly poorer long term outcomes of the joint cartilage and hence should be used cautiously, and in conjunction with exercise (Dancy et al, 2025). PRP and BMAC injections have not had high quality evidence to support their use and thus further research is required (Dancy et al, 2025).

In some individuals, physiotherapy and injections may not be able to sufficiently reduce symptoms, or they may have significant changes in joint range or radiological findings. For these individuals, surgery is another option to reduce risk of progression of hip osteoarthritis (OA) (Dancy et al, 2025). This is particularly pertinent in hips with large cam-type lesions, as the repetitive contact of the hip joint applies shear forces to the tissues in the hip joint which are proposed to cause changes to the labrum and cartilage and contribute to hip OA. Some studies have shown that surgery such as arthroscopy may reduce the risk of progression of OA by reshaping the ball-and-socket joint to reduce the premature and abnormal contact. However, given the cost involved and other potential side effects of invasive management, surgery may be reserved for situations where conservative treatment yields no benefits and progression of symptoms is occurring, or for high risk populations described above.

So what should I do if I think I have FAI?

If the symptoms of FAI sound similar to what you are experiencing, the good news is you can start implementing some of the tips as discussed above:

Reducing time in aggravating positions such as sitting in a deep seat
Temporarily avoiding moving/stretching into end range and painful positions such as deep squats or high kicks
Adding hip and core strengthening exercises with a focus on the painful side to build strength

Our physiotherapists are also experienced in assessing specific strength deficits and identifying if your movement patterns may be aggravating your symptoms. As such, if you are experiencing symptoms that are not improving with self-management, it can be worth booking an appointment with one of our physiotherapists who can help you identify specific areas to target and give specific advice tailored to your situation.

Click here to start your hip rehabilitation with one of our team

References:

Bagwell, J. J., & Powers, C. M. (2019). Persons with femoroacetabular impingement syndrome exhibit altered pelvifemoral coordination during weightbearing and non-weightbearing tasks. Clinical Biomechanics, 65, 51-56.

Dancy ME, Oladipo V, Boadi P, Mercurio A, Alexander AS, Hevesi M, Krych AJ, Okoroha KR. Femoroacetabular Impingement: Critical Analysis Review of Current Nonoperative Treatments. JBJS Rev. 2025 Apr 16;13(4):e24.00211. doi: 10.2106/JBJS.RVW.24.00211. PMID: 40238927; PMCID: PMC11939100. https://pmc.ncbi.nlm.nih.gov/articles/PMC11939100/

Diamond LE, Dobson FL, Bennell KL, et al. Physical impairments and activity limitations in people with femoroacetabular impingement: a systematic review. British Journal of Sports Medicine 2015;49:230-242.

Freke M, Kemp JL, Svege I, et alPhysical impairments in symptomatic femoroacetabular impingement: a systematic review of the evidence. British Journal of Sports Medicine 2016;50:1180

Griffin DR, Dickenson EJ, O'Donnell J, et al. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. British Journal of Sports Medicine 2016;50:1169-1176.

Lewis, C. L., Loverro, K. L., & Khuu, A. (2018). Kinematic Differences During Single-Leg Step-Down Between Individuals With Femoroacetabular Impingement Syndrome and Individuals Without Hip Pain. The Journal of orthopaedic and sports physical therapy, 48(4), 270–279. https://doi.org/10.2519/jospt.2018.7794

Terrell, S. L., Olson, G. E., & Lynch, J. (2021). Therapeutic Exercise Approaches to Nonoperative and Postoperative Management of Femoroacetabular Impingement Syndrome. Journal of athletic training, 56(1), 31–45. https://doi.org/10.4085/1062-6050-0488.19

Wall, P. D., Dickenson, E. J., Robinson, D., Hughes, I., Realpe, A., Hobson, R., Griffin, D. R., & Foster, N. E. (2016). Personalised Hip Therapy: development of a non-operative protocol to treat femoroacetabular impingement syndrome in the FASHIoN randomised controlled trial. British journal of sports medicine, 50(19), 1217–1223. https://doi.org/10.1136/bjsports-2016-096368

Best type of exercise to do post menopause

Fri, 10 Oct 2025 03:49:16 GMT

How to slow down (& potentially reverse) bone & muscle loss

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Do I really need to lift heavy weights to improve my bone density?

Thu, 09 Oct 2025 04:51:15 GMT

There is a lot of conflicting information around about whether it is really necessary to lift heavy weights to improve bone density. What is the truth?

There is a lot of discussion around at the moment around whether you need to lift heavy to build bone health.

A number of bone density programs that exist suggest that it is necessary to lif t heavy & for low repetitions (Watson et al., 2017) . However, this reccommendation is based mainly from one study. In this study, participants lifted heavy weights for low reps (5 sets of 5 reps). Another group lifted light weights for higher reps. The heavy lifting group had an improvement in bone density; the light weight group did not.

This shows us that heavy lifting is effective, and that lifting light weights at a low effort is unlikely to be. It does not provide information about any other scenarios (e.g. what about lifting light weights towards failure? what about lifting moderate weights for moderate repetitions?).

A number of systematic reviews indicate that as long as you are lifting weights that are heavy relative to the number of repetitions you are doing , and are progressively heavier over time , this is beneficial to bone (Souza et al., 2020), (Brooke-Wavell et al., 2022).

What does this mean in practice:

It means that you are likely to build bone if you lift a weight for 5 reps (that you are only able to lift 5-6 times in total); or a lighter weight for 10 reps (heavy enough you could only lift 10-11 times in total); or a lighter weight again for 20 reps (that you could only lift a total of 20-21 times). That is, it doesn't matter how heavy it is, or how many reps you do, as long as you are lifting a weight that is heavy enough that you are working towards failure.

To add to the confusion, it is probably true that for some people, lifting light weights no where near failure will be enough to maintain their bones. However, for people already doing this, or doing lots of exercise, who still have declining bone density, osteoporosis, or osteopenia, I think being aware that most likely lifting weights that are relatively heavy (for any number of reps) is likely to add some benefit.

The other thing is practicality: for me, personally, i do not like lifting weights more than 8-10 repetitions, so I am very unlikely to choose a weight I would need to lift 15-20 times, as I find that type of lifting very tiring! Though it might SOUND easier that the weight is lighter, if the effort is matched, I really don't think it is.

Bottom line: it seems that lifting weights for low, moderate, or high repetitions can all benefit your bone health, as long as you are going towards failure (i.e. it is hard work!).

References:

Alnasser, S. M., Babakair, R. A., Al Mukhlid, A. F., Al hassan, S. S. S., Nuhmani, S., & Muaidi, Q. (2025). Effectiveness of Exercise Loading on Bone Mineral Density and Quality of Life Among People Diagnosed with Osteoporosis, Osteopenia, and at Risk of Osteoporosis—A Systematic Review and Meta-Analysis. Journal of Clinical Medicine, 14(12), 4109. https://doi.org/10.3390/jcm14124109
Brooke-Wavell K, Skelton DA, Barker KL, Clark EM, De Biase S, Arnold S, Paskins Z, Robinson KR, Lewis RM, Tobias JH, Ward KA, Whitney J, Leyland S. Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis. Br J Sports Med. 2022 May 16;56(15):837–46. doi: 10.1136/bjsports-2021-104634. Epub ahead of print. PMID: 35577538; PMCID: PMC9304091.
Souza D, Barbalho M, Ramirez-Campillo R, Martins W, Gentil P. High and low-load resistance training produce similar effects on bone mineral density of middle-aged and older people: A systematic review with meta-analysis of randomized clinical trials. Exp Gerontol. 2020 Sep;138:110973. doi: 10.1016/j.exger.2020.110973. Epub 2020 May 23. PMID: 32454079.

Is walking enough to improve my bone density?

Wed, 08 Oct 2025 09:44:23 GMT

"Weight-bearing" exercise such as walking is often suggested as adequate to prevent bone loss. Is this true?

Something we hear often in the clinic is people being told that all they need to do for their bone density is to do weight-bearing exercise.

The term “weight bearing” is super vague, but most people interpret it to mean any exercise that involves moving the weight of their own body against gravity (e.g. walking, hiking, yoga, etc).

Now - for SOME people this will be adequate to build and maintain their skeletal strength. Absolutely.

But if you have already been diagnosed with osteoporosis or osteopenia and you are using walking/ pilates/ yoga/ swimming / hiking as your main forms of exercise, it is likely that for you these are not enough to maintain your bone strength.

It is true that people who walk probably have higher bone density in general than people who don’t, however, the strain on the bone from walking is most likely not large enough to facilitate laying down new bone, and in lots of cases, may not be large enough to prevent loss of bone, either.

This DOES NOT mean stop walking or doing yoga, because meting exercise guidelines for bone health matters, too (150-300 min a week minimum)!

But it does mean you may benefit from adding another type of exercise to your week: the recommendation is adding strength training, a minimum of twice per week. It needs to be strength based exercise that targets the entire skeleton, and can be made progressively more challenging over time. The idea is that it needs to be stimulus that is novel or new for your skeleton, and so needs to be distinctly more load than it your bones have been exposed to in recent years.

So if you currently do no exercise, and your bone density is declining, adding yoga or pilates might be enough to create a new strain on the bone and have an impact. If you are already doing yoga or pilates, and your bone density is still declining, you likely need to introduce something that challenges your muscles more i.e. is heavier and thus causes a larger strain on the bones.

Check out our osteoporosis e-book (download link on the front page at www.fkbphysio.com ) for more information.

Note: not to be taken as medical advice & please seek tailored medical advice for your specific circumstances.

References

Odilon Abrahin, Rejane Pequeno Rodrigues, Anderson Carlos Marçal, Erik Artur Cortinhas Alves, Rosa Costa Figueiredo, Evitom Corrêa de Sousa, Swimming and cycling do not cause positive effects on bone mineral density: a systematic review, Revista Brasileira de Reumatologia (English Edition), Volume 56, Issue 4, 2016, Pages 345-351, ISSN 2255-5021, https://doi.org/10.1016/j.rbre.2016.02.013.
Hong AR, Kim SW. Effects of Resistance Exercise on Bone Health. Endocrinol Metab (Seoul). 2018 Dec;33(4):435-444. doi: 10.3803/EnM.2018.33.4.435. PMID: 30513557; PMCID: PMC6279907.

Barbell back squats: common challenges for beginners

Fri, 22 Aug 2025 05:11:56 GMT

Barbell back squats are a popular exercise in the gym and often prescribed as part of a bone health program (as well as a part of most general strength programs) because they load a large number of muscle groups at once. The use of the barbell across the shoulders also limits being restricted by how much weight you can hold in your hands.

Not everyone is able to get under the bar, however, due to various differences in their anatomy or injury history etc. Below we outline a few different options to help you be successful with back squats , or if not, what you could do instead.

Getting the bar into position on the shoulders

A common difficulty people experience is literally just getting the bar into place on the shoulders.

There are 2 options for where you can place the bar: high bar, or low bar position. High bar is the most common and it involves resting the bar on your upper trap muscles. Low bar involves rolling the bar a little further down the back to sit more across the top of the shoulder blades.

The first 2 minutes of this video discusses how to get in under the bar, specifically outlining the difference between high bar and low bar at minute 1:00-1:23.

A lot of people report discomfort with this position.

Neck discomfort

If the discomfort comes from resting the bar against the bones in the neck, this is incorrect - the muscles of the neck should have tension in them to cause some ‘bulk’ in the muscles, allowing the bar to rest on those as opposed to on the bones of the neck.

Shoulder/upper arm discomfort

If the discomfort comes from the shoulders, or you are conscious of feeling the exercise in your shoulders/arms, this may be due to shoulder mobility.

We suggest really pulling yourself into position under the bar, pulling your shoulders back as you get in under the bar, as opposed to getting under the bar first and then reaching behind you to find the bar. The way we suggests encourages your shoulder blades and shoulders themselves to move backwards, which will make the most of the range you do have available in the shoulders.

We describe this in the video below:

If, despite using this technique, you still cant get under the bar, you can try a few mobility exercises across a number of weeks and see if it becomes any easier.

These are described in this video:

Still struggling to get the bar on your back? A few more ideas...

Wider hand width

A way around shoulder mobility is to have your hands wider. Experiement with different distances to see what could work.

Safety bar squats

Safety bar squats are great if the main reason you can’t back squat is because of shoulder mobility, but they do require having access to one of these bars.

Options if you need to avoid barbell back squats all together

While barbell back squats are a great way to progressively overload the squat pattern, they aren’t achievable for everyone. Here are some options you can try instead.

Goblet squats

Goblet squats are a great option if you can’t tolerate the bar on your back. You will be limited in how much you can progress the weight with these by your arms fatiguing holding the weight. Holding the weight as close as possible to the body helps. In the video we show you how to get the weight up into position, too. Most likely, you will need to do more reps of these to get a similar level of fatigue in the legs compared to barbell squats.

Kettlebell squats

Kettlebell squats eliminate more of the upper body fatigue from goblet squats but will still be dependent on your grip strength and also likely to load your lower back a little more than other variations. Focus on bending your knees a lot and yea

Leg press

The leg press trains similar muscles to squats and can be a good choice to use instead.

We describe each of these options in this video:

Hopefully this has given you some alternative ideas to give you success when doing loaded squats of any sort!

Frances & Jaslynn

Interpreting DEXA scans

Fri, 22 Aug 2025 04:19:18 GMT

Osteopenia and osteoporosis are common conditions in Australia, with up to 7.5 million people affected by poor bone density. In populations over the age of 50, an estimated 66% have either osteopenia or osteoporosis. These conditions happen when bone density is reduced, and the structure of the bone is affected. This increases risk of fracture, even with a low force injury. Hence, it is crucial for early diagnosis and treatment or management of these conditions, to prevent fractures from happening.

To diagnose bone health disorders, dual energy x-ray absorptiometry (DEXA) scans are considered the gold standard diagnostic tool. DEXA scans are safe, low radiation imaging that measure the mineral content of bones, such as calcium content.

In Australia, DEXA scans are eligible for Medicare rebates if you meet certain criteria. The criteria are listed in the table below:

Patients over 50 with risk factors:

- Early menopause

- Hypogonadism

- Anticipated glucocorticoids/corticosteroid use ≥ 4 months, ≥7.5mg/day

- Coeliac disease/malabsorption disorders

- Rheumatoid arthritis

- Primary hyperparathyroidism

- Hyperthyroidism

- Chronic kidney or liver disease

- Androgen deprivation therapy

Patients with a minimal trauma fracture

- DEXA recommended to establish a baseline BMD for treatment

Suspected vertebral fracture – to be referred for spinal x-ray first

- Height loss of 3cm or more

- Thoracic kyphosis

- New onset back pain suggestive of fracture

- Refer for DEXA if fracture is confirmed and therapy is indicated

Patients with osteoporosis

- T-score equal to or less than -2.5 eligible for one scan every 2 years

Patients over 70 years of age

- Both men and women eligible

- Patients with a normal result or mild osteopenia (measured by a T-score down to -1.5) eligible for one scan every 5 years

- Patients with moderate to marked osteopenia (as measured by T-score less than -2.5 and above -2.5 will be eligible for one scan every 2 years)

If you do not meet the criteria but still are at high risk of poor bone health, you can still be referred by your doctor for a DEXA scan, but may have to pay for it.

DEXA SCAN REPORT INTERPRETATION

When you receive the result of your DEXA scan, it can be difficult to interpret what all the alphabets and values mean. Let’s break down how to understand all the different acronyms and numbers.

The sites that are typically imaged for DEXAs are usually the L1-L4 or L2-L4 vertebra, the pelvis and the upper part of the thigh bone (femur) and femoral neck. These are some of the areas that are at high risk of fracture, especially in a fall. However, wrists may also sometimes be assessed, especially in patients who are unable to lay supine for scans on the hips or lumbar spine.

BMD refers to bone mineral density, which refers to the amount of mineral content (e.g. calcium) in bone tissue. This is your specific bone density value which is used to be compared against other people to obtain your T-score and Z-score. It is also worth noting that the presence of osteoarthritis in one of these areas can artificially inflate BMD in that area, which may explain why one site may be significantly osteoporotic, while another site may have seemingly high BMD. This does not mean that the area is not osteoporotic, as osteoarthritis structurally changes the bone, which still increases risk of fracture.

T-score is the standard deviations that your bone density is, compared to a young healthy adult of the same sex. Essentially, this number determines whether your bone density is significantly more or less, compared to that of the peak bone density of a younger healthy adult of the same sex. In populations over 50 years of age or menopausal women, a value of -2.5 or lower is considered osteoporosis, and a value between -1 and -2.5 is considered osteopenia.

Other than using the T-score to diagnose osteoporosis, individuals over 50 years of age with a low trauma hip or vertebral fracture are also considered to have clinical osteoporosis. Individuals over 50 years with low trauma fractures in other areas, and a T-score below -1.5 are also considered to have clinical osteoporosis.

Z-score compares your bone density to someone of the same age and same sex. The normal range is -2.0 to +2.0. At any age, a value of -2.0 or lower is outside the norm and further investigation should be considered to exclude underlying disease which may be causing bone loss. For younger populations under the age of 50, the Z-score is more accurate in predicting risk of fracture and bone health disorders, rather than the T-score.

In some DEXA reports, there may also be some additional values such as Absolute Fracture Risk, Trabecular Bone Score and Vertebral Fracture Assessment. These values do not attract MBS rebates but can be helpful in screening for fracture or risk of it.

Absolute Fracture Risk (AFR) uses a calculation tool named FRAX to assess fracture risk over a 10 year period. This may include a percentage value for either a major osteoporotic fracture, or a hip fracture. This is the percentage likelihood that you may sustain a fracture in those categories. This value is calculated by considering a collection of inputs such as demographic information, alcohol use, metabolic diseases and corticosteroid use. It is recommended that adults over 50 years of age with a 20% or greater risk of a major osteoporotic fracture or a 3% or greater risk of hip fracture should be treated to improve bone health.

Trabecular bone score (TBS) is obtained via analysis of bone quality and bone micro-architecture. The degree of connectivity and organization within the internal structure of the bone is measured. This score can help predict whether someone is more susceptible to fracture. A higher TBS score represents greater trabecular density, better bone connectivity and less trabecular separation, which is likely to be associated with a lower fracture risk.

Vertebral Fracture Assessment/Lateral Vertebral Assessment (VFA/LVA) is a screening tool for asymptomatic vertebral fractures. Fractures detected with this tool should be confirmed by plain x-ray.

MY DEXA SHOWS I’VE GOT OSTEOPOROSIS/OSTEOPENIA! WHAT NOW?

Hopefully, this blog was helpful in helping you make sense of your DEXA scan! If your DEXA shows or if you’ve been told you have osteopenia or osteoporosis, there are steps that you can take to reduce your risk of fracture and further bone health deterioration. Bone tissue is living tissue which is adaptable and can respond to stimuli.

Our bone density classes are aimed at increasing the load and demand on your bone tissue, which encourages bone remodeling and growth. We tailor exercises to a level that is suitable for you.

If you are interested to find out more on how to improve your bone health, do reach out or book an appointment and we can discuss your next steps further!

Written by Jaslynn Lim. Jaslynn runs classes and 1:1 sessions at our Bowen Hills and Fortitude Valley Brisbane clinics on Mondays, Wednesdays and Fridays.

If you prefer a video or audio format for this type of information, below is a youtube version, and there is also an episode on our podcast in spotify.

The best type of exercise for bone density- 2025 update

Mon, 21 Jul 2025 06:43:55 GMT

What type of exercise is likely to help you improve your bone density the most?

Note: nothing in this blog is intended to be taken as medical advice or in place of medical advice from a health professional. It is recommended to seek personal advice for your specific needs.

Scroll down for a link to this in podcast & youtube formats if you prefer to listen rather than read.

In the last 5 years there have been a number of systematic reviews (things that collate all available research on a topic) as well as region specific management guidelines that discuss the optimal exercise for preventing & managing osteoporosis.

A common feature is that the studies are so different that they can’t easily collate the information together or make any claims with strong certainty. Because so many factors influence the outcomes of an intervention, this is pretty common in healthcare research. Each review also makes slightly different conclusions from the studies they have included.

Despite this, there are some consistencies that appear from these studies and practice guidelines:

Main take home points:

Exercise likely has a positive impact on bone density & therefore meeting exercise guidelines (a minimum of 150 minutes per week) is important.
To improve bone density:
Exercise must target all major muscle groups to effectively target the whole skeleton.
Strength based exercise that is hard, and made progressively harder over time is necessary.
This type of exercise should be performed a minimum of 2-3x per week
A combination of interventions is likely to be more beneficial than a sole intervention (i.e. strength training + impact training + cardio)
Balance training should be incorporated to reduce falls risk.

Resistance training provides an effective way to load the entire skeleton, while also progressively overloading over time. Progressive overload = exercises need to be made harder once they become easy.

This is GENERAL advice; for some people, they may maintain their bone density effectively without ever picking up a weight. However, for those people who have osteoporosis/osteopenia and are wanting to try and change their situation through exercise, it is necessary to provide realistic advice about what might be the most effective way to go about doing this.

Though exercises like yoga and pilates are a form of resistance training, it is difficult to progressively overload them in a way that is likely to build bone (Fernández-Rodríguez, 2020).

A look at the last 5 years in bone density research (through systematic reviews)

Defining low intensity and high intensity lifting in the context of resistance training

Before going into any more detail about these studies, I want to clear up a few terms: a lot of the studies refer to ‘high intensity resistance training’. Specifically in relation to resistance training, this term refers to weights that are very heavy for the person. I.e. high intensity refers to weights that are 80-85% of a person’s 1 repetition maximum or 1RM lift. This means a weight that someone could lift once, and only once, which is their true 1RM; a weight that is 85% of 1RM is a weight they could lift only 5 times. A weight someone could only lift 10 times is equivalent to about 75% 1RM. So in this context, high intensity = >80%1RM, so a weight someone could lift only 1-5 times; moderate intensity = 60-80% 1RM (~10-15 reps); low intensity = 40-60% 1RM (20-30 reps).

There is a difference between lifting a light weight (40% 1RM, for example) for say, 10 reps, which would be a very low effort overall exercise, and lifting that same weight until failure, i.e. lifting it until no more reps could be completed, which might mean lifting it 30 times or more, which would be very tiring and hard. This is a really important distinction to make.

Here are the summaries of the UK, Canadian, and Australian guidelines:

UK guidelines - Brooke-Wavell et al., 2023

Strength training
For all people with osteoporosis, it is recommended to do strength based exercise 2-3x per week
Strengthening should include progressive muscle resistance training
Work up to a maximum weight that can be lifted 8-12 times for 3 sets
All muscle groups should be targeted including back muscles
General exercise
Daily physical activity is recommended as a minimum
People should be encouraged to continue forms of exercise they enjoy
Impact loading
For those safe to do so, moderate impact exercise is recommended on most days: ideally about 50 moderate intensity impacts (5 sets of 10) with a low impact exercise in between
Low impact exercise like walking is recommended for those people who are not able to safely perform moderate to high intensity impact exercise
Balance training
Falls prevention may factor in for those less steady or older individuals though balance training likely to be covered by a number of the impact/ strength exercises
Precautions
Individualised exercise prescription from a trained health professional is recommended
Rapid, repetitive, end of range, sustained or weighted end of range twisting and flexion spine movements should be avoided for those at high risk of fracture

Canadian guidelines (Morin et al., 2023)

Strength training
Balance and functional training should be performed at least twice per week
Progressively increase resistance training and balance training over time to achieve progressive overload
Resistance exercise should target major muscle groups in upper and lower body as well as abdominals and back
General exercise
People should be encouraged to continue forms of exercise they enjoy, but be aware that these should not take the place of resistance and balance exercises
People should aim to exceed 150 minutes of moderate to vigour physical activity per week
Impact exercise
If safe to do so, impact exercise should be performed at a moderate intensity and progressed to high impact over time
Precautions
Rapid, repetitive, end of range, sustained or weighted end of range twisting and flexion spine movements should be avoided for those at high risk of fracture
Individualised exercise prescription from a trained health professional is recommended

Australian guidelines (Healthy Bones Australia, 2024)

Strength training
It is recommended to do 2-3 sets of maximal weights that can be lifted for 5-8 repetitions, 2-3 days per week,
Exercise should be progressive heavier over time and should include the whole body, including back muscles and back extension in particular
Note that patients with very low BMD may require lower weights and higher repetitions to start with
Impact loading
50 impacts of 2-4x body weight (moderate intensity) should be performed a minimum of 3 days per week, introduced gradually and performed according to what is safe for the patient
General exercise
Accumulate at least 3 hours a week of any exercise that helps balance
Aim to encourage exercise, rather than coaching patients to avoid particular types of exercise
Precautions
Excessive spine flexion and twisting should be avoided
Recommend submaximal lifting below 1RM for safety considerations
For people with an osteoporosis diagnosis, exercise should be supervised

Systematic reviews from the last 5 years

Souza et al. 2021

This study compared the effects of low and moderate intensity resistance training with high intensity resistance training on bone density in middle aged and older people.

It specifically challenged the notion that high intensity training, that is, lifting weights so heavy you are only able to lift them 1-5 times (> or = to 80-85% 1 RM or 1 rep max), is superior to moderate intensity (weights you can lift 10-15 times or 60-80% 1RM) exercise for bone density. They correctly identify that the main studies that indicate it is necessary to complete high intensity weight lifting did not compare this intervention directly to to moderate intensity lifting, rather to very light exercise, and as such it is not reasonable to conclude specifically that high intensity is more effective than moderate intensity lifting.

They argued that muscle tissue itself may be positively associated with bone health, that is, having larger muscles may facilitate having higher bone density. To increase the size of muscles, it is not necessary to lift with a high intensity (low reps close to 1RM), it is simply necessary to lift weights towards failure. This finding is backed up by recent research by Lasevicius et al. in 2022. Their review found that results on bone density improvement with resistance training was similar with high intensity vs low and moderate intensity lifting, provided effort was adequate .

This is really important - it does not mean that lifting relatively ‘light’ weights for a given number of reps is just as effective as lifting heavy weights; it means that it is necessary to go towards failure, which might mean lifting those weights for very high repetitions. Either way, high intensity or low/moderate intensity, the exercise needs to be ‘hard’ for the person.

As stated by the authors, lifting weights in this manner is often quite unpleasant and as such this may be a deterrent to reaching the desired effect, which may lead people to choose heavier weights for lower repetitions in a practical setting.

It is important to note that half the studies included in this review did show an increased effect of high intensity training compared to lower load resistance training, while no studies found an increased effect of low load training compared to high load. The authors also found that higher loads are likely to correlate to more significant improvements in people who have higher baseline BMD, and that higher intensity exercise may be more effective at improving BMD at the hip compared to low and moderate loads.

The main take-aways from this are that it is not necessarily required to lift very heavy weights at low repetitions to have a positive impact on bone density, and that as long as effort is matched, low and moderate loads may work just as well, though applying this practically can have challenges.

Kitagawa et al. 2022

This study compared high intensity resistance training (> 80% 1RM) and high impact loading (>4x bodyweight, defined as jumps with stiff legged landing and high load aerobics) to moderate intensity resistance training (60-80% 1RM) and moderate intensity impact loading (ground reaction force between 2-4x body weight, defined as hard heel drops and light aerobics) on postmenopausal women with osteoporosis.

It found that high intensity exercise was more effective than moderate intensity however these findings were very low certainty in nature. The study found that performing exercise more frequently likely correlated to more specific improvements, recommending performing the exercises 2-3 times per week. It also found that improvements in bone density were found at the lumbar spine but not at the femoral neck, which is fairly consistent across the research.

Alnasser et al. 2025

This study compared lots of different types of exercise and their impact on bone density across the lifespan, ranging across young through to older adults. The aim of the study was more to look at the effects of progressive exercise loading compared to no exercise. The findings were generally that all exercise can help improve bone density, provided it is progressive.

Xiaoya et al., 2025

This study compared resistance training and aerobic training interventions for improving BMD in post-menopausal women. It found that it was possible to improve BMD at both the femoral neck and the lumbar spine, and that the most effective modalities were resistance training combined with aerobic training, or resistance training alone to a lesser extent. The authors determined that aerobic training may have a positive effect on BMD for its impact on metabolic and endocrine functioning.

A few studies mentioned whole body vibration, however at present none of the guidelines suggest it, and some draw backs are that it does not improve strength or balance and so it may not be as all-around effective as other modalities, though we will keep our eye on the research to see if anything changes in that space.

Limitations of the research generally:

A major limitation of all research in this space is that it tends to be quite short in duration, which is tricky because bone changes very slowly. For example, a study by Nicholson et al. 2015 found that body pump, a low intensity, high rep class that does not go near to failure with the exercises performed is effective at maintaining bone density in the lumbar spine in post-menopausal women. It would be interesting to know, however, if this result would still be the case in 5-10 years time, as people are unlikely to have been able to significantly change or progress their weights in that time.

It is also important to recognise that there is a difference in maintaining vs building bone density, and a difference in exercise effects for people with osteoporosis or osteopenia and those without.

As always, treatment interventions need to be tailored to the individual. A 75 year old woman with osteoporosis who has never exercised is likely to need a different intervention to a 60 year old woman who runs and does pilates 5 times week with osteoporosis.

If you are not sure how to get started, book in with one of our physios, in person or online to start your own tailored program.

We run classes in Brisbane that are personalised and designed based on this information. These classes are both to help to prevent osteoporosis or osteopenia, or to reduce the progression of these conditions. Book in to get started.

References:

Alnasser, S. M., Babakair, R. A., Al Mukhlid, A. F., Al hassan, S. S. S., Nuhmani, S., & Muaidi, Q. (2025). Effectiveness of Exercise Loading on Bone Mineral Density and Quality of Life Among People Diagnosed with Osteoporosis, Osteopenia, and at Risk of Osteoporosis—A Systematic Review and Meta-Analysis. Journal of Clinical Medicine, 14(12), 4109. https://doi.org/10.3390/jcm14124109
Brooke-Wavell K, Skelton DA, Barker KL, Clark EM, De Biase S, Arnold S, Paskins Z, Robinson KR, Lewis RM, Tobias JH, Ward KA, Whitney J, Leyland S. Strong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosis. Br J Sports Med. 2022 May 16;56(15):837–46. doi: 10.1136/bjsports-2021-104634. Epub ahead of print. PMID: 35577538; PMCID: PMC9304091.
Fernández-Rodríguez R, Alvarez-Bueno C, Reina-Gutiérrez S, Torres-Costoso A, Nuñez de Arenas-Arroyo S, Martínez-Vizcaíno V. Effectiveness of Pilates and Yoga to improve bone density in adult women: A systematic review and meta-analysis. PLoS One. 2021 May 7;16(5):e0251391. doi: 10.1371/journal.pone.0251391. PMID: 33961670; PMCID: PMC8104420.
Kitagawa T, Hiraya K, Denda T, Yamamoto S (2022), A comparison of different exercise intensities for improving bone mineral density in postmenopausal women with osteoporosis: A systematic review and meta-analysis, Bone Reports, Volume 17, 2022, 101631, ISSN 2352-1872, https://doi.org/10.1016/j.bonr.2022.101631. (https://www.sciencedirect.com/science/article/pii/S235218722200465X)
Lasevicius T, Schoenfeld BJ, Silva-Batista C, Barros TS, Aihara AY, Brendon H, Longo AR, Tricoli V, Peres BA, Teixeira EL. Muscle Failure Promotes Greater Muscle Hypertrophy in Low-Load but Not in High-Load Resistance Training. J Strength Cond Res. 2022 Feb 1;36(2):346-351. doi: 10.1519/JSC.0000000000003454. PMID: 31895290.
Morin SN, Feldman S, Funnell L, Giangregorio L, Kim S, McDonald-Blumer H, Santesso N, Ridout R, Ward W, Ashe MC, Bardai Z, Bartley J, Binkley N, Burrell S, Butt D, Cadarette SM, Cheung AM, Chilibeck P, Dunn S, Falk J, Frame H, Gittings W, Hayes K, Holmes C, Ioannidis G, Jaglal SB, Josse R, Khan AA, McIntyre V, Nash L, Negm A, Papaioannou A, Ponzano M, Rodrigues IB, Thabane L, Thomas CA, Tile L, Wark JD; Osteoporosis Canada 2023 Guideline Update Group. Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update. CMAJ. 2023 Oct 10;195(39):E1333-E1348. doi: 10.1503/cmaj.221647. PMID: 37816527; PMCID: PMC10610956.
Nicholson VP, McKean MR, Slater GJ, Kerr A, Burkett BJ. Low-Load Very High-Repetition Resistance Training Attenuates Bone Loss at the Lumbar Spine in Active Post-menopausal Women. Calcif Tissue Int. 2015 Jun;96(6):490-9. doi: 10.1007/s00223-015-9976-6. Epub 2015 Mar 14. PMID: 25772806.
Xiaoya L, Junpeng Z, Li X, Haoyang Z, Xueying F, Yu W. Effect of different types of exercise on bone mineral density in postmenopausal women: a systematic review and network meta-analysis. Sci Rep. 2025 Apr 5;15(1):11740. doi: 10.1038/s41598-025-94510-3. PMID: 40188285; PMCID: PMC11972399.

Managing the onset of a new pain when training in the gym

Fri, 11 Jul 2025 06:17:10 GMT

In the 6 years that separate the two instances of my having significant shoulder pain from training, my understanding of pain and injury have changed a lot, and I thought sharing my experience might be of value to other people who are experiencing a new pain, particularly when training.

I thought I’d share my recent shoulder pain experience after a few discussions in the clinic with patients assuming that injuries do not happen in relatively young, relatively fit people, & also challenging the assumption that injuries are always the result of doing something wrong that could have been avoided (I have found this is rarely the case - it is often only in retrospect that the contributing factors can be seen more clearly).

Take home thoughts:

You do not need to completely rest when you have an injury
A lot of the time, injuries are not caused by “moving wrong” and do not require in depth movement analysis to address (but I would always check how my patients move just to screen for anything really significant that may be relevant)
Load management is often a big part of the picture with injuries in active people, however it is not always as straight forward as just looking at overall volume. in this case, it was most likely in part a change in how I was doing an exercise that led to the onset of my symptoms - the wider grip on the bench, as that seemed to be the main thing that hurt - however it was decreased exposure to this movement that caused symptoms rather than the movement being inherently wrong
The human body de-conditions quickly to things it may have been very conditioned to (within weeks) which can be really hard to fully appreciate when it happens to you
Acute pains HURT, but often can resolve quickly if treated properly

Back in 2019, when I started bench pressing a lot more often, I developed quite bad shoulder pain on my left side. Because it was so sore, I went looking for reasons it might be hurting. I would record myself training and notice that it moved differently to the other side. It wasn’t good at doing really small, isolated, end of range exercises (like prone Y lifts). I became convinced that this was the reason why it was so sore - that I ‘moved wrong’, my shoulder blade was tilting forward too much, and this is what was causing the problem.

I ended up consulting my favourite specialist shoulder physio Adam Meakins about it (online) once the problem had gone on for more than a year. He pointed out a few things:

The difference in range of movement in my shoulders was probably because of different demands on my skeleton when I was growing up, as I played tennis - not better or worse on one side, just different
There was generally equal strength in my shoulders, despite one being very sore
There was a clear change in loading (adding bench press) which coincided with my symptom onset

He recommended cutting the volume of my pressing movements by at least 50%, and lo and behold, gradually my symptoms abated over another few months. The reason this took SO long is because it was most likely a type of bony stress reaction, where the end of my collarbone was never quite recovering between loading doses. Bones recover very slowly and need more significant rest than I was willing to give (COVID & Gym closures may be the only reason it got better, if I’m honest!).

This experience highlights something I have found so often in my physio practice - that load management is so commonly a major culprit in new onset pain. It may be relevant that my shoulder moved differently to the other side - possibly why this side became painful instead of the other one (though the right one ended up developing a similar problem at some stage as well), however most of the time, we can’t change things like this, particularly if it relates to the literal shape of our skeletons!

As my physio practice and understanding of pain and movement evolved, I started thinking a lot less about these tiny specifics of how I moved, and in the following years, I bench pressed more often and more heavy than ever (4x a week most weeks, as my sport at the time powerlifting involves lots of bench press), with no problems. Having been given the permission and freedom from Adam not to worry about how I moved, I barely thought about my shoulder again.

This year, after having a month off weight training in January for my sister’s wedding overseas, I returned to the gym, but for training Hyrox instead of powerlifting, meaning I was doing a lot more running, a lot more cardio in general, and a lot less bench pressing - just once a week.

About 2 months ago, I noticed my shoulder was feeling sore again, in the same place. It started off fairly gradually - I would notice it was a bit sore for a day and wasn’t quite sure what was causing it. It’s pretty normal for something to hurt now and then when training hard (I am nursing a few other niggling long term lower body problems), so I opted to just keep my eye on it and not change anything straight up.

One day, however, it was particularly painful training, especially doing the bench press. I ignored it, and pushed through, but once I cooled down my shoulder was so painful all day that I found I could barely move it. It continued into the next day.

Initially, I couldn’t understand why it was so sore. My updated understanding of how things work meant my brain didn’t immediately leap to thinking I ‘moved wrong’, or was ‘lacking strength’ for this issue, but when I thought about my loading profile, I couldn’t understand it from that perspective, either. Objectively, I was doing so much less pressing than ever before! The pain also only re-started months after returning to training, so the month off didn’t feel that relevant, either.

Eventually I realised that at about the time the pain started, I had swapped from training on a commercial gym bench, which is a bit more slippery & meant I had a narrower bench press grip (ring finger on the bars) and was pressing a bit less weight due to feeling unstable, onto a powerlifting bench, where I had a wider grip (index finger on the rings) and could lift a bit more weight (~15% more). I realised that the pain was present with most pressing exercises, but it was pushed into unmanageable territory on the bench press in particular.

Despite having done this ‘powerlifting style’ bench press at weights heavier than my bodyweight 4x a week for literally years, re-introducing it once a week after ~4 months off that particular variation was enough to give me shoulder pain bad enough I could barely move my arm for a couple of days. There was pain simply from the pressure of my jumper resting against it when I walked.

I am at about week 6 since the worst of the pain, and it seems to be almost completely resolved - some tenderness to touch after heavier upper body sessions and some aching after long walks or runs, and it still hurts to reach behind my back with that side.

Here’s how I managed it:

Relative rest, but continued training

Stopped any heavy weighted pressing until the more severe pain stopped (~ 2 weeks)
Continued all leg exercises, including things like squats and deadlifts that involve the arm but don’t directly train it
Continued hyrox training, involving burpees & wall balls; continued to teach my gym classes involving push ups & relatively light barbell push presses - would increase symptoms for a few hours but manageable
Avoided sleeping on it

Gradual re-loading

Re-introduced weighted upper body exercises that didn’t hurt too badly after 2 weeks such as rows, pulldowns and chin ups
Continued hyrox training & classes as above
Re-introduced heavy dumbbell chest presses at week 4 but ensured they were pain free. Weights were about ~20% lighter than my max pre-pain
Re-introduced barbell bench press at week 6 (trialled at week 4 and 5 but much too painful still), at ~ 80-90% previous load.
Have avoided dips all together - priority is feeling good for Hyrox in 2 weeks and there doesn’t seem any point in testing it out on these yet

Technique adjustment

When I returned to the bench press I made sure to really drive through my feet and create a big arch through my back to reduce shoulder range (this is a powerlifting technique)- this is what my body has conditioned to over the years & reduces pressure on the shoulder
No other changes

It is always interesting to go through the process of having an injury yourself when you are a physio and I think it is always worth sharing these types of experiences, in particular to challenge the narratives out there that training hard is inherently risky, that there are hard and fast right and wrong ways to move, and that you shouldn’t train while injured - of course nuance to all of these things which I hope I have covered well enough in this blog!

Injuries are of course multi-factorial and so there were likely other contributing factors as well that are harder to specifically identify (lifestyle/stress/etc), but I thought I'd talk about this aspect as I find it is often so surprising how such seemingly small changes can have such significant impacts. Figuring out what might be a main contributor to someone's new pain or injury is so important, and is largely why we try to take really detailed histories with our patients at FKB.

Frances

How do medications like Ozempic and Wegovy / GLP1s affect bone density?

Mon, 16 Jun 2025 03:30:41 GMT

In recent years, there has been a rise in popularity in glucagon-like-peptide-1 medications, commonly referred to as GLP1s and more likely to be known under their brand names such as Ozempic, Wegovy or Mounjaro. These medications are commonly used to treat type 2 diabetes and certain brands are approved in Australia to be used for chronic weight management. With a number of patients coming through our doors taking these medications, it prompted us to have a look at their impact on bone health.

Diabetes impact on bone health

According to Healthy Bones Australia, people with type 1 diabetes are at a higher risk of having low bone mass, as the condition can impact them at at time when they are building the majority of their skeletal mass, in childhood and adolescence. While type 2 diabetes is different, and may not have a direct impact on bone density, those with type 2 diabetes have a higher lifetime risk of developing a fracture. The reasons appear to be multi-factorial, some relating to the impact higher blood sugar can have on bone density and architecture, and others relating to complications that can arise as a result of the condition that may result in increased risk of falls later in life.

GLP1-s and bone health

According to a review by Zhao et al. in 2017, GLP1 medications may be beneficial to bones, if we consider them in isolation to any weight loss. That is, the drugs themselves may actually have a bone preserving effect, though research is currently inconclusive.

The main outcome of taking these medications is significant weight loss, and it is actually this that is most likely to have a detrimental effect on muscle and bone health. Studies looking at the impact of these drugs show that in the studies spanning 68-72 weeks, participants lost up to 10% of their muscle mass, which is the equivalent to the muscle mass lost across 20 years of ageing (Mechanick et al., 2025). Another study found that between 25-39% of all weight loss while taking these medications is from muscle mass (Prado et al., 2024).

With such rapid loses of muscle, and even just considering the significant loss of size that accompanies significant loss of body mass, it is necessary to consider the bones. Our bones remain dense directly in correlation to how much force is put through them. That is, how much our muscles are contracting and pulling on the bones. With less muscle mass, and less body mass, there is less loading on the bones, and as such losses in bone density can accompany losses in body weight, particularly when occurring in such high amounts and at such high speeds (Jensen et al., 2024).

How to reduce muscle and bone loss

There are a couple of really important considerations from an allied health standpoint when taking these medications and that is to consult with a dietician alongside taking these medications to avoid completely depriving the body of the nutrients required to continue to function in a healthy manner. The other is to commence resistance based exercise program to maintain muscle and bone mass and to mitigate loss of these tissues as much as possible. Some early research has indicated that exercise can mitigate bone density losses associated with these medications (Jensen et al., 2024).

Many GPs are sending their patients for DEXA scans prior to starting these medications as well as referring to physio/exercise physiology and dietetics to facilitate appropriate support throughout the process. This may be particularly important in the context of diabetes or other co-morbidities that might already impact bone health.

Take aways:

GLP1s like Ozempic and Wegovy are being prescribed for diabetes management and in some cases for chronic weight management
A side effect of these medications is often significant weight loss
Significant weight loss is likely to include muscle mass
Loss of muscle mass results in loss of bone & can be dangerous to your health in the long term
You can mitigate these effects with appropriate dietary measures as well as by doing resistance training
Getting regular DEXA scans while on these medications likely to help in monitoring their effect on these aspects

We offer 1:1 consultations and small group classes to help you with an exercise program to help support you when taking these medications. Click here to get started with any of our physios.

References:

Healthy bones Australia, https://healthybonesaustralia.org.au/resource-hub/fact-sheets/diabetes-bone-health/ .
Zhao C, Liang J, Yang Y, Yu M, Qu X. The Impact of Glucagon-Like Peptide-1 on Bone Metabolism and Its Possible Mechanisms. Front Endocrinol (Lausanne). 2017 May 3;8:98. doi: 10.3389/fendo.2017.00098. PMID: 28515711; PMCID: PMC5413504.
Mechanick JI, Butsch WS, Christensen SM, Hamdy O, Li Z, Prado CM, Heymsfield SB. Strategies for minimizing muscle loss during use of incretin-mimetic drugs for treatment of obesity. Obes Rev. 2025 Jan;26(1):e13841. doi: 10.1111/obr.13841. Epub 2024 Sep 19. PMID: 39295512; PMCID: PMC11611443.
Prado, Carla M et al. (2024), Muscle matters: the effects of medically induced weight loss on skeletal muscle, The Lancet Diabetes & Endocrinology, Volume 12, Issue 11, 785 - 787
Jensen SBK, Sørensen V, Sandsdal RM, Lehmann EW, Lundgren JR, Juhl CR, Janus C, Ternhamar T, Stallknecht BM, Holst JJ, Jørgensen NR, Jensen JB, Madsbad S, Torekov SS. Bone Health After Exercise Alone, GLP-1 Receptor Agonist Treatment, or Combination Treatment: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open. 2024 Jun 3;7(6):e2416775. doi: 10.1001/jamanetworkopen.2024.16775. PMID: 38916894; PMCID: PMC11200146.

Jaslynn's story

Thu, 22 May 2025 23:58:15 GMT

Hi! I’m Jaslynn, I’m the physiotherapist who just joined FKB Physio this month.

I graduated from the University of Queensland in 2023 and have since mainly worked in private practice settings.

A bit about myself

I’m actually from Singapore. I moved here for studies and then stayed for work!

Outside of being a physiotherapist, I illustrate designs for t-shirts, occasionally do Brazilian jiujitsu and regularly go to the gym. I’m also miserably trying to work on my cardiovascular fitness.

I have a rather terrible caffeine habit that I wish I could kick but alas… coffee is too good to resist.

Why did I become a physiotherapist?

I was very fortunate to have had very positive experiences with allied health and alternative health practitioners when I was growing up. Their care and support left a strong impression on me, and I grew up thinking I would love to be able to pay it forward and do that for someone else.

After completing high school, I originally considered studying medicine. However, after seeing the lifestyle my sister (who is now a family doctor) led, I didn’t think I would enjoy it. So I started exploring other health professions. I was also interested in fitness at the time, and would get plenty of social media content from physiotherapists on my feed and that sparked my interest!

To explore this possibility more, I shadowed physiotherapists in hospitals. I very nearly got put off by it as I was mainly shadowing inpatient physiotherapy and it wasn’t really what I could see myself doing. But on one of the last few days, I got to shadow a physiotherapist on the outpatient department.

Immediately I thought; this is it.

This is what I want to do.

I’m not even joking when I say I had tears in my eyes at that point, but it does sound rather overdramatic now, looking back!

Anyway, from then on, I became fully committed to becoming a physiotherapist.

Funnily enough, I actually never personally saw a physiotherapist until I was about 18, which is when I started Brazilian jiujitsu and exposed myself to a new world of injuries.

Injuries?

I’ve had my fair share of injuries, given that I’ve done Brazilian jiujitsu for about 7-8 years now and was pretty obsessive for some of those years. But the one that has affected me the most, and also shaped the way I treat as a physiotherapist, would be my shoulder subluxation in March 2023.

To be honest, it was almost entirely my fault. I was competing on that day and had 9 matches. About halfway through my 5 ^th match, I felt a click or small pop in my shoulder and immediately lost almost all my strength in it. Somehow, I managed to pull through and win that match.

A wise person would have stopped there.

But I was young and foolish, so obviously, I didn’t. I did a couple of shoulder tests on myself with the assistance of a fellow physiotherapy student, and thought I’d give it a go and at worst I’d just stop if it got really bad.

I never got the chance to stop.

My left shoulder got into an end range position which I get into all the time in training – but this time I had obviously already damaged some stabilizing structures.

I felt my left shoulder shift out of place.

It was the most disgusting feeling I’ve ever had in my life, but luckily enough the subluxation spontaneously reduced on the spot.

It was the worst injury I’ve had in my life, which really isn’t that bad compared to some of the really messed up injuries you can get. I didn’t have any fractures from it thankfully, nor did I tear any of the rotator cuff muscles, though I believe I did get some labral damage. It did, however, put me out of action from jiujitsu.

I wouldn’t say it was a bad thing overall. I learnt a lot about shoulder management from that experience, and also gained a much deeper understanding of patient’s experience of injury. It’s probably not the best way to go about gaining empathy for patients, but it definitely is one of the most effective!

An injury is never just physical, it also has emotional, social and psychological impacts. The injury gave me insight to these things, and I think it has made me a much better physiotherapist overall.

That’s also why I have a passion for working with athletes, especially martial arts athletes, to reduce injury risk and improve function. But to be honest, this is not really limited to athletes, they apply to most of the general population as well. Anyone who is facing injury, pain or any other dysfunction would know how it can affect their life. And I have come to really realize the importance of having guidance through that process, and being really grateful I can provide that to someone going through an injury, managing pain or other dysfunction.

I guess in a full circle sort of moment, I realized I have become a source of support for people going through health concerns like what I received when I was young!

So that’s the story of how I got into physiotherapy and my experiences with injury.

I think the body’s ability to adapt after injury is amazing, and I think we’re finally in a new era where people are more receptive to actively work on it rather than just rest. It’s really encouraging to see all the class participants at FKBPhysio lifting heavy and working hard to get stronger and improve their health and bone density, and I’m so honoured that I get to be part of the process ��

Take homes from a professional development evening

Tue, 13 May 2025 00:31:49 GMT

Take home points:

- Physiotherapy's role in managing pain and injury is often largely about education, finding modifications to lifestyle and activity factors, and rehabilitating strength rather than passive treatment strategies

- The medical system can be quick to refer for injections but often do not explain that these are not fixes

- Tendinopathy is often not treated & ignored for other pathologies (like bursitis) which can often lead to inadequate management strategies

- Early bone loading can facilitate faster/better recovery than complete rest and immobilisation after a fracture

Thoughts after attending a multi-disciplinary professional development evening

Sarah and I attended a professional development seminar the other week, featuring talks from allied health and medical professionals. It got me thinking and I thought I’d share my take-aways from the evening as they touched on some really common issues that come up in the clinic that I think warrant more thought and discussion.

The role of physiotherapy in musculoskeletal pain

One of the presenters was a sports exercise physician. These are doctors who have extra training in sports and musculoskeletal (MSK) problems.

I often feel a degree of anxiety when patients see a doctor for an MSK concern, as they are often referred immediately to a surgeon or for an injection with no further instruction (not always, just sometimes). They can also be given extreme advice (never lift overhead! Never lift more than 5kg! Etc).

I can also feel a little anxious when people are referred for physio with no explanation as to what to expect, as I presume the majority of the population expects this means massage +/- dry needling +/- stretches +/- mild exercises with a theraband.

The sports medicine physician put what I perceive physiotherapist’s role into a few succinct dot points that completely resonated with me:

- Education

- Load management

- Strength & conditioning

I actually think offering these as the main interventions as a physiotherapist is hard - even though I believe they are the most high value - because they involve talking/ planning and not much ‘doing’. People often expect that something will be ‘done’ to them at the appointment.

This is not to say I don’t practice manual therapy, or that I am against it, it is simply that I do not generally feel it is the most high value treatment that people can receive, though it is often perceived as such. These 3 things (in my opinion) are the main physiotherapy interventions that matter. Manual therapy can help reduce symptoms in the interim. However I have often found that it distracts from these main points. I find when manual therapy is performed additionally to these management strategies, if a patient returns a few weeks later and is no better (as you advised would be the case, as the condition has a natural history of weeks to months) they perceive the entire treatment as ineffective, because the manual therapy had no real impact. It is often at this point a patient will seek surgical advice, citing physiotherapy didn’t work; however often in these cases in my opinion the most powerful interventions haven’t actually been given a fair go.

Without the manual therapy, there is less distraction from these (kinda boring, and often hard to sell as an intervention) things being the main management strategies.

It was really reassuring to hear a sports doc talk about these things in a way that showed me that the medical profession can and physiotherapists actually support each other really well and can be a great team for a patient, when the roles of each are properly understood.

Something we do at FKB Physio is provide our patients with a written summary after their initial appointment with the decisions we have come to together around load management & a clear explanation of what to expect for their recovery, which I continue to believe is essential and really important. Also important is the idea that we come up with a plan together - it is no use telling a patient to stop doing a movement all together that they need to be doing in order to continue to work, or look after their family; coming up with ways to reduce load that is actually actionable for that person is crucial.

The role of cortisone injections in tendinopathy

The sports medicine physician also discussed cortisone and PRP injections. It was reassuring to hear a person who provides these interventions be honest about their role as part of a whole picture, rather than a treatment in themselves.

It is all too common for a patient to be diagnosed with bursitis (commonly shoulder or outer/lateral hip), be given a cortisone injection and sent on their way. I always try to advise my patients that it is rare for bursitis to exist independently (to my knowledge just 2% of the time in the hip, for example) and more commonly for it to exist alongside tendinopathy. Tendinopathy is a condition involving inadequate tendon healing in response to load. Bursitis is largely inflammatory. As an anti-inflammatory modality, cortisone may have a positive effect on an inflamed bursa, but will not have any role in treating an unhealthy tendon.

I have often felt that cortisone could be useful in people whose pain level is completely intolerable/unbearable (e.g. affecting sleep), to at least provide some pain relief, but not indicated for everyone, and not a treatment in itself. The sports medicine physician essentially confirmed this bias of mine, and made it clear that with his patients, he outlines cortisone as a ‘cover-up’ that allows them to function, but that they need to remember there is a tendon problem that continues underneath this that is likely to cause symptoms again once the cortisone wears off.

Honestly, this simple explanation is missing in the majority of patients I have seen who have been prescribed a cortisone injection and I think it’s so important as so often cortisone is seen as a ‘fix’. Bear in mind that every diagnosis and pathology is different, and I am exclusively talking about tendinopathy here.

I find in bursitis/tendinopathy conditions in particular people are often diagnosed exclusively as having bursitis and are prescribed a cortisone injection in isolation which, as the sports doc mentioned, does nothing to address the tendon itself.

Load management (reducing load to allow recovery then gradually adding it again) + strength and conditioning (around the affected area and gradually on the muscles attaching to the tendon) + education (advise that often these conditions can have LONG healing times & that is normal).

The role of early loading in bone healing

Finally I was also interested in the occupational therapist’s talk about early loading for bone healing. A phrase she repeated was that early, controlled stress can help a bone to heal faster. That is, instead of completely immobilising a bone (e.g. in a cast for a broken wrist), it can be better to immobilise only the affected joint, and do so in a way that enables lots of movements of the surrounding joints; then facilitate some loading of the affected joint as soon as the bone is ready, to reduce overall recovery time and overall time immobilised.

We know that immobilising joints is often one of the worst things for them due to it weakening all surrounding soft tissues and often contributing to longer recovery times to restore the movement lost from prolonged immobility.

This concept ties into the overall general idea that pure rest is often not actually that great for us. Though it historically is often promoted as the best option for treating injuries, it is interesting to note that as time has gone on, more and more, the negatives of rest and immobility are highlighted, and trying to rest for as short a duration as possible and keep everything else moving as much as possible is a consistent theme.

Always great to hear from other professions to have a better understanding of what they each do and know when it is appropriate to refer a patient on.

Frances

Osteoarthritis Myths

Tue, 08 Apr 2025 08:02:21 GMT

Before we get started...

Osteoarthritis: Osteoarthritis refers to joint pain and stiffness with associated joint changes, such as thinned cartilage and additional bone remodelling around a joint (i.e. extra bone laid down around a joint, changing its shape).

Osteoporosis: weakened bones - NOT related to osteoarthritis and is asymptomatic

Rheumatoid arthritis: an autoimmune condition that requires specific management

This blog post specifically discusses osteoarthritis.

MYTH: Having arthritis means guaranteed pain and decline over time. It's the beginning of the end!

Age related joint changes and arthritis are not the same thing. Just because your joints show signs of ageing, that does not guarantee that this will be painful - think of it like wrinkles on the inside.

Arthritis specifically refers to when a joint is also inflamed and therefore painful, which is not guaranteed with joint changes alone. It is important to remember that because we are humans, and not objects, our joints are able to continue to adapt over time, even as we age - they do not simply ‘wear out’ over time (Anderson & Loeser, 2010). It is possible to be diagnosed with arthritis and never develop any further symptoms from it - it is not guaranteed to get worse.

MYTH: High impact exercise like running and jumping causes arthritis

This is a common misconception and so far has not been proven. Joint damage is a predictor of developing joint arthritis, for example tearing a meniscus or rupturing an ACL (Anderson & Loeser, 2010). General exercise, however, even more intense forms of exercise, do not specifically cause joint damage and therefore are not predictors of arthritis.

Observational data on runners shows that recreational runners have lower rates of osteoarthritis than people who don't run (Dhillon et al., 2023). Of those who have arthritis and are runners, less runners progress to needing knee replacements than non-runners. Observational studies checking the progression of pre-existing joint conditions such as meniscus tears or cartilage damage in marathon runners show that there is no progression of these conditions over the course of training for a marathon (Dhillon et al., 2023).

MYTH: Arthritis is wear and tear

The idea that arthritis is 'wear and tear' of the joints is also not entirely accurate. In fact, it is thought that arthritic joints are actually working extra hard to repair themselves, and going overboard (Arthritis.org).

Arthritis is more recently being thought of more as a problem relating to the entire joint, meaning it affects the soft tissues surrounding the joint as well as the joint itself. It is thought that the main contributor to developing symptomatic osteoarthritis is the presence of chronic low grade inflammation, which can be exacerbated by both modifiable and non-modifiable factors (Terkawi et al., 2022). That is, you can reduce inflammation with a healthy diet, reducing alcohol and smoking, and doing regular exercise; however this is only part of the picture and some health conditions or genetic profiles are more predisposed to higher levels of inflammation. Current research suggests the contribution of genetics to the development of arthritis is at least 50% (Spector & MacGregor, 2004).

Again this is important to know, as people are often discouraged to continue movement and exercise, fearing that it will further wear out the joint. Conversely, exercise is a way to reduce inflammation in the long term.

MYTH: Severity on imaging predicts symptoms

There is absolutely a place for imaging in the management of arthritis, particularly to monitor a joint over time, however research indicates that symptoms only match imaging findings some of the time. A systematic review found that people with arthritis visible on an x-ray had pain between 15-81% of the time, showing just how unpredictable the relationship between imaging and symptoms can be (Bedson & Croft, 2008). Best practice guidelines suggest that imaging should not be used in isolation, and rather a combination of imaging findings alongside clinical presentation is necessary when determining a management plan (Anderson & Loeser, 2010).

No two people are the same, and so it is important to recognise that a particular severity of arthritis on imaging does not directly match to what treatment is likely to be needed.

MYTH: Once you have “bone on bone” the only option is surgery

This ties in to the point made in the prior paragraph. Though it may sound as though if you have 'bone on bone' there is no way forward, the human body is actually quite incredible and not everyone with bone on bone experiences severe symptoms.

In our classes, for example, there are a number of people who have been told they have bone on bone in their knees. They were told this at ages varying between 40 and 70. Their symptoms range from mild stiffness and occasional discomfort; to moderate stiffness and regular discomfort; to severe pain and significant discomfort. Treatments have varied from exercise, to arthroscopies, to joint injections, to surgery. The outcomes of each have also been diverse.

It is not possible to predict one’s experience or future experience through another person’s, as there are so many factors influencing how each of us experience the same diagnosis. The language used by doctors and other clinicians can have a huge impact on patient perceptions and choices and as such i personally believe we should be very careful about the language we use - i personally try to stick with "normal joint related changes", "a little less cushioning than before", or "wrinkles on the inside" as opposed to saying things like bone on bone.

Beliefs can significantly impact treatment trajectories, which is why the language around these sorts of things is so important. For example, someone with 'bone on bone' who believes surgery is the only option for them may be more likely to go straight to that option, without trying anything else. Someone who hates the idea of surgery and has a favourable history with exercise might be more inclined to try exercising as a way to manage their diagnosis.

A large review of people with hip and knee osteoarthritis found that willingness to undergo surgery was the biggest predictor of one progressing to that option (Gustafsson et al., 2024). The same review also found that it was possible to delay or avoid joint replacement surgery all together for some people by taking part in a non-operative management plan consisting of lifestyle modifications and exercise.

MYTH: Knee arthroscopies help clean out the joint and slow down joint damage

Degenerative meniscus tears are very common. It has been explained to me by an orthopaedic surgeon to consider the meniscus like cushioning in a shoe. It gets thinner over time and may tear a little at the edges but it still works as a cushion and protects your foot from the ground. That is a great way, i believe, to think of our menisci over time. Once we are over 40, they will be a little thinner and a little less robust, but they can still do their job just fine. Going in and cutting it away causes trauma to the joint, and we know now that any joint trauma is likely to increase rates of arthritis later on.

This was demonstrated in this study comparing arthroscopy surgery to sham surgery (as in they went in with surgical probes but didn’t actually do anything), which found that outcomes in the short term for arthroscopy vs. non-operative management was the about the same, but that rates of arthritis were higher in the knees that actually underwent surgery 5 years later (Sihvonen et al., 2020).

I find myself saying often at work that things WILL get better if you just wait long enough (in most cases). Meniscus tears can be incredibly slow, but if you just wait it out, they generally get better on their own, it is just a matter of maintaining strength and function while they do. When i say 'get better', I mean the symptoms are likely to diminish; the tears don't generally heal on imaging. Again, the human body is great like this, there are likely lots of imperfections throughout your body that you are blissfully unaware of that don't hurt, so you don't know about them.

TRUTH: For some people, joint replacements are the best option

Even if you do everything right, unfortunately, sometimes joint pathology progresses to the extent that means joint replacement is the best option. While it is probably not advisable to jump straight to this as a treatment option without trying any non-operative strategies first, it is important to recognise that for some people, this is a viable and successful option. Joint replacement surgeries are most common in the hip and knee.

What can you do to help manage your symptoms of osteoarthritis?

Generally, exercise helps to maintain joint health by maintaining movement, and the more global effects of exercise on health markers are likely to have a positive impact on arthritis. Exercise also helps with maintaining overall function and ability.

Exercise is the main treatment we suggest for those with osteoarthritis, and we do specialised programs for our patients with hip and knee arthritis that focus more on these areas, while also including general full body strength and bone density maintenance. Lifestyle factors can also play a significant role.

If you are interested in having an assessment to start regular exercise & have some tailored lifestyle advice to help manage your osteoarthritis, book an initial physiotherapy consultation here.

References:

Anderson, S, Loeser RF. Why is osteoarthritis an age-related disease? Best Pract Res Clin Rheumatol. 2010 Feb;24(1):15-26. doi: 10.1016/j.berh.2009.08.006. PMID: 20129196; PMCID: PMC2818253. https://pmc.ncbi.nlm.nih.gov/articles/PMC2818253/

Bedson J, Croft PR. The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature. BMC Musculoskelet Disord. 2008 Sep 2;9:116. doi: 10.1186/1471-2474-9-116. PMID: 18764949; PMCID: PMC2542996. https://pmc.ncbi.nlm.nih.gov/articles/PMC2542996/

Dhillon J, Kraeutler MJ, Belk JW, Scillia AJ, McCarty EC, Ansah-Twum JK, McCulloch PC. Effects of Running on the Development of Knee Osteoarthritis: An Updated Systematic Review at Short-Term Follow-up. Orthop J Sports Med. 2023 Mar 1;11(3):23259671231152900. doi: 10.1177/23259671231152900. PMID: 36875337; PMCID: PMC9983113.

Gustafsson K, Cronström A, Rolfson O, Ageberg E, Jönsson T. Responders to first-line osteoarthritis treatment had reduced frequency of hip and knee joint replacements within 5 years: an observational register-based study of 44,311 patients. Acta Orthop. 2024 Jul 15;95:373-379. doi: 10.2340/17453674.2024.41011. PMID: 39007806; PMCID: PMC11249020.

Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Kalske J, Nurmi H, Kumm J, Sillanpää N, Kiekara T, Turkiewicz A, Toivonen P, Englund M, Taimela S, Järvinen TLN; FIDELITY (Finnish Degenerative Meniscus Lesion Study) Investigators. Arthroscopic partial meniscectomy for a degenerative meniscus tear: a 5 year follow-up of the placebo-surgery controlled FIDELITY (Finnish Degenerative Meniscus Lesion Study) trial. Br J Sports Med. 2020 Nov;54(22):1332-1339. doi: 10.1136/bjsports-2020-102813. Epub 2020 Aug 27. PMID: 32855201; PMCID: PMC7606577.

Terkawi MA, Ebata T, Yokota S, Takahashi D, Endo T, Matsumae G, Shimizu T, Kadoya K, Iwasaki N. Low-Grade Inflammation in the Pathogenesis of Osteoarthritis: Cellular and Molecular Mechanisms and Strategies for Future Therapeutic Intervention. Biomedicines. 2022 May 10;10(5):1109. doi: 10.3390/biomedicines10051109. PMID: 35625846; PMCID: PMC9139060.

Tim D. Spector, T, MacGregor, A. Risk factors for osteoarthritis: genetics11Supported by Procter & Gamble Pharmaceuticals, Mason, OH, Osteoarthritis and Cartilage,Volume 12, Supplement, 2004, Pages 39-44, ISSN 1063-4584, https://doi.org/10.1016/j.joca.2003.09.005.

How my personal experience with hypermobility and chronic pain led me towards physiotherapy

Sat, 30 Nov 2024 08:32:02 GMT

From dislocating her knees putting on her jeans to approaching her first 100kg deadlift, our physiotherapist Sarah talks about why she chose to become a physio, and why she is so passionate about supporting people with pain and hypermobility to learn safe ways to move their bodies.

I have a bit of an unconventional background for a physiotherapist.

I was a pretty inactive kid and always found exercise incredibly difficult growing up so would avoid it where I could – I remember mum trying to make me feel better about coming last in my first cross country when I was 5 – to be honest 5 year old Sarah didn’t understand the point of a race and it didn’t make sense to me that everyone was running (running did not feel good so why would people do that on purpose)- point being I wasn’t an exercise person.

In my teen years I had a few atraumatic dislocations – my kneecaps dislocated wearing tight jeans, and each of my shoulders dislocated at separate times when turning a lamp off, and taking off a jumper. (Strangely), I didn’t think that these were too problematic so didn’t seek medical advice. The kneecaps involved a lot of screaming but when my parents tried to move me they self-reduced (went back to where they’re meant to be) and the pain dropped off considerably. I don’t think I even told my parents about the shoulders, but they also luckily went back to where they belong with some panicked reflexive movements and I just pushed on.

In hindsight, this isn’t standard body behaviour, and is likely due to the fact that I am hypermobile – which means my joints can move further than most peoples are able to. Not all hypermobile bodies are the same and not all people are hypermobile for the same reasons. Some hypermobile people have no dislocations/pain, and others on the more severe end of the hypermobility spectrum may experience frequent dislocations and debilitating pain, among other symptoms that often coexist with severe hypermobility and related diagnosis’.

Anyway, I continued to hate and mostly avoid exercise until I was about 18 , when I was invited to try social futsal. For those who are not aware, futsal is like soccer but on a tiny court, so less running, which seemed alluring. I am super competitive, so made up for my lack of skill by throwing my body into people (I don’t recommend this because 1. It’s pretty bad sportsmanship which I didn’t realise at the time, and 2. It’s dangerous for everyone). Luckily, I only ended up injuring myself – I tore my meniscus (some cartilage in my knee) and the pain stopped me from putting weight on my leg, so off to the doctor I went.

The doctor referred me to a physio. I’d like to say this was where I became inspired to study physiotherapy but unfortunately not. I had no idea what a physios role was at the time, and when my pain wasn’t immediately cured I (ironically) decided that physio was rubbish and didn’t go back.

So instead of rehabbing my knee I limped around on crutches for a while, ended up overusing and hurting my other knee, and developed chronic bilateral knee pain that would not budge.

After about 6 months I realised I needed to do something about this because the pain was getting worse. I heard about Pilates somehow so signed up for a class and quickly became hooked. For the first time, I enjoyed exercising – the movements were slow enough and the load light enough for me exercise without bad pain/exhaustion/feeling completely uncoordinated, and I loved the feeling of exercising independently in a group setting. The type of Pilates I was doing was very low intensity strength training but because I was starting from ‘joints randomly dislocating sometimes’ level strength this was enough of a stimulus to get results. My knee pain improved a little bit, and my other random aches and pains weren’t as noticeable. The classes I went to were not based on the principles of progressive overload, and the same workout was used for all abilities, so it wasn’t the most effective exercise I could have been doing, but it was enough to start improving my strength and pain.

I became pretty obsessed with Pilates, and in my early 20s I decided it was time to turn things up a notch – exercise was making my body feel a bit better so I figured more would help further – which seems pretty plausible. Despite my best intentions, I didn’t have a solid understanding of the principles behind exercise so ended up underfuelling and overtraining to the point where my body had had enough. I was no longer making progress, things were starting to hurt more than they were when I began, and I was tired all the time. It got to the point where a five minute walk would leave me exhausted and I was napping 3 hours every day.

At this point, I wasn’t able to continue exercising, and my mental health absolutely plummeted. I realised how important movement was for mental wellbeing, and also came to the conclusion that I needed to learn a whole lot more about how to exercise safely and effectively . I tried google, but it seemed everyone had a different approach/opinion and many of these were limiting, contradictory and unsubstantiated. I did a bit of research on where I could find reliable information and decided that studying physiotherapy would help me acquire the knowledge I was seeking. Luckily I got in.

Almost everyone in my family has chronic pain, so prior to studying physio I didn’t think it was that unusual to have low grade body wide aches and pains everyday , and trouble carrying 3 litres of milk/feel the effort standing up after going to the loo in my 20s. I knew I was on the less fit side of things, but figured that the jump between where I was and where I wanted to be just required a bit more knowledge and ‘discipline’. I still didn’t quite realise that the way my body responded to exercise wasn’t the norm for most.

As I learned about exercise principles and progression, I tried to apply them to myself. The hardest thing was finding the right baseline to start off with and build from. I also needed to learn to manage my shoulder and knee pain. This took a lot of time/patience/trial and error, as due to my hypermobility, it was tricky to find movements that didn’t hurt. The appropriate baseline I needed to work from was significantly less than what the exercise guidelines recommend and what most people can typically tolerate . I tried and failed what ‘should work’ over again, until I gradually developed the understanding of how my individual body responded to exercise and what it needed for strength training to be effective.

Once I got this right, I was able to progress my strength training much more quickly. As I developed strength, my aches and pains became less frequent and intense , my knee and shoulder pains were no longer limiting during training sessions, and I just generally felt a whole lot better. I remember realising when it became easy to get up off the loo, carry groceries and walk uphill. Things got even better again when I started working with a coach (shout out to Michael Bates from Be You Coaching ) , who was able to further my knowledge again and show me where I could afford to push myself further – Because I would overshoot when I first began exercising, I tended to undershoot once I found my baseline, and working with Michael helped me to learn when and how to progress the weights I was lifting at a safe and tolerable but still effective pace.

I’m a bit of a major nerd If I’m interested in something. Because chronic pain and difficulty with exercise is something myself and much of my family has experienced, my curiosity went nuts when we began learning about pain during my physio studies. Pain science has rapidly evolved in the past few decades, and although we know much more than we did several years ago, healthcare’s collective understanding of pain and how to best manage it still has a way to go.

Due to the complexity involved with chronic pain, unfortunately there is no simple one-size-fits all approach to treating it – all bodies respond differently to different treatment approaches, and I find it really rewarding to work with people and help them solve their individual ‘pain puzzle’. There is always something new to learn about pain, and since graduating last year I have completed the Neuro-orthopaedic Institutes ‘Explain Pain on Demand’ course, recently attended a conference on understanding and conceptualising pain by the researchers at University of QLD’s Recover Injury Research Centre, and read several books by some incredibly clever people at the forefront of pain research (that my poor partner has had to hear all about) to continue to develop my understanding of how to effectively help others with pain. I am stoked to be able to work somewhere where keeping up with the research and providing evidence based, person-centred care is prioritised, and I hope to upload a blog post soon about some key takeaways about pain from these experiences – so stay tuned!

I am incredibly lucky to have had the support and opportunity to learn to self-manage my pain and improve my physical capacity. I’d like to point out that I was fortunate that my experience of chronic pain was only briefly preventing me from participating in things I found important and I had the resources to learn to manage it independently – I recognise that for many people, chronic pain is debilitating and consuming in all aspects of life, and unfortunately rarely has a straightforward one-size-fits all management approach. I am incredibly passionate about helping others learn how to develop their strength and fitness whilst managing and working with chronic pain, and feel my personal experience provides unique insight into helping people with hypermobility/chronic pain/low exercise capacity get started. It is such a privilege to help people discover their strength and see the change that gradually happens when they realise they can do something they never thought possible.

Sarah is available for bookings on our services page . You can also contact her at info@fkbphysio.com.

Osteoporosis myths

Wed, 30 Oct 2024 05:58:36 GMT

This month it was world osteoporosis day. It feels like as good a time as any to go through a few of the more common misconceptions we hear in our clinic around bone health.

Myth: Osteoporosis only happens to very frail/elderly people

Reality: This is not true. Though age is a major risk factor, it can affect anyone of any age.

For those who are over 50, it is estimated that > 66% of all Australians above this age have what is considered poor bone health. It is nothing to be ashamed of and does not reflect anything about your general health or frailty (Australian institute of health and wellness, 2020).

Stress fractures, which are common in younger athletes, can also be an indicator of poor bone health - it can affect people at any age & fitness level.

Myth: Osteoporosis means you are unfit/unhealthy

Reality: Osteoporosis is not a reflection on your overall health or fitness levels. In fact, some research has found bone density in endurance athletes such as long distance cyclists can be lower than that of sedentary individuals (Olmedillas et al., 2012). Many people who have osteopenia or osteoporosis have been exercising their whole lives and still end up with it. It is important to remember that so much of our bone health is determined from a young age, and that a lot of factors impacting bone health are out of our control. For example, people who are of a very small build are at more risk. This is something that we essentially have no control over.

Myth: You know whether you have osteoporosis or not based on how you feel.

Reality: Unfortunately osteoporosis is silent. There are no symptoms. It is essentially impossible to know whether you have it or not without a scan. This is not to scare everyone into having a scan by any means, but if you carry some of the risk factors (the most obvious risk factor being simply age) it is worth checking out, as we do with screening for numerous other health conditions.

Here is a (non exhaustive) list of risk factors for having poor bone health from the RACGP website:

Myth: Only women get osteoporosis

Fact: Approximately 30% of all healthcare spending relating to poor bone health in Australia last year was on men (Australian institute of Health and Wellness, 2023).

Myth: The only risk of osteoporosis is falling and fracturing a hip

Fact: Insufficiency fractures are also a risk with osteoporosis. That is, fractures that occur from very low load incidents when a fracture ordinarily should not occur (e.g. pushing hard against something). These are not “broken bones” in the way you may think of one; a bone is not snapped in half, rather, it is that the bone is compressed. In the case of a vertebral fracture, the vertebrae will ‘crush’ down and become shorter in size, often more specifically at the front of the vertebrae, leading to a loss of height and an increased forward curve in the spine. Unfortunately these types of fractures can occur in the absence of any falls.

Myth: You can’t change it: building bone density as an adult is impossible

Fact: This is not true, at least not for everyone. Research has found that it may be possible to build bone density for some people, even those over 50, even those with osteoporosis. The degree to which this can occur is fairly minor in the literature; for example the famous LIFTMOR trial (Watson et al., 2018) found an average of about 1-4% improvement in bone density with strength training which does not meet minimal clinical significance. However, this is only a very short period of time (8 months) and has promising potential long term implications (e.g. 1-4% a year over 20 years of strength training = ?).

There are also some case studies in the literature indicating significant improvement, and anecdotally we have seen similar.

For example, Meigh et al. (2022) completed research on older adults with osteoporosis lifting kettlebells and found a 12.7% increase in BMD in the spine and 5.9% at the femoral neck on one of their female participants. This piece of data alone disproves the idea that it is impossible to improve bone density after a certain age - though again, these results will not be the case for everyone.

Myth: weight bearing exercise, such a walking or yoga, is enough to improve bone density.

Reality: Unfortunately, though the term weight-bearing exercise is commonly used to refer to the type of exercise beneficial for bones, light exercise like walking or yoga does not cause adequate strain on the bones to facilitate improved bone density (Healthy Bones Australia, 2024).

Bones adapt to the load placed upon them. There needs to be adequate strain on the bone to cause deformation of the bone, which then leads to laying down of new bone cells. If there is not enough load on bones, they gradually become less dense over time. It is thought that the degree of loading on bones needs to be supra-physiological, that is, much bigger than normal day to day loads to facilitate new bone growth. Resistance training that causes large muscle forces that then pull on bones is a way to facilitate this (

Myth: Running improves bone density.

Reality: Some research has found that runners, and active individuals in general, are likely to have slightly higher bone density than their sedentary counterparts (Scofield et al., 2012). Endurance runners, however, may have lower bone density than sedentary people, likely due to the specific metabolic conditions caused by endurance sports that are inherently difficult for bone density maintenance (Scofield et al., 2012).

Running is considered moderate to high impact, meaning the forces going through your bones when your feet hit the ground may be 2-4 times body weight (REF). Though this is likely to be large enough to cause some bone deformation & therefore adaptation, the repetitive nature of running means that it is not as effective as more short/sharp doses of loading for bones, as the cells receptive to load in your bones tend to become desensitised after ~20 foot falls (Warden et al., 2019).

Observational research indicates that runners who participate in strength training or cross-train in sports that involve multi directional jumping and hopping have better bone density than those who dont (Warden et al., 2019).

Essentially, running is not a great form of exercise to build bone, due to its repetitive nature. Distance running in particular can at times be detrimental to bone health due to the specific metabolic demands of the activity. This does not mean running isnt good for you for other reasons, or that you should stop running; rather that if you are a runner, you may need to supplement it with other activities to protect your bone health, and that it is not likely to be worthwhile using as an exercise modality to build bone health.

Take home points:

R esistance training with progressively heavier weights is one of the best ways to reduce loss of bone density & potentially increase it in some cases; to reduce loss of muscle mass associated with ageing; and reduce falls risk. Having an adequate intake of food, meaning calories in general as well as enough protein & calcium is also necessary to protect your bone health.

We offer supervised group strength training for bone health - get in touch to get started.

Australian Institute of Health and Wellness. (25 August 2020). Osteoporosis. https://www.aihw.gov.au .
Healthy Bones Australia (2024), Exercise Prescription to Support the Management of Osteoporosis For Physiotherapists and Exercise Physiologists February 2024, https://healthybonesaustralia.org.au/wp-content/uploads/2024/02/hba-ex-presc-final-compressed.pdf
Neil J. Meigh, Justin W.L. Keogh, Wayne Hing, Effect of kettlebell training on bone mineral density in two older adults with osteoporosis: a multiple-case study from the BELL trial.
Olmedillas, H., González-Agüero, A., Moreno, L.A. et al. Cycling and bone health: a systematic review. BMC Med 10, 168 (2012). https://doi.org/10.1186/1741-7015-10-16
Scofield, Kirk L. MD, CAQ1,2; Hecht, Suzanne MD, CAQ, CCD1. Bone Health in Endurance Athletes: Runners, Cyclists, and Swimmers. Current Sports Medicine Reports 11(6):p 328-334, November/December 2012. | DOI: 10.1249/JSR.0b013e3182779193
Warden SJ, Edwards WB, Willy RW. Preventing Bone Stress Injuries in Runners with Optimal Workload. Curr Osteoporos Rep. 2021 Jun;19(3):298-307. doi: 10.1007/s11914-021-00666-y. Epub 2021 Feb 26. PMID: 33635519; PMCID: PMC8316280.
Watson, S. L., Weeks, B. K., Weis, L. J., Harding, A. T., Horan, S. A., & Beck, B. R. (2018). High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. Journal of Bone and Mineral Research, 33(2), 211-220. https://doi.org/10.1002/jbmr.3284

Exercise to support osteoporosis management

Tue, 27 Aug 2024 06:05:48 GMT

This year, healthy bones Australia released an updated position statement regarding the use of exercise to manage osteoporosis. This position statement was developed by an expert Working Group, Advisory Committee and a National Roundtable, and was released in February (2024).

The guidelines are here if you want to check them out for yourself.

In this blog, I will go over the major recommendations in this statement, as well as those made in similar guidelines that are available for the UK and Canada (as they are all slightly different).

At FKB Physio we use a combination of these guidelines alongside clinical expertise to design our programs for osteoporosis prevention and management.

DISCLAIMER: Please do NOT undertake any of the recommendations stated in this article on your own. There is an inherent risk associated with introducing exercise when you have poor bone health. The guidelines specifically indicate that exercise MUST be done under supervision. This article is NOT designed to be taken as medical advice.

What’s osteoporosis again?

If you want a bit of a refresh about exactly what osteoporosis and osteopenia are, you can click here.

Briefly, osteopenia and osteoporosis are words that refer to poor bone health. A diagnosis is made once your bone density declines past a certain threshold. It is often only once a diagnosis of either osteoporosis or osteopenia has been made that people start to work on their bone health. Knowing that bone health essentially peaks at 30 and then slowly declines from there , it makes sense to both aim to maximise peak bone mass early in life , and work to reduce the decline in bone density associated with ageing as much as possible. This means paying attention to things that are good for bones as early as possible and continuing to do so across the lifespan.

Exercise for osteoporosis management

Exercise should always be part of osteoporotic management as medications may improve bone density but do not have any impact on reducing falls risk or sarcopenia (loss of muscle mass associated with ageing), or other impacts of osteoporosis such as loss of height and increased curvature of the upper back (hyperkyphosois). The osteoporosis guidelines specifically state that resistance training and balance exercises should be prioritised. Exercise obviously also carries some pretty significant other benefits, in that it can reduce the impacts of other co-morbidities such as high blood pressure and diabetes, among others.

Additionally, independent of the relevance to osteoporosis and bone health, the WHO specifically recommends all adults participate in strength training at least twice a week. Less than 25% of adults in Australia currently meet these recommendations. This is something that is beneficial across the lifespan and I really do believe that encouraging all adults to take up strength training in a way that is enjoyable and sustainable for them is really, really important.

Exercise for bone health recommendations

I meet a lot of people who are very active and who have done their best to lead a healthy lifestyle and they have still ended up with osteoporosis, which seems very unfair!

Remember that even with your best intentions, this condition can happen due to non-modifiable risk factors that are out of your control. I believe in trying to control the elements you can control, where possible, and it is here that having a little more information about what types of exercise are likely to be the most beneficial to the bones may be useful.

Low impact exercise, such as mat pilates, walking, swimming, and cycling, will not have a positive effect on bone density (Kistler-Fischbacher et al., 2021). This is important to note as people often assume that the resistance offered with reformer pilates as an example is adequate, however, this does not appear to be the case. Running is also unfortunately not helpful for bone density - i will discuss why later in this post.

Osteogenic loading – what is it?

Osteogenic loading refers to loading that promotes bone growth or produces bone. During movement, the skeleton undergoes force from the muscles pulling on the bone, as well as ground reaction forces. Both of these types of force cause deformation of the bone or strain on the bone, which causes microdamage that stimulates the remodelling process (Warden et al., 2021).

A particular magnitude of bone strain is required to facilitate the production of new bone (Healthy Bones Australia, 2024). It is thought that bone strain that is of a high velocity and high magnitude, that is, is large and is performed quickly causes the most significant response and consequently most significant improvement in bone health. It would seem that exposure to load also needs to be low volume (i.e. not too many repetitions) as the mechanoreceptors that detect mechanical loading of the bones become saturated quickly (Warden et al. 2021).

As such, it seems that low repetition, low volume, high intensity doses of loading are the most effective. This translates to high muscle forces, i.e. lifting heavy weights, and high ground reaction forces i.e. impact loading (jumping).

Exercises such as running, while being relatively high magnitude, are not effective due to their highly repetitive nature that lead to decreased sensitivity in the mechanoreceptors. It is also important to note that the loads required to facilitate bony adapation need to be significantly higher than those caused by activities of daily living.

Bear in mind that the studies showing these findings are primarily animal studies and as such the results need to be interpreted with caution, however when we combine these findings with other research the findings become more likely, including:

Observational studies showing increased bone density in sports with multi directional fast loading such as tennis as opposed to those with repetitive same direction loading such as running;
Observational studies showing runners who strength train having higher bone density than those who don’t (Wardern et al. 2014)
Studies such as the LIFTMOR trial that show improved bone density with heavy low rep lifting in comparison to high rep light lifting (Watson et al., 2017)

We can be relatively sure that heavy lifting and high impact loading probably have some positive impact on bone health.

2024 recommendations (Healthy Bones Australia Position Statement):

1. Exercise prescription should follow general principles of osteogenic loading: The most osteogenic protocol includes low numbers of high intensity loads, including impact and resistance training

2. Exercise can reduce falls risk if performed > 3 hours per week and includes high level balance challenge.

3. Exercise for osteoporosis needs to include resistance training, balance training, and impact loading.

4. Exercise should be patient centred, with a focus more on how people can be active rather than messaging relating mostly to things that should be avoided.

5. Exercise interventions need to be tailored taking into account other co-morbidities.

The osteoporosis guidelines specifically state that resistance training needs to be progressive, which means that the weights need to progressively increase over time where possible.

These guidelines are fairly recent and quite a deviation from what was recommended historically for osteoporosis. Previously, high impact (i.e. jumping) and high intensity (i.e. heavy lifting) exercises were avoided in older adults and particularly those with osteoporosis due to the assumed risk of fracture it posed, however there have been few adverse events noted in recent studies using this type of exercise in participants with osteoporosis (Daly et al., 2020; Watson et al., 2017).

That said, it is very important that this is done progressively over time, and if any period of time is taken off exercise, it must be re-introduced very gradually again.

It is also VERY important to note that all guidelines suggest that this exercise should be supervised, as those with poor bone health do carry a higher risk of injury and as such exercise must be supervised and tailored by health professionals to minimise any adverse responses.

This is taken from Healthy Bones Australia website, you can find it here

Suggestion 1: Include high intensity resistance training minimum x2 per week

In this instance, the words ‘high intensity’ relate to heavy weights training. Australian guidelines for exercise for osteoporosis suggest lifting weights 75-85% of 1RM. 85% 1RM means a weight that is 85% of the weight you could only lift for one repetition, which should correlate approximately to a weight you could lift a maximum of 5-6 times. 75% 1RM is a weight you could lift about 10 times. Lifting weights at > 85% of 1RM is considered high intensity.

The recommendation in the Australian guidelines is lifting 5-8 reps for 2-3 sets at this weight. This is quite specific to our guidelines; the British guidelines suggest lifting weights of 8-12 repetitions going close towards fatigue (e.g. if instructed to lift a weight for 12 repetitions, this would be close to maximal; you would not be able to lift the weight 15 times); and the Canadian guidelines simply state it is beneficial to lift weights that progressively get heavier with no specifics around repetitions or intensity.

The number of reps prescribed in a program determines the weight – a 5 rep set should be heavier than a 12 rep set. In my experience, people dramatically underestimate the amount of weight they can lift and are hesitant to really push towards fatigue (understandably!) which means that commonly prescribing a 5 rep set will result in people lifting a weight 5 times that they really could lift for 10 reps, which isn’t really a worthwhile situation. Finding a balance between pushing towards heavier weights and lower repetitions and making sure people are actually getting a training effect from their session can be challenging and where supervision really is of benefit.

A way to check if you could possibly be lifting heavier is to check how many repetitions you are capable of doing at a given weight. So for example if you are doing 10 repetitions at a weight and don’t believe you could go any heavier, see how many reps you can do until you truly can’t do any more. If it is more than 2-3 higher than the suggested repetition range, you can probably increase the weight, but do less reps than prescribed.

E.g. you are advised to do 10 repetitions of a seated row at 20kg. You see how many reps you can do until fatigue, which is 15; so you increase the weight to 25kg, but only do 8 repetitions.

Real life application —> in our classes, we tend to use a variety of rep ranges with people. We tend to use lower reps, anywhere from 2-8 on squats and deadlifts. We use higher reps to begin with, then gradually reduce the reps as people become more confident with lifting heavier. As these exercises are usually performed first, and are amongst the biggest/hardest/use the most number of muscles, lower repetitions make sense.

We use 8-12 repetitions on exercises that are more isolated, but still cross multiple joints, such as seated rows or lunges, as this gives people more of a chance of actually reaching a degree of muscle fatigue and completing a number of repetitions at a weight that is truly hard for them. Occasionally, we include higher reps, often just for one program (6 weeks) before going down again. It is often this variety in repetitions that helps people develop a better understanding of what their body can do and keep things progressing over time.

Suggestion 2: Impact loading minimum x3 per week

Impact loading refers to jumping and leaping type of exercise. For those who are safe to do so, the guidelines suggest 50 impacts done in shorter blocks done at least 3 days per week. The guidelines state that landing with a force of 2-4x bodyweight is considered moderate impact, which is that which is experienced landing from a jump or hop. It appears that impact loading of more than 2x bodyweight is required to facilitate a bone density adaptation.

Both the British and Australian guidelines recommend this, with a recommendation of 50 impacts per day on most days if possible. Ideally, these impacts would be of varied velocity and direction - for example, 1x10 jumps on the spot, 1x10 hops on each leg, 1x10 lateral leaps side to side, 1x10 jumps forward and backwards, 1x10 jumps side to side, to maximise sensitivity of the mechanoreceptors to different types of loading.

For runners, it is recommended to leave it at least 6 hours between running and doing the jumping, as this is about how long it takes for the bone cells to ‘reset’ and become sensitive to load again (Warden et al., 2021).

Landing from a height (e.g. jumping off a step) is considered high impact and is not be recommended for those at higher risk of fracture, but may be of benefit for people without osteoporosis (Brooke-Wavell et al., 2022). The UK guidelines suggest that anyone with a vertebral fracture or a history of multiple insufficiency fractures in the lower limb should be very cautious about even moderate intensity impact loading. In this case, lower impact loading such as brisk walking is considered a safer choice.

Deciding whether to include impact loading is something to be discussed on a case by case basis with the input of a health professional. I STRONGLY DISCOURAGE anyone with any bone health concerns to take up impact loading without specific guidance.

Suggestion 3: Postural & “spine health” training

The next recommendation is around exercises that promote good strength and stability in the muscles that support the trunk. While these muscles are engaged with some of the larger exercises already described like squats and deadlifts, including some targeted movements for these muscles is reccommended, particularly to minimise increased curving of the upper back that is common with osteoporosis. The recommendation is to include these at higher repetitions, 3 sets of 10-15, a minimum of 2x per week.

In our classes, we include things such as plank holds, back extensions, overhead shoulder press, prone T lifts, prone thoracic lifts, to cover this recommendation. Essentially exercises that encourage using the upper back muscles and shoulder blade stability muscles and encourage keeping the upper back as straight as possible.

It is important to note that for many people it is NOT POSSIBLE to have a straight upper back! The upper back is naturally curved (it is called kyphosis, and it is normal). Many people have an increased kyphosis naturally, and particularly those with osteoporosis are likely to. So it is important to note that the recommendation is to TRY and keep the spine as straight as possible, to facilitate these muscles engaging, as opposed to actually keeping it straight, as this will not be achievable for many.

Suggestion 4: balance training

The next recommendation is that exercise that challenges balance can be effective in falls prevention but it must be performed 3+ hours a week to be effective. While this sounds like a lot, it is important to note that lots of things count as exercise to improve balance. For example, performing lunges, or jumps, counts as balance exercise, as they involve a reduced base of support, and working to control a landing. Strength exercise also is beneficial in improving balance, generally.

For people at particularly high risk of falling, introducing some more specific balance exercises like walking forward/backward/ standing on one leg/ etc may be of benefit, more benefit than to people who are at a higher level of function. This is because it is unlikely that they are performing exercises targeting other areas (strength, cardio etc) that are challenging enough to benefit their balance.

Suggestion 5: patient centred

Finally, as obvious as it sounds, it is important for exercise to be tailored to the individual. We are always dealing with people who have concurrent diagnoses such as pelvic floor dysfunction, osteoarthritis, neurological conditions, injuries, post surgeries, etc, that mean these recommendations need to be tailored.

There is always a starting point, and an entry point, to exercise, for every body.

At FKB Physio we pride ourselves on being able to figure out what works for you and gradually build from that point. If you are interested in getting started, book an initial appointment with any of our physios.

Beck, B. R., Daly, R. M., Singh, M. A., & Taaffe, D. R. (2017). Exercise and Sports Science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis. J Sci Med Sport, 20(5), 438-445. https://doi.org/10.1016/j.jsams.2016.10.001
Beck, B. R. (2022). Exercise Prescription for Osteoporosis: Back to Basics. Exerc Sport Sci Rev, 50(2), 57-64. https://doi.org/10.1249/jes.0000000000000281 https://doi.org/10.1002/jbmr.3865
Brooke-Wavell K, Skelton DA, Barker KL, et alStrong, steady and straight: UK consensus statement on physical activity and exercise for osteoporosisBritish Journal of Sports Medicine 2022;56:837-846.
Daly, R. M., Gianoudis, J., Kersh, M. E., Bailey, C. A., Ebeling, P. R., Krug, R., Nowson C. A., Hill, K., & Sanders, K. M. (2020). Effects of a 12-Month Supervised, Community-Based, Multimodal Exercise Program Followed by a 6-Month Research-to-Practice Transition on Bone Mineral Density, Trabecular Microarchitecture, and Physical Function in Older Adults: A Randomized Controlled Trial. J Bone Miner Res, 35(3), 419-429. https://doi.org/10.1002/jbmr.3865
Kistler-Fischbacher, M., Weeks, B. K., & , B. R. (2021). The effect of exercise intensity on bone in postmenopausal women (part 1): A systematic review. Bone, 143, 115696. https://doi.org/https://doi.org/10.1016/j.bone.2020.115696
Kistler-Fischbacher, M., Yong, J.S., Weeks, B.K. and Beck, B.R. (2021), A Comparison of Bone-Targeted Exercise With and Without Antiresorptive Bone Medication to Reduce Indices of Fracture Risk in Postmenopausal Women With Low Bone Mass: The MEDEX-OP Randomized Controlled Trial. J Bone Miner Res, 36: 1680-1693. https://doi.org/10.1002/jbmr.4334
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Osterhoff, G., Morgan, E. F., Shefelbine, S. J., Karim, L., McNamara, L. M., & Augat, P. (2016). Bone mechanical properties and changes with osteoporosis. Injury, 47 Suppl 2(Suppl 2), S11-20. https://doi.org/10.1016/s0020-1383(16)47003-8
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Watson, S. L., Weeks, B. K., Weis, L. J., Harding, A. T., Horan, S. A., & Beck, B. R. (2018). High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. Journal of Bone and Mineral Research, 33(2), 211-220. https://doi.org/10.1002/jbmr.3284
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Osteoporosis: What is it and why should I care?

Mon, 26 Aug 2024 11:57:42 GMT

Prevalence

Osteoporosis Australia estimate that in 2022, 6.2million Australians over 50 have osteoporosis, osteopenia, or poor bone health, which is 66% of all Australians over 50. Of these people, 22% have osteoporosis and 78% have osteopenia. It is estimated that 29% of health system expenditure on falls can be attributed to low bone density (Australian institute of Health and Wellness, 2023), and that osteoporosis and osteopenia cost the Australian healthcare system $2.75 billion annually. Though osteoporosis is thought to be something that primarily affects women, this is not to say that men are completely unaffected: men account for approximately 30% of osteoporotic fractures recorded.

What is osteoporosis/osteopenia?

Both of these conditions are diagnoses that are made based on your bone density, which is determined through a DEXA scan.

The official diagnosis according to the WHO is made based on your T score, which is a measure of your bone density relative to an average healthy 30 year old person of the same sex. This is calculated based on how many standard deviations you are away from that person. If you are more than 2.5 standard deviations away from the 30 year old, you are considered to have osteoporosis. Being between 1 and 2.4 standard deviations away is osteopenia. Any better than this is considered normal.

For people under 50, a T score is not used, rather a Z score is used which shows how far you are away from other people of your age and gender (Beck et al., 2017). This is likely because a T score is unlikely to be as sensitive at younger ages, that is, less able to detect an issue comparing to younger person so is more accurate comparing to your peers. Sometimes, on your scan you may see both the T and Z score. For example, I have had a patient in her 80s who had a T score of -1.2 that only just saw her into osteopenic range, which actually placed her above normal for her age, as seen with her Z score, which was +0.5. All of this is to say that these numbers are relevant, but are all recorded as relative values rather than set figures to aim for.

Osteoporosis is SILENT

Osteoporosis is silent, in that it has NO symptoms. A lot of people don’t know they have it until they have had a fracture, either from a fall, or from what is known as a “low trauma incident”, such as falling from standing height, or stepping down hard from a curb. There is no ache in the bones or joints, and no indication that you can feel that your bone density is low. I think this is an important point to make as patients often do not know this and believe that if they do not have pain, their bone density must be fine, and as such are not aware it may be something they should be checking. I always make sure to go through the difference between osteoporosis and osteoarthritis with my clients when they have a diagnosis of either.

Diagnosis is made by DEXA, but DXA is not perfect

DEXA scans are the current gold standard for bone density checks, however, there are issues with their accuracy.

There are DEXA Scans that look at whole body bone density, but it is particularly important to look at the bone density of the lumbar spine and hips as they often show lower scores, earlier, and as such are more sensitive to detect a decreasing density. Using whole body T scores is likely to underdiagnose osteoporosis or osteopenia (Rajaei et al., 2016).

DEXA scans are known to be relatively inaccurate. You are advised to get their scan at the same place every time. There are inaccuracies between pieces of equipment, brands, and also from practitioner technique. Going to the same clinic has the best chance at being accurate, and even then, a clinically significant difference is considered to be 4% change in bone density or more, anything less can be put down to measurement error.

A DEXA scan is also only a part of the story. The actual architectural structure of the bone is also important, a feature which is not represented by your typical bone density scan. Belinda Beck warns in her 2022 article that a DEXA does take into account all aspects of bone health such as cortical thickness of the bone. It is thought that BMD accounts for only 60% of the actual profile of bone fragility as it cannot measure changes in structure or bone material composition (Osterhoff et al., 2016). There are also certain conditions such as severe osteoarthritis can also affect the accuracy of the scan. Osteoarthritis makes T scores higher due to the additional bone that is a feature of the condition. So it is common to see people with a high T score in their spine but a very low T score in their hips, which is often more likely that their spine is osteoarthritic rather than that their hips are substantially worse.

Just a personal anecdote, my patients who have had low trauma fractures from have at times been women in their 50s with osteopenia, yet a lot of my clients in their 60s and 70s with osteoporosis have never had them. This is indicative of the DEXA scan being able to tell us one thing (BMD/T score) but not the whole story (bone architecture and general strength otherwise).

Despite these flaws, DEXA scans are a worthwhile screening tool to capture people whose bone health is declining, which is important as earlier detection allows for earlier interventions.

Management of osteoporosis

Everyone with osteopenia or osteoporosis is managed a little bit differently because everyone’s case is different. For example, a fit 60 year old with osteoporosis may be managed differently to a more frail 80 year old who has had a number of falls. This is particularly true when it comes to medical management of the condition.

There are a number of medications available on the market for osteoporosis, some which work to reduce the activity of bone break down, and others which work to increase the regeneration of new bone. Some names you may have heard are prolea or zolendronic acid, or the word bisphosphonates. There are newer ones coming out all the time. There are some reasons for and against medication that mean not every person with osteoporosis will be advised to start them straight away. There is somewhat limited data on the effect of the medications in the longer term (more than 10 years) (Hinton et al., 2015). Medication can be quite effective at reducing fracture risk, with some studies stating they can reduce fracture risk by up to 40% in the hip and 70% in the spine (Hinton et al., 2015). There are a number of potential side effects that are brought up and this is entirely a conversation to be had between a patient and their doctor.

Vitamin D and calcium are also important in the management of this condition and once again a conversation of whether to supplement these or not is something that is considered on an individual basis and is not within my or our scope to discuss. I will say that the guidelines set by osteoporosis Australia do not recommend supplementing vitamin D or calcium for people without diagnosed deficiencies, however, this is different to guidelines in other countries. It is best to consult with your GP about your specific situation.

The Canadian guidelines have a flow chart that is really useful to look at when considering the potential benefit of medication in the management of osteoporosis - you can check them out here and scroll down to page 4.

Lifestyle changes to reduce risk

There are lifestyle modifications that promote bone health. Osteoporosis Australia has released a set of guidelines that apply to post -menopausal women and men over 50:

Adequate calcium and protein intake
1300mg a day of calcium and 1g per kg of body weight of protein (this is A LOT of calcium - could be worth tracking your intake for a day and seeing how close you get)
Adequate but safe exposure to sunlight as a source of vitamin D
Avoid smoking and excessive alcohol consumption (considered more than 2-3 drinks a day)
Participate in progressive resistance training and balance training exercise 2-3 days. Per week, moderate to vigorous, varied, and designed to reduce fracture and falls risk, as well as treat sarcopenia.

Exercise in the management of osteoporosis

All osteoporosis guidelines that I have come across recommend exercise as a pillar of bone health management, not just to improve bone density but also to reduce falls risk.

I believe that all adults who have the means to do so would benefit greatly from resistance training. If you have a bone density concern, it is really important to consult a healthcare professional who specialises in the area to help guide you towards a safe and effective program. If you don’t have any bone density concerns that you know of and are otherwise fairly fit and healthy, taking up strength training is probably one of the best things you can do. It is never too late to start, but the earlier you start the better!

If you want more specific information about exercise to manage osteoporosis, check out this blog post (coming soon!)

References:

1. Beck, B. R., Daly, R. M., Singh, M. A., & Taaffe, D. R. (2017). Exercise and Sports Science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis. J Sci Med Sport, 20(5), 438-445. https://doi.org/10.1016/j.jsams.2016.10.001

The dark side of 'fitspo'

Thu, 25 Jul 2024 07:16:13 GMT

The "no excuses!" rhetoric might be motivating for some, but it can be damaging for others

I work as a physiotherapist. I run my own business where we focus primarily on encouraging people to become more physically active where possible.

I go to the gym on the reg and work as a group fitness instructor. I exist in a lot of fitness/wellness/health spaces.

What I notice is that the exact traits that are generally applauded in this area - being highly self-disciplined, goal-oriented, consistent, having a high attention to detail, etc - and the types of messages often used to motivate people to move more (’no excuses!’ Etc) are the EXACT things that can have a negative impact for some.

It is true that the majority of the population is not adequately physically active. But there is a small group of the population that is quite the opposite. These people often need encouragement and permission to do LESS, not more, and are likely to hear exercise motivation narratives as encouragement to keep doing more and more and more.

I know this, because I probably am one of these people.

I got pretty seriously into exercise when I started going to the gym regularly when I was 17. I decided to become a Body Attack and Body pump instructor in 2007, mainly because I wanted access to the music and to be able to pick my own fun mixes to teach. Becoming an instructor meant the technique and fitness focus was ramped up. For the first time in my life I felt really fit, and started to identify more with someone who was a ‘gym/fitness person’.

After a few years of instructing, I felt like I needed a way to measure my progress, having always been a pretty goal-oriented person. Running seemed like a good option as it has clear metrics of progress like distance and speed associated with it.

This sent me on a 3 year not-so-love-affair with running, where I entered 10 or so half marathons, finally hitting my goal of doing one at a speed goal I had set for myself. Despite achieving this goal, I was surrounded by people (mainly men) who could run much faster than me, so I was not really happy with my time. I decided I needed to do something harder - a full marathon!

I trained consistently for the marathon, took it very seriously, sacrificed lots of social events and gave up alcohol for the 3 months in the lead up. I recall enjoying the long runs as each one gave a sense of achievement of a new distance unlocked, but I remember being upset to the point of crying pretty regularly on any shorter runs I did in an attempt to improve my speed.

Of course this attitude gradually made me HATE running. I finished, ran the vast majority of the way, but the experience was essentially so unenjoyable I quit running and have barely done any in the 10 years since.

I decided to swap straight into another goal oriented, numbers focused sport - powerlifting.

As a ‘newbie’ powerlifter, progress is almost guaranteed and you can make lots of gains in your first few years. I was no exception and I enjoyed a continual sense of progress and achievement through my first ~5 years of lifting. Inevitably, as stress levels ramped up running my own business, and probably also in part due to reaching my mid 30s, progress slowed down. Things started hurting, and old injuries kept coming back to haunt me. No more newbie gains. I trained for a competition and essentially did no better than a year before, but did manage to hurt myself multiple times in the process, as well starting to become increasingly fed up and frustrated.

I started hating when people would ask me how my training was going, or what I was aiming for.

After a year or so of constantly pushing it and getting nowhere, I recognised that continually trying to progress at this thing that kept hurting me (literally and figuratively, in the context of my life at that time), I needed to back off and just chill.

Over the last 12 months, I have been attempting to simply enjoy the process of training and avoid attaching any achievement or goals to it.

It has been a strange time, as without making any real clear progress in any measurable way in the gym, I have noticed that it is less exciting, and there are no real ‘highs’. I have questioned whether I even like the type of exercise I am doing numerous times.

Exercise is good for you. Strength training and cardio are both really important to maintain fitness and health and longevity. These things are true. But balancing the truth of these against an internally driven NEED to exercise in order to achieve a certain outcome is definitely a challenge that I suspect is a lot more common in the health and fitness space than people on the outside of it would realise.

On the plus side, lately, I have had a few moments of doing exercise that I cannot measure in any form where I noticed that I really enjoyed the feeling of my body moving. And I realised it has been a LONG time since I had felt anything like that - enjoyment exercising simply because I am moving my body and it feels good, no pressure to achieve anything in particular.

I have also been working on being more flexible. When training for goals I have set myself, I tend to follow a set training program to the T and never miss a session, regardless of how I feel or what else is going on. The idea that you should ‘never miss a Monday’ in the gym (common social media fitspo rhetoric) is not helpful. I actually have done the exact opposite and set Mondays as my rest day, as I find training on Mondays makes me feel rushed, tired, and gross trying to fit it in before the first work day back after the weekend.

The exact things that often are applauded as positive traits in the fitness industry: commitment, not missing sessions, continually striving for more, always setting higher and higher goals, training even when you don’t feel like it, etc, are most likely helpful for people who struggle with consistency and setting a habit of exercise, but I find they are pretty unhelpful for those of us who feel bound by our own rules around not skipping workouts.

I see it in my clients, who have personalities similar to me, that are unable to see when they are over-doing it and probably need to pull back something in some way, because they cannot see past themselves as a fit/busy/high achieving person. Our society glorifies this hustle/ single-minded/ goal-driven mindset SO MUCH. I think its important to be honest about how it does not always serve us well.

It can be a massive barrier to getting better after an injury, or for those people who are trying to manage a chronic health or pain condition. It can feel like we are losing control or losing who we are, but it is often actually a giant barrier to general well-being that is not really servicing us the way we might think it does.

I think its important to talk about this stuff, because I almost never see this type of content on social media or in the gym space. Rather, it is simply people telling you to work harder, and do more, or show how much progress they have made. While that can be great, and motivating (and I do it too, all the time, honestly), I just wanted to talk about a different side of ‘fitspo’, that encourages listening to your body and giving yourself a break sometimes.

Frances

What are the best shoes to wear for running, or for the gym?

Tue, 13 Feb 2024 06:22:54 GMT

A common question that comes up for me in the clinic as a physio, as well as in my group strength classes and at my body attack classes is:

What shoes should I be wearing for _____?

First and foremost, I think it is important to mention that there has been a Cochrane systematic review (highest possible level of evidence) that covers this topic, specific to runners and running injuries. This review found that no type of footwear is better than any other in preventing injuries (from running).

You can check out this study here:

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013368.pub2/full

Now information like this is often quite difficult to implement in the clinic, because you know as well as I that for you as an individual there will be shoes you have worn that feel GREAT, and others you have worn that feel TERRIBLE. Research is quite poor at reflecting this, and as such it can be easy to disregard. But what I take this to mean is simply that you cannot generalise advice to an entire population (e.g. statements like ‘the best shoes for running are ______’ are likely to not apply to everyone) and rather that what suits you as an individual is more important.

So my first piece of advice is this: choose a pair of shoes that feel really comfortable for you, as this is most likely as accurate a measure of what is going to work for you as anything else that the shoe store person etc might say.

** note: i am not a podiatrist, who are the experts in this space. If you have foot pain or any major issue with your feet then you should consult a podiatrist for more tailored advice. **

Barefoot shoes: are they better for you?

It is true that wearing no shoes, or barefoot shoes, will demand more work of your foot muscles. It can be argued that this is preferable to being reliant on super highly cushioned shoes, and could be better for your feet in the long term.

HOWEVER.

It requires a LOT of time to get used to this type of footwear. Because we spend so much time on our feet, and our entire body weight is resting down upon them, feet are very sensitive to any changes in footwear.

If you do wish to move towards less supportive shoes, it needs to be done extremely gradually.

For example, I used to wear off the counter shoe inserts to work, as I got plantar fasciiopathy immediately upon starting full time work and standing all the time (yes, at 21, lots of things are not a feature of ‘getting old’ but rather of introducing something new too suddenly). I can now tolerate barefoot shoes at work, but I would say it took a number of years to get here, and I still can’t wear barefoot shoes for more than a day or 2 in a row or I will start to feel that tell-tale lump under my foot start to reveal itself again.

A suggestion of how to gradually work your way into less supportive footwear is to have a few pairs of shoes on the go, and swap into the minimalist shoes for just a few hours here and there per week.

If you are thinking of wearing these types of shoes for something more than leisure wear, keep reading for my thoughts.

Shoes for running and other repetitive high impact activities (e.g. aerobic classes such as body attack)

You have probably heard two completely different narratives regarding the best types of shoes for running:

Shoes with less cushioning are better as they mimic barefoot running which is more natural. This is more likely to reduce injuries in the long term.
Shoes with more cushioning are better as they support your feet. This is more likely to reduce injuries in the long term.

No wonder people are confused when there are these conflicting types of messages out there!

Wearing barefoot shoes for impact exercise requires magnitudes more strength and conditioning of the foot to be able to handle it, compared to wearing this footwear for leisure only. It is probably preferable to aim for the least supportive shoes you can get away with, to promote as much strength of your feet as possible. This is unlikely to be barefoot shoes for most people, but it may be shoes with a lower drop (less of a steep decline from the heel to the toe) and a bit less cushioning that you have worked your way up towards being able to tolerate.

If you are looking to take up running or another form of high impact exercise for the first time, it could take MONTHS and MONTHS to build up adequate resilience to tolerate minimalist footwear and most people will find that more supportive shoes help support them to take up the new activity more quickly with fewer issues.

Research also indicates that having a couple of pairs of running shoes at once and alternating between a newer pair and an older pair is a great way to reduce your risk of injury, as it is common for something to start hurting as your shoes start to get older. This is not ‘proof’ that supportive shoes are in fact better for you, rather, that running on shoes that are becoming less cushioned is something you body is not used to, and doing lots of mileage in conditions you aren’t used to is often how overuse injuries quickly develop.

Rotating your shoes (e.g. newer shoes for longer and high intensity/speed sessions; older shoes for shorter and slower runs) is a great idea.

You can check out this study here: https://pubmed.ncbi.nlm.nih.gov/24286345/

Shoes for lifting weights

Resistance training is the ideal time to work on your foot strength, which is great, as wearing very flat/minimalist shoes to weight train is also optimal for performance in this domain.

Wearing big, cushioned running shoes for lifting weights is not really advised for a number of reasons.

First of all, it is because it is less stable. Lots of exercises, such as lunges and squats, require lots of ankle stability, and this is much trickier when balancing on a soft 2cm cushion of foam!

Second, highly cushioned shoes do not allow for as much proprioception, i.e. the ability to feel the floor under your foot, something which is necessary for stability and performance. A tip I often use with people is to try and think of the 3 points on their foot (ball of foot, outside of top of foot, and heel of foot), and try to ‘grab’ the floor underneath these 3 points. This is a great way to set up a stable base for exercises such as squats, lunges, or deadlifts, and is much easier when you are able to feel the floor easily.

Third, if you are lifting heavy, pushing down through centimetres of cushioning wastes energy. It is much more efficient to simply drive straight down into the floor to generate force than it is to push through a cushion first.

Fourth, if you are deadlifting, cushioned shoes bring you further away from the floor, meaning you need to reach further down to lift up the bar, which is less efficient.

Finally, using barefoot or minimal shoes while strength training is a great way to improve the strength in your foot in a way that is unlikely to overload it (for most people) as it is not super repetitive or long in duration.

These Saguaro shoes are GREAT value and what I have been using lately:

https://www.saguaro.com/products/luck-1

Caveat

Bear in mind, EVERYONE is different, and some people NEED very supportive shoes and orthotics. As always, it is impossible to cater to all needs in a blog post!

I recommend consulting your physio, EP or podiatrist if you are unsure about any of this and how it relates to you, and as always, this is NOT intended as medical advice.

Take home points

No shoe is ultimately superior to any other in terms of injury risk reduction
It is personal preference as to what type of shoes you feel are the most comfortable
Minimalist/barefoot shoes will take longer to get used to than cushioned shoes
Cushioned shoes may provide an easier base for getting into high impact exercise
Flat shoes are likely to be better when lifting weights (for performance)
Everyone is different and there is no hard and fast right or wrong when it comes to shoes

Thanks for reading,

Frances

Sports & Exercise Physiotherapist

New to the gym? Here's some tips to help you feel at home

Sun, 13 Aug 2023 03:51:18 GMT

As part of my job, it is common for me to introduce people to the gym who may have never stepped foot in a gym in their lives before. I understand that it can be very daunting to step into a gym, let alone onto the weights floor if this is new to you.

I noticed that a lot of things that seem obvious to me in a gym setting are not obvious at all to people who are new to training, so I thought I’d compile a list of common ones and share them with you.

How to take the clips on and off

You push down on the little bit (often, but not always, a different colour) in the middle of the clip while pulling up on the clasp part. Hard to describe in words, check out the video!

How to add up how much weight you are lifting

You add up the weight of the barbell plus the weight of the plates. Remember most barbells are 20kgs. Some are 15kgs . It will sometimes say on the bottom of the bar, like on the circle part on the end, but if not you can tell by the thickness. 20kg bars are consistently the same width - after a time you’ll (hopefully) start to get a feel for which is which.

On weights machines there can be a lot of variation and it is more realistic to track your weights relative to the same machine every time, not different machines across different gyms, as the machines themselves often weigh different amounts making it hard to add up accurately.

How to structure your workout (within a session)

In general, big or ‘compound’ exercises will be early on. These are exercises that use lots of muscles at once and are tiring e.g. squats, deadlifts, bench press, overhead press. The workout will then move to more isolated movements that use less parts at once, e.g. side raises, bicep curls, knee extensions. If you are brand new to the gym, it would be very helpful to get someone else to write a program for you, or buy a template online.

How & why to warm up for lifting weights

Warm up sets are to warm your body up for the exercise you are about to do, but also to build up to the weight you intend to lift.

If you are lifting a weight that is not that heavy for you for 12-15 repetitions, you probably don’t need to warm up - lifting the weight is the warm up. However, if you are intending to lift a weight that is heavy for you, and for a small number of repetitions, you will need to warm up.

For e.g. if you are capable of deadlifting 60kg as a maximum weight, you may do 5x30kg, 3x40kg, 1x50kg as warm ups before working with 60kg. The heavier it is, the more warm up you need, however again this will depend entirely on you and your experience level.

Usually you would do large compound exercises at the start of the session and warm ups matter a lot here (eg deadlifts, back squats etc). Later when doing more isolated exercises you are likely to go higher rep and may be able to go straight to your working weight (eg seated rows, lateral raises). You may not need any warm up sets for exercises later in the workout that are high repetition.

As with everything it depends also on experience and how certain you are you can do a given weight - this makes knowing how many warm up sets you need etc more definite.

Everyone needs to build up to a heavy first exercise but with more experience you may be able to start heavier & make bigger jumps. No one is turning up and squatting their max weight with no warm up!

Warm ups help get your body prepared for the exercise, so they reduce risk of injury but also make it more likely that you’ll be able to actually lift the intended amount.

How long to rest between sets

If you want to really get stronger, you should be lifting heavy enough that you couldn’t do the same weight again 30 seconds later.

If you’re going near a max effort lift for 1-2 reps you may find you need up to 5 mins to repeat it. Doing 5-6 reps you may need 3 mins or so.

The most effective way to convince yourself of the truth of this - do something you find super hard (eg chin up) and try to repeat it 30 sec later … then wait 5 mins and try again. Once you’ve felt the difference that extra recovery makes, you won’t need to be convinced!

A way to make your workouts go a bit quicker is to superset upper and lower body exercises together so that you can rest one body part while working another. In this way, you may be taking 2-3 mins rest between working one part of your body, but you don’t need to spend it sitting and doing nothing. When going really heavy, however, like with your first exercise of the day (usually a big compound lift) and you are trying to build strength, it is probably better to just sit for 2-3 mins between rounds (if you have time).

How many sets and reps to do

Reps = how many repetitions of an exercise in a row

Sets = how many rounds of that exercise

E.g. 5 sets of 3 reps = 5 rounds with 3 repetitions in each.

How many sets and reps you have been given for an exercise as part of a program is not arbitrary. If you are doing less reps, you should be going heavier than when you are doing more reps. If your program says to do 3 reps, for example, there is no real point doing 3 reps of a weight you could do for 10. A way to think of this is ‘reps in reserve’, which is how many repetitions you think you could do if you had to keep going. So, if you are programmed 10 reps, you lift a weight you could do for 12/13 reps, but not 15. A good way to check if you are on the right track is to see how many reps you can actually do of the weight you’re lifting (go until fatigue, like you cant do any more) and see how close you are. In my experience, women tend to hugely underestimate their weight selection!

Sometimes my clients say things like, ‘you programmed 3x10, so I’m doing 30 reps, I just did them all in a row’. T echnically this should not be possible; you should be able to do about 12-13 reps only of that weight, then need to rest a solid minute or two before doing It again.

How many sets and reps to do for each exercise is very dependant on your goals and how frequently you train and is outside the scope of this blog.

How to structure your workouts across a week

If you are exercising 2 days a week it makes the most sense to do a full body workout both days and allow a few days rest in between. The more days you train, the more you can separate out what you work on. Just as a general rule of thumb, targeting each muscle group twice a week as a minimum is ideal, so consider this when deciding what to train when. Doing just upper body and lower body training splits does not make sense if you are only training twice a week, but can make sense if you are training 4-5 times per week.

Whether it matters if you can feel a muscle working or not

It does not matter if you can’t feel the muscles working that you are supposed to be targeting. Being able to feel it I think comes with practice, but it is not necessary to see benefits. For compound exercises, that is, exercises that use lots of muscles at once (e.g. squat, deadlift) you will almost certainly not feel any particular muscle working. For isolated exercises, such as the knee extension machine, you almost definitely will feel your muscles working. Neither is better than the other, it is just that one uses so many muscles at once it is unlikely to cause a real ‘burn’ in any.

If you are feeling confident with how to do a particular exercise and are interested in feeling where it is working, you can think about the muscle it is intended to target, and intentionally try to picture the feeling of that muscle working (will feel like warmth). Over time you are likely to get better at noticing, though again this isnt necessary especially in the rehab sphere (more important for performance e.g. bodybuilding).

What shoes are best to wear

If you are lifting weights, wearing very flat almost barefoot shoes (or training barefoot) is probably ideal. This is becuase you are not losing energy pushing into the squashy soles of your running shoes, and you are likely to be more stable in flat shoes that you can feel the floor in. It may also help to strengthen the muscles in the underneath of your feet.

If you are running or doing something with lots of jumping, it is ultimately your preference of what shoes to wear. Cushioned shoes are not necessarily better, but bear in mind the less cushioning the longer it may take to adapt to a new activity.

Film yourself to check your technique (if your gym allows it)

Some exercises are pretty technique heavy, like barbell back squats. Filming your lifts helps you to really see what you are doing with them. You can also use it to check if the lift seemed to move well - as you get better, you will notice that easier lifts move more quickly and harder lifts slow you down. Watching them back on video can provide more insight into how hard the move really was for you. Sometimes something FEELS heavy, but moves fast.

If you’re lucky you’ll capture fun moments between yourself and your coach as well as awkward trips most likely from not wearing your glasses to train ��

How to get heavy dumbbells up to press them

Often you will be able to press much more than you can lift with your arm, so you need to use a bit of technique to get the weights safely into position. Hard to explain in words - check out the video!

Hope these tips were helpful!

Please don't hesitate to reach out if you have any specific things you'd like me to cover.

Frances

FKB Physio is 3. Here's the backstory

Mon, 31 Jul 2023 06:14:09 GMT

On the third anniversary of opening FKB Physio I thought it would be timely to reflect on my journey and share some of it with you. It may surprise you to know there was a time when I truly believed I had made the wrong choice in selecting physiotherapy as my career and was on the brink of quitting! How much things have changed since then.

Why I became a physiotherapist

I decided to study physiotherapy when I was actually in first year engineering. It never occurred to me at school that I might want to be a physiotherapist. I associated physiotherapy with girls who were sporty, which I was not. I was always more interested in the academic side of school. That said, I did play sport. I played tennis consistently (thanks to dad who took me to all my games on the weekend and encouraged me to keep it up!), and from memory I also played softball and volleyball, though absolutely did not take them seriously and probably selected them because they were easy.

I was also lucky enough that my parents somehow introduced me to the local gym (what is now Goodlife Ashgrove but was then Ashgrove Body Designers) and I think from about grade 10 I had a membership and would go to body combat, body balance, and body attack. I remember my fitness gradually going up each year so that by year 12 I actually placed in the top 10 in the cross country, simply because I ran the whole way and almost no one else did!

I was all set to become a software engineer when I finished school, however, I found the course extremely boring and the mathematics was beyond me, despite thinking I am a fairly mathematically oriented person. I went along to a lecture with a friend who was studying human movements (a biology lecture, from memory), and found it more interesting than anything I’d learned in my course!

At the 6 month point, halfway into my engineering first year, I decided it wasn’t for me. At that time, I’d also started going to Body Attack and Body Pump ALL the time at the gym, as well as running to and from classes in my dunlop volleys that I wore to work (in the Coles Deli). Unsurprisingly, I developed shin pain and went off to the physio to sort it out. This event, combined with my dissatisfaction with my engineering degree, and attending that lecture with my friend, made me decide to try swapping to physiotherapy instead. I also became a group fitness instructor in the 6 months between finishing engineering and starting physio, a job which I still do now.

The course change was absolutely the right decision. I enjoyed physiotherapy immediately, though I found having to interact with people in such a close and fairly intense manner extremely challenging. I am an introvert and a perfectionist, and those things are pretty hard to manage at 18 as it is, let alone in a university course that demands you perform assessments on your classmates in exams!

I repeatedly was called out for being too blunt, too rude, too cold, unapproachable, unfriendly, and being unable to form a rapport with clients. In fact I think I actually had a ‘fake’ patient that we had at uni (for practice) complain about me to one of our lecturers. Not off to a great start in the profession!

Here's a few photos from back in the day!

What made me disillusioned with physiotherapy

I worked in private practice in Brisbane and Melbourne for the first 5 years after I graduated. I couldn’t tell you what I really was doing in probably the first 3 of those, as once again, I found the entire process of people paying me for my time and experience extremely stressful and daunting as a young new-grad. But as my career went on, and I got comfortable enough to allow my brain to think about what I was doing a bit more, I started to find some issues with how we were practicing. I honestly never understood the focus on manual therapy. I never really got why it was supposed to help people.

We were taught at uni that manipulations (chiropractic cracking) and massage were both not evidence based, but apparently performing the same sorts of movements but at a lower velocity (joint mobilisations, which is what physiotherapists do) were fine. This did not make sense to me!

I also didn’t understand the fact that at uni, we were barely taught massage, and were not allowed to use it as a treatment modality in exams, and yet in practice as a physio, massage was expected and performed on nearly all patients. People would come in and ask for a sports massage, which again, didn’t sit well with me, as it didnt feel like my job or my role. The fact that people decided whether to stick with me or not based on whether or not I was good at massaging did not really seem like what I should be doing. I specifically remember going to a course one weekend and being asked if the course taught us how to ‘get in deeper with our massage’. That was actually from a receptionist at one of my workplaces. I have no qualms with massage therapists, but it did not feel right that I was continually confused with one.

Another issue that slowly arose was that I could see we were quite good at getting people to feel better soon after a new onset of pain, but not very good at preparing them to get back to their full capacity. For example, I remember having a patient who hurt her lower back doing burpees. We would do some massage (and “joint mobilisations”), tape her back, get her feeling normal again, and perhaps do some generic pilates exercises, and inevitably she would hurt her back again. There was no direction towards getting her back to burpees, specifically, or doing anything really hard enough in rehab to get her to where she needed to be.

Now I know not all physios in my position would have struggled to appropriately clinically reason a valid exercise program for these people in the way that I did, but I just felt that there was absolutely no focus on this type of thing in the physio circles I was moving in, and rather a lot more focus on treatments that involved lying on the bed, or doing pilates exercises that were not specific or hard enough to make any real difference. I was only ever really questioned about why patients didnt come back more times, or why I wasnt bringing in enough money, and never about why my exercise prescription wasn’t tailored enough, or my rehab plans detailed enough.

This struggle to make sense of what I was doing, combined with short, 20 minute, back to back appointments eventually wore me down to the point where I thought I’d picked the wrong career, and that my introverted self was not meant to be a physio.

At this point, I decided to try moving to the UK for a working holiday.

The road to how I practice now

In the UK, all physiotherapy is covered by the NHS, which means it is free of charge to the individual. Remove the pressure to make money and notice the difference it makes to the profession! Immediately the type of treatment offered was completely different and the focus more on seeing the person when they really needed to be seen, with no financial incentive. I got to work in a chronic pain and shoulder instability team at a large orthopaedic hospital in the UK and that was probably the most eye opening experience I could have had.

These people had often received years of standard physiotherapy care: massage, light stretches, basic exercises, etc, with no improvement. We basically considered that they had not had any rehabilitation as yet when we met them.

This more hands-off approach (no, that does not mean not putting hands on at all, or not assessing people properly using hands on assessments, it means hands off in terms of treatments used) worked towards finding a baseline that a person could tolerate and increasing their movement from there made a WHOLE lot more sense to me. For the first time, I could see real logic to what I was doing.

Fast forward a few years and when my visa ran out I moved to Kuwait in the Middle East, working as the sole physiotherapist in a team of personal trainers. Despite having gone to the gym consistently for years, I had actually had fairly little exposure to personal trainers. I’d started lifting weights fairly consistently while in the UK and I started noticing more and more that the exercises I would do myself were really different to the ones id give my patients. I also noticed that the ‘physio exercises’ I’d give to my patients were much more unnecessarily awkward and difficult than the exercises I would be doing.

Like, I would personally find it really difficult to do a prone W or Y exercise, and would never warm up my shoulders with band exercises before lifting, but I’d prescribe this to my patients. I would often think I was strong at general exercises, like push ups or overhead press, but really weak at physio exercises, like external rotations or something, or anything that involved external hip rotation…. And eventually… I started thinking… wait a minute, I’m just strong. The physio exercises are irrelevant. Who cares if I can’t do a very isolated random movement that is apparently important when I can do everything else?

I ended up googling these sorts of questions, like, do activation exercises do anything, or are trigger points even real, and I stumbled across Adam Meakins’s blog. I would say it was finding his blog that was the second huge change in my practice, alongside working in the NHS. (Co-incidentally, Adam also works in the NHS, though I don’t actually think the link is why I found both things helpful!)

Adam had all the same questions and discomfort I had, but had already worked through it, clinically reasoned it out, researched his way around it, etc, and put some real weight behind why he had the questions he did. It was finding him that made me feel compelled to continue to practice and have confidence to change how I did things.

Working in Kuwait in the gym with personal trainers gave me a great opportunity to perfect my exercise perscription skills. I did a PT course, worked with a PT, and read a lot about programming and started to get the hang of providing full gym programs and rehab programs for people that were actually hard enough to get them back to their prior selves.

I also found that as I got older, I became more comfortable working with people. I realised what is true about myself is that I really, really care, a lot, about a lot of things, including other people, and that despite being sometimes awkward or not as relaxed as other people, truly caring about a patient’s well-being is probably one of the most ideal traits of being a physiotherapist. I also came to realise that a lot of people were not performing ‘perfectly’ at their chosen professions; other gym instructors weren’t perfect, neither were other physios, and it was ok. This helped me to give myself a bit of a break and relax a little more, which helped me to enjoy my job a bit more too.

The birth of FKB Physio

When I came home in 2020, I decided to start my own business because I couldn’t find a single job that advertised a physiotherapy role like the one I wanted. Almost all the job ads listed dry needling and pilates as major components of the role, and I just couldn’t bring myself to go back to practicing in that way.

I started my own business renting a room out of a local gym and started hosting bone density classes for my parents, who brought along their friends, and that has now grown into nearly 20 bone density classes per week. Bone density classes are so ful-fulling to me for so many reasons. Firstly because they make sense - we know that loading the bones with resistance training is likely to be beneficial for their density. We also know that there are irrefutable other benefits that come from lifting weights, like the reduction of muscle loss, maintenance of balance, and reduction of falls risk. To me it is a no-brainer to offer this type of service. On top of that, it’s fun, and people get to make really exciting gains! Some of my women have made mind blowing progress in the time I’ve known them, and it is really great to get to see that on an average day at work.

I also completed my Master of Sports Medicine through Melbourne uni from 2020-2022 which means I can call myself a Sports & Exercise physio. The main thing I got from the course was being much better at critically analysing research and applying it better to my practice. After being out of uni for 10 years I think it was the perfect way to re-focus on this.

I still see physio clients, though I tend to mainly attract those who have tried lots of other things that haven’t worked - which is how I like it. I have heaps of time for my appointments. I have an hour for initial assessments, but sometimes I will take even longer if I think the person needs more time to get out their story. For people who have been battling pain for a long time, sometimes their story can take 40 minutes to go through. I have no idea how clinics with 30 minute appointments are meant to facilitate this, but then again, I assume they probably aren’t. Busy clinics with short appointments are perfect for people with quick problems like a stiff neck. That’s not what FKB Physio is really here for.

I like working with people to figure out how we can get them back to where they were before they developed their pain. Often this is working with them to figure out just what they want to be doing and a plan to get them back to it. This is different to trying to fix their problem.

Ill give you an example.

Imagine someone with knee pain, who has been told they have a meniscus tear. They want to be able to run again.

“Fixing” the injury approach: surgery to fix the meniscus, try returning to running once healed from surgery. (Note, often people do not do any real rehab after this and never get back to their sport).

Person/goal centred approach: a rehab program targeted at gradually building the strength and tolerance of the knee to be able to handle running. Whether or not this involves surgery at some point will depend on the patient, as people with meniscus tears can often return to running with or without surgery - it depends on the person, but all treatment should be directed towards returning to the desired activity, not at ‘fixing’ the pathology.

This may sound like a strange approach, but you would be surprised how many times people get suck on an endless merry-go-round of treatments to fix their injury and over time are getting further and further away from what they wish they could be doing, when really, they could be taking steps to get back to that right from day 1. Often trying to fix something, or waiting until it gets better, can lead to such a long period away from activity that it makes it extremely difficult to get back in.

Having no pressure to see patients a certain number of times, or get them back in sooner than I would like, makes my job extremely enjoyable.

My dream for FKB Physio is to continue working at the 2 locations I currently do, hopefully with a few more staff members. I want to change what physiotherapy means for people and provide a clear alternative to gentle exercises and passive treatments that don’t really get people anywhere after a certain point.

I love working with people and I can honestly say I never dread going to work, though I do get very tired and often a bit burnt out because of how seriously I take everything. Hoping to work on this to make sure I have longevity in this role!

Happy 3rd birthday to FKB Physio and here’s to hopefully many more to come.

Home based exercise for bone health

Wed, 12 Jul 2023 00:38:13 GMT

Getting started with the foundation movements to improve your strength, balance, and bone health at home

Disclaimer: This site contains health and fitness information and is designed to be used for educational purposes only. You should not use this information as a replacement for or substitute to advice from a medical professional. The use of any information provided on this site is to be done at your own risk.

I have had lots of requests from people regarding exercise for bone density that can be done remotely or at home.

Today I am going to share with you the foundation movements that we do in my bone density classes that form the base for everyone who is starting out. These are the base level movements that can be progressed as you improve, and can be done in your own home.

If you have been diagnosed with osteoporosis or osteopenia, it is recommended that you exercise under supervision of a health professional such as an exercise physiologist or physiotherapist to reduce your risk of injury or falls.

Aiming to perform 2-3 sets of 10-15 of each of these exercises 2-3 times per week would be a great place to start. Start with the lowest number and gradually work up to the highest, if possible.

The squat

The most basic form of a squat is to practice moving from sit to stand. Set up with feet just outside hips. Sit down into a chair that is about at knee height. Use the arms of the chair if you need to. You can progress this movement by holding something in your arms as you do it, such as a bag with books or full water bottles in it.

The hinge

The hinge forms the basis for another movement, known as the deadlift. To hinge, you have your knees soft, and you push your hips backwards so that you tip forwards at the hip. Try to keep your lower back fairly straight. Common mistakes are keeping the knees totally straight, or curving the back too much - the movement comes from hinging at the hip rather than curving the spine.

The lunge (more advanced - start with the first two for a few weeks before trying this one)

Lunges are done with your feet set one in front one behind with your feet hip width distance apart. All your weight should be in your front foot. Bend both knees until your knees reach 90 degrees (if possible; if not, just as far as you comfortably can). You may need to hold on. All your weight should be in your front foot.

The upper body horizontal push

Push ups are a great way to build upper body pushing strength. You can start out at the wall. Put your hands on the wall at shoulder height, then bring your chest in towards the wall. Push away again until your arms are straight. The next level for this exercise is to try it on the floor, knees under hips and hands under shoulders. More advanced versions involve having your knees further away, or knees off the floor all together (this is super advanced, only a select few in my classes can try this one!).

Upper body pull (horizontal and vertical)

These ones are generally difficult to do without any equipment. If you have a band, tie it to something overhead, and sit or stand underneath it. Reach your hands up overhead then pull with each hand down until shoulder height. You can also do this in a horizontal direction by attaching it to something in front of you and pulling backwards, pulling shoulder blades back at the same time.

Core

If you are able to get up and down off the floor, you can try bridging and planking for some core exercises. To bridge, lie on your back with your knees bent, and lift your hips up off the ground.

To plank, set up lying on your front, then lift yourself onto your elbows and knees and brace your stomach muscles, keeping a fairly straight back. Try to hold this as long as you can (often I will try 3-5x10 sec holds with my new clients.

Jumping and balance (more advanced - if you have osteoporosis or a lower limb injury or pelvic floor dysfunction do not try this at home on your own)

Jumping is a common feature in bone classes. There is some evidence to suggest it is helpful for bone density. I also think it is helpful to maintain capacity in your tendons, as most of us stop jumping when we leave school. The way I introduce this with people is to start by holding onto something in front, squatting down, then raising up fast onto toes. After a few weeks of that, we can progress to small jumps leaving the floor, and eventually jumps without holding on if people are capable and comfortable. This doubles as a great balance exercise as well, as landing from being airborne involves a fair bit of balance!

Is this enough?

It is currently generally established in the guidelines published by the Exercise & Sports Science Association Australia that in order to truly build bone density it is necessary to lift progressively heavier weights. Some exercise is always better than no exercise, so do not be disheartened if this is not something you have the option to do. But, if you can, getting into a gym and adding weight to these exercises (under supervision by a coach or health professional ideally) is likely to be more beneficial in the long run.

If you have a diagnosed health condition, or struggle with ongoing pain or have an ongoing injury, you are likely to benefit from working with a physio or exercise physiologist so that they can continue to load you adequately without aggravating these issues. Bear in mind that there are many ways to work around an injury that do not involve total rest.

I offer personalised bone density classes as an affordable option to get you progressively lifting heavier in a safe and supportive environment. Head over to my bookings page to make a time to come in and get started.

Tendinopathy: what it is and how to manage it

Mon, 24 Apr 2023 07:47:56 GMT

I am writing this blog as a guide for some of my patients with tendinopathy so that I have a resource that is easy to refer them to to read in their own time. While I will do my best to make sure the information is accurate and evidence based, I will not be delving deep into the research as this is more interesting for clinicians than patients and that is not who this is directed at.

Ok. So first of all, what is tendinopathy?

Tendinopathy is basically the term given to tendons that have been persistently painful and have a loss of function relating to loading (Alex et al, 2020). The terms tendonitis or tendinosis are other words that you may have heard, which essentially are just other names for the same thing. The general consensus is to use the word tendinopathy these days, but don’t freak out if you hear one of the other ones; they all mean essentially the same thing and the word teninopathy covers all bases. Large tendon tears are something different that I wont be covering in this blog post.

What does a tendinopathy typically feel like?

Tendinopathies tend to have a set of clear clinical symptoms:

They hurt when you use them
They often warm up with use and then feel better
They feel worse upon waking the next morning
They feel stiff and/or sore when you have been still for a period of time and then move the affected area

Anyone presenting with these symptoms in an area where there is a tendon will make a clinician immediately suspect a tendinopathy.

Common areas that get tendinopathy are:

High hamstring tendon (high up at the top of the thigh, in the buttock)
Achilles tendon (behind the heel)
Plantar fascia (a fascia that acts like a tendon, underneath your foot, felt in the heel)
Wrist extensors (outside of the elbow)
Patellar tendon (front of the knee)
Rotator cuff tendons (shoulder. These tend to act a bit differently to other tendons and as such arent the focus of this blog post).
Gluteal tendons (outside of the hip)

Why does tendinopathy happen?

As with most things in the human body, there is some debate as to the exact mechanism that causes a tendinopathy. The general concept is as follows. Our tendons are designed to adapt to load. If we use a tendon more than normal, theoretically, the tendon should adapt to that load and become a bit stronger. With a tendinopathy, however, this process is disrupted. This could be because we load the tendon again too soon before the recovery has occurred, or it could be because the amount of load was simply too great for the tendon to adapt to. Instead of getting stronger, the tendon actually gets weaker (Cook et al., 2016). The tendon can become very thick when it is unhealthy and can have vascular cells and adipose tissue (i.e. fat cells and cells designed for circulation) deposited in the tendon where they are not supposed to be.

Tendons usually take about 48-72 hours to adapt to something new, though this may be more or less depending on particular circumstances (Magnussen et al., 2010). Certain factors about a person may make a tendon less likely to adapt as well. For example, as we get older, our tendons are less adaptable. Certain health conditions can make tendons less easily adaptable. Our history of how we have used the tendon will have an impact on how it responds to new loads. Someone who plays sport is likely to find it easy to adapt to a new activity compared to someone who is sedentary, for example.

Tendons tend to be happiest doing a similar amount of work to what they have been doing recently. So for example, say you have gradually worked your way up to being able to run 10kms. If you then have 6 weeks off running, and try to run 10km again, while you may still be capable of doing it, your soft tissues are no longer as adapted to be able to manage. Your tendons and soft tissues are adapted to what you have been doing for about the last 4 weeks.

(I am basing this from a Peter Malliaris blog written in 2016 that discusses the research that looks at how long it takes for a tendon to return to baseline after a period of de-training, as well as considering how long it may take one to start to lose strength after ceasing strength training which is often said to be starting from about 3 weeks. Reference: https://www.tendinopathyrehab.com/blog/tendinopathy-updates/the-effect-of-detraining-on-tendons-and-how-to-prevent-it-causing-tendon-pain-in-your-patients)

Do I need a scan to diagnose my tendinopathy?

No. Scans are generally not indicated for tendinopathy (sometimes they may be). A diagnosis can be made with symptoms alone. Research has generally found that findings on scans correlate poorly to symptoms, which means that someone with a very bad looking tendinopathy can have much fewer symptoms than someone with a very minor looking tendinopathy. This fact alone makes the role of imaging questionable, especially as it can elicit fear due to the scary sounding language in the scans.

How can I reduce my risk of developing tendinopathy?

My favourite way to consider this question is with the concept of capacity (Cook & Docking, 2015). As I just outlined, your tendons are happy doing things they are familiar with. If you exceed their current capacity, you are more at risk of having an issue. Building a high degree of capacity may reduce your risk of tendon injury, as it means you need to do a lot to send a tendon ‘over the edge’. Keeping active helps to keep your tendons strong and ready for whatever you throw at them.

For upper body tendons this means doing strength and resistance training a few times a week. The same is true for your lower body tendons, though it makes sense to also include some jumping movements for the lower body, as tendons are particularly sensitive to energy store and release (i.e. explosive movements like running or jumping), which you are more likely to do with the lower body.

If I have a tendinopathy, what should I do to manage it?

The mainstay of tendinopathy treatment is load management. This is because tendinopathy is generally a load problem. That is, a tendon was loaded more than it could handle. In my opinion there is no real treatment outside of this that makes much sense, as none of the other treatments address the root cause (loading) (Cook et al., 2016). (Bear in mind this is a huge over simplification of tendinopathy as there is a lot more to it and still a lot of mystery surrounding the condition.)

Treatment involves, firstly, offloading the tendon just enough to enable some healing to occur. This means offloading it ONLY AS MUCH as required, and no more. This can require some close monitoring of symptoms to figure out what activities in particular make symptoms noticeably worse. Paying attention to the 24 hour pattern of symptoms is necessary, as tendons tend to hurt more the next morning if they have been overloaded. So this may mean allowing someone to exercise with a degree of tendon pain, provided it does not feel worse the next day.

Tendinopathies are sensitive to two types of load: compressive load and tensile load, and a combination of both can be the most difficult for them (Lauren et al., 2022). So they are sensitive to being squashed (compressed) as well as being loaded directly (which will cause a tensile load from the muscle pulling on it). This is important to consider, as people often only think of load from use, not load from compression. Note that in certain tendon locations, loading can also cause a degree of compression against the bone the tendon is near… which is probably why some tendons seem to develop these issues more than others!

A list of common tendinopathies & what positions may cause them to be compressed:

High hamstring tendinopathy: compressed in hip flexion with a straight knee e.g. bending forward at the hips. Compressed with sitting, particularly hard chairs. Compressed with hamstring stretches.
Achilles tendinopathy: compressed with calf stretches and sitting/standing with calves on stretch (e.g. sitting with a flat foot and foot pulled underneath chair, standing with weight shifted forwards).
Plantar fasciiopathy: compressed with high arch support, rolling on golf balls.
Wrist extensor tendinopathy: compressed when wrist is bent downwards.
Patellar tendinopathy: compressed when knee is bent backwards.
Rotator cuff tendoniopathy: compressed to lie on.
Gluteal tendinopathy: compressed to lie on, compressed when sitting with legs crossed.

As tendons do not like compression or tensile load, it is often best to avoid stretching them, foam rolling them, or pressing hard on them.

The next component of tendinopathy management is to strengthen them. A tendon that has a tendinopathy is often less able to handle load itself, and if it has been chronic, the muscle attached to the tendon often also becomes weaker. It is not uncommon to see muscle wasting in the muscle adjacent to a long standing painful tendon. It is important to perform exercises that are actually hard for the muscle and tendon. Research indicates that the exercise must be harder than 40% of a muscle’s maximum contractibility (you need to be working greater than 40% of your maximum force output) to actually create any changes at a muscular or tendinous level. The exercise you select ideally should be one that does not cause too much compression at the tendon, especially in the earlier stages. While it is ok for the chosen exercise to be a bit uncomfortable, it should not make symptoms worse 24 hours later.

There is an argument for allowing a degree of pain during tendon rehab exercises, as there is likely to be a degree of sensitisation (the area around the tendon becoming overly sensitive) once the pain has been ongoing for a period of time. Allowing some pain during exercise may help to reduce this sensitisation, but monitoring for symptoms afterwards is necessary.

A graduated return to painful activities occurs concurrently to the above. The ‘harder’ the activity the tendon needs to get back to, the harder the rehab will need to be. e.g., a plantar fasciiopathy that needs to get used to standing still will not require the level of rehab exercises as one that needs to get used to someone playing basketball.

The final component of tendinopathy management is PATIENCE. Tendons take a very long time to gradually re-model. Another reason why it is important to only rest just as much as you need to, and work to gradually increase how much you are doing over time, so that it does not take too much space up in your life.

Should I have shockwave/acupuncture/dry needling/cortisone/PRP?

As stated above, my personal opinion is no. This is because these treatments will not restore the ability of a tendon to tolerate load, and will not restore the muscle weakness that is likely to accompany the tendinopathy. These treatments are often painful and expensive and carry a degree of risk. Cortisone in particular should be avoided if possible, as it is likely to weaken the tissues and possibly cause worse outcomes in the long term (Cook et al., 2016).

Take home points:

Tendinopathy occurs when a tendon is loaded beyond its capability
The tendon becomes less able to handle load instead of more able to
Tendons ‘like’ a similar amount of loading to what they have been exposed to in recent weeks
A sudden load of too much, or repeating a given load again too soon can lead to a tendinopathy developing
Treatment involves off-loading the tendon just enough to allow some recovery of symptoms
Off-loading needs to consider both tensile and compressive loads (i.e. consider load on tendon in static postures not just while moving)
Targeted exercise to restore capacity to a tendon is necessary
A graduated return to activity is also part of appropriate tendon rehabilitation
Tendons are SLOW to recover - you may need to allow 12 months for a tendon to feel back to normal
It is important to avoid total rest as this will not heal the tendon and will also cause the tendinopathy to have too much of an impact on your life

I am working on specific advice pages for different tendinopathies that will be uploaded as I finish them!

Alex, S., Kipling, S., Hakan, A., Roald, B., Jill, L. C., Brooke, C., Robert-Jan de, V., Siu Ngor, F., Alison, G., Jeremy, S. L., Nicola, M., Magnusson, S. P., Peter, M., Sean Mc, A., Edwin, H. G. O., Craig Robert, P., Jonathan, D. R., Ebonie Kendra, R., Karin Gravare, S., Cathy, S., Adam, W., Jennifer Moriatis, W., Inge van den, A.-S., Bill, T. V., & Johannes, Z. (2020). ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical Terminology. British Journal of Sports Medicine, 54(5), 260. https://doi.org/10.1136/bjsports-2019-100885
Cook, J. L., & Docking, S. I. (2015). “Rehabilitation will increase the ‘capacity’ of your …insert musculoskeletal tissue here….” Defining ‘tissue capacity’: a core concept for clinicians. British Journal of Sports Medicine, 49(23), 1484. https://doi.org/10.1136/bjsports-2015-094849
Cook, J. L., Rio, E., Purdam, C. R., & Docking, S. I. (2016). Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?British Journal of Sports Medicine, 50(19), 1187. https://doi.org/10.1136/bjsports-2015-095422
Lauren, P., Jill, L. C., Erik, W., Arne, B., Luc Vanden, B., & Evi, W. (2022). Exploring the role of intratendinous pressure in the pathogenesis of tendon pathology: a narrative review and conceptual framework. British Journal of Sports Medicine, bjsports-2022-106066. https://doi.org/10.1136/bjsports-2022-106066
Magnusson, S. P., Langberg, H., & Kjaer, M. (2010). The pathogenesis of tendinopathy: balancing the response to loading. Nat Rev Rheumatol, 6(5), 262-268. https://doi.org/10.1038/nrrheum.2010.43

How to progressively lift heavier weights with older adults?

Sun, 25 Dec 2022 22:18:21 GMT

Osteoporosis guidelines recommend lifting heavy weights at 80-85% intensity.

That means, 80-85% of whatever weight you could lift for 1 repetition only (and not 2 repetitions - this is called your 1 rep max or 1 RM), which should be able to lift 5-6 times. So say you can lift 50kg once but not twice; you should theoretically be able to lift 40-42.5kg for 5-6 repetitions. Commonly you would do this in 4-5 sets. The reason for this is because you are not lifting the weight all that many times - only 5 in a set- so you need more sets to get more total workload done. This is how normal strength training is often completed, and seems to be particularly important for bone health.

I have been running bone density classes for 2 and a half years and have had some great results with women being able to lift nearly 1.5x body weight (though a number of these women have been training for >5 years at another clinic before starting with me). A couple of people have reached out to me to ask how they managed to get there, so I thought I’d write a blog with a bit of a crash course detailing how I personally manage our progressions.

Note, this is not intended to be used as medical advice or as a guide, it is just detailing how these ladies in particular achieved this.

Older adults with limited lifting experience (no training before 60 years old for most of them) with osteoporosis have specific requirements and so I progress them pretty carefully and slowly. You technically shouldn’t be training on your own if you have osteoporosis as it is considered high risk , but obviously it is not always possible for everyone to have access to supervised weight lifting sessions.

Something to bear in mind is that often these ladies have an increased curve in their upper back (kyphosis) which is a result of their osteoporosis, and they may have limited mobility in their hips and knees (or have joint replacements), so the way they lift may look a bit different to how you may have been taught is technically 'correct'. For me, it is about being mindful of what these women have done up until this point to determine whether their body is likely to have adapted enough to handle an increase in weight, even if done using a slightly different than “ideal” technique, using the principle of adaptation which states the human body is able to adapt to tolerate the loads placed upon it. Generally this means progressing a fair bit slower than I would in a different population.

How I begin:

To begin with, I start first with teaching how to hip hinge as a base exercise. We usually do this in our initial 1:1 consultation.

Next we use a dumbbell and practice hip hinging, usually a 10kg and build it up gradually over a few weeks. Usually I would do this with something like 4 sets of 10 as it is a light weight and more repetitions are helpful to practice the movement pattern. When they can lift the 20kg dumbbell, we progress to the barbell as the lightest option is 25kg (a 15kg bar and 2x5kg plates).

As soon as the client is comfortable lifting the bar I drop the reps back to 4 sets of 5-8 reps, as the weight is now relatively heavy, and they are unlikely to be able to lift it as many times. We practice 25kg then gradually up the weight 2.5kg at a time. How fast this happeneds depends on the client.

When they can lift 30kg, I introduce the trap bar, as the lightest this can go at my gym 34kg. We will practice 4x5-8 reps in the trap bar at this weight and gradually increase from there.

We will alternate between trap bar and regular bar each session, and usually have a third day with a different exercise option in it.

I base progressions in weight on:

Body weight: lighter people I start lighter and progress more slowly as how much you can lift is relative to your body weight.
Training experience. People who havent lifted before I progress much more slowly.

Age, but this is not as important and is relative to training age, but I will be a bit more willing to introduce the barbell and trap bar to people under 60 without using the dumbbell first, though it really depends. New Paragraph

Once my ladies can happily complete reps in the trap bar (the hexagonal bar in the top photo - its a bit easier technically as the weight is either side of you instead of in front of you and the handles are higher up on your leg) and on the regular barbell, I start to play around with the sets and reps.

Bear in mind that if you do less reps the idea is that you should be able to do more weight as you don’t have to do it as many times. The goal when doing 5-6 reps in my classes is to be lifting at an intensity where you could physically only do 2-3 more reps after you’ve done your programmed number (something which is pretty hard to get near if you have not trained much in your life!).

I will start the reps in the first proper training block with the barbell with 5 sets of 6 -8reps, for 6 weeks. In this time, we often will gradually just add a bit of weight each set.

For example, they may warm up for 2 sets of 6 at 30kg then 35kg. Their 5 working sets might look like: 35, 35, 37.5, 37.5, 40kg.

I find when people are less familiar with lifting heavy weights, this way works better, as they are getting used to the feeling of the heavy weight with each set.

I use higher reps still because often people are not lifting anywhere near their true max - it is a bit pointless to do only 5 reps of a weight you feel you could have done for 10.

Once my ladies have completed a 6 week training block of steady linear increases in weight, I will play around with the reps a bit more.

I will do something like 5 sets of 6, 6, 5, 5, 4 reps, so that we can bump the weight up even more on the last set, so that they get used to the feeling of the heavier weight again. As it gets heavier, i really re-enforce the importance of rest breaks: a minimum of 2 minutes between sets.

I may then do something similar the next block but drop the reps even lower, for e.g. 5 sets of 5, 5, 4, 4, 2, once for the same purpose of introducing heavy weight on that final set.

Once it has been a consistent 18 weeks or so of training, I will swap the order of the lifts around to try a top set of 3 at the start, then lighter back off sets. This is only possible for the women coming who are pretty confident with lifting heavy and we both have a fairly good idea of what they can do from their last training block.

So we will do something like a top set of 1x3 and back off sets of 3x5. This requires more warm up sets as we are starting heavy so need more time to build up there.

For example, we might do a warm up set of 5 at 40kg, 4 at 45kg, 2 at 50kg, then a top set of 3 at 55kg, with 3x5 back off sets at 47.5kg. I work these numbers out with my ladies on the day depending on how they feel, how fast the weight moves, and what they have done in the past.

After this block we might then build on it again and do a top set of 1, followed by a back off set of 3, and 2-3 back off sets of 5 reps. This is a great way to round out 30 weeks of training (5x 6 week training blocks) and also gives a bit of an indication of what their 1RM lifting ability is to base their next blocks on when we go back to the beginning again.

Note that I avoid ever going to a true 1RM with this population, but what they can lift for 1 repetition will still give a good idea of what they are capable of for 3-5 reps as a general calculation (5 reps should be approximately 15% less than what you can do for 1 rep, ish).

I hope this helped to provide some idea of how you can progress your weights as someone who may not be super familiar with strength training!

Podcast: Women and Bone Density

Thu, 18 Aug 2022 05:56:34 GMT

Podcast episode 2: women and bone health

https://open.spotify.com/episode/17EaWhxNMWNXi3655qeg4w?si=uIRQYY5WS7Cb79kcGfDdsg

[00:00:00]

Hi everybody. And welcome back to FKB physio podcast. So today's episode is just me and my own not interviewing anybody today. Because I have a lot to say about bone density. And in particular, I really wanted to talk about the importance of bone density in women. So bone density is important for everybody, but problems with bone health or having poor bone health seems to be more of an issue in women. The reason for this there's a few, one of them is just simply the fact that men seem to start off with a higher bone mass than women.

And I'm not sure why that is, but if you look at the research about this. Men have a higher bone mass initially. For both men and women, our bone density will decline across the lifespan. But because men have a higher bone mass to begin with, that slow decline might not push them into the osteoporotic range. Like it will for women. Uh, and the other thing is that when women go through menopause, they have this sudden drop off of estrogen. And that is quite bad for your bones. So I think I read that women can lose as much as 10% of their bone density in the first five years post-menopause, which is pretty significant. Those are two of the reasons why it does tend to affect women more often than men. Just as a statistic. I think for people over 50 one in three women will develop osteoporosis and one in five men so it's not that rare in men, but it is definitely more of an issue for women.

I also think that women are disadvantaged because women are told constantly their whole lives, that they should be smaller and smaller. Low [00:02:00] body mass is a risk factor for poor bone health. And that annoys me because women are told their whole lives, lose weight, eat less, be smaller. And then when they get older, It's them who suffer the consequences of such choices. And then things such as, you know, there's all these so-called health social media accounts out there. Claiming that dairy's bad for you, giving women these ideas of how they can get away with eating less and less and less. And on top of that, then women are discouraged often from heavy lifting. And it's seen as a masculine thing and jumping and high intensity sports.

So here are all the things that are likely to help you build your bone density, adequate food, maybe being a bit heavier, maybe having more muscle mass, maybe getting enough dairy, enough calcium. Lifting heavy, jumping, playing sports, and they are things that women are discouraged from over [00:03:00] and over and over.

I want to fight all of those ideas. We shouldn't constantly be striving to be smaller as women. We shouldn't be told to be afraid of lifting heavy or jumping or building muscle. There's nothing more empowering than these little ladies, over 60, all of a sudden realizing that their bodies can do these pretty epic things that they never thought they could do.

There is evidence that suggests that improving your bone density a younger age can delay the onset of osteoporosis or osteopenia. Having a 10% higher bone mass to start off with can reduce the onset of osteoporosis by 13 years. So basically you build 90% of your bone mass by age 20. Which is a massive advertisement to have active children because it's active kids that are jumping, running, eating enough that are going to reach a higher bone mass by the time they're 20. Then you [00:04:00] keep building that final 10% throughout your twenties. And from what I understand till about mid thirties and then your bone mass starts to go down. I remember at uni, we learned that you can't improve your bone density after that, which has been somewhat disproven.

But I think the reality is, you probably can make little changes to your bone mass but I do think that building as much as you can before mid thirties makes sense.

Of course there's all the co-morbidities that negatively influence bone density that no one has any control over like, kidney failure, celiac disease, h aving to take steroids for a prolonged period of time, as in corticosteroids, like for asthma things like that. ,

So there's a bit of a background of the whole situation. So why does this matter? The reason that matters is it's actually fracture risk. So the stats in Australia are that one in two women over 60 will sustain a hip fracture in their lifetime. Which is quite staggering, really. It's thought that [00:05:00] 66% of all Australians over 50 have poor bone health and that's from the Australian Institute of health and wellness.

So it's the bone health as well as falls risk that are fracture, risk factors, especially fractures of the hip. So in order to reduce the risk of having a fracture, we need to target improving bone density and bone health. And also look to reduce falls risk in these people.

There are medications out there for osteoporosis. The problem is you can't get those medications until you've had a diagnosis of osteoporosis. So often the first sign that someone has osteoporosis is that they have a fracture from a low trauma, like they sneeze and they break a bone. So often waiting for diagnosis of osteoporosis before you start trying to do something about it is a bit too late.

Something I really like about exercise for bone density is you can start without a diagnosis.

There are also some negatives with the [00:06:00] medications. Like, I know that some of them they don't really know the longterm outcomes and a lot of them, it sort of suggested that you might only go on them for 10 years at a time. But as soon as you stop taking it, i t reverses everything good that it did. And there's a small risk of these really adverse side effects that are nasty. I often think that those medications might be reserved for those people that are very frail and very high risk of fracture and the benefits outweigh the risks. But a lot of people who might be late fifties, early sixties who have osteoporosis or osteopenia who are hoping to live until their nineties, it might not be a great option for them yet, but that's obviously for people to discuss with their doctor or I guess endocrinologist.

What can we do to improve bone health?

So then ESSA guidelines, which have been put out that basically very clearly outline what type of exercise you should do for people with osteoporosis and how often. The main things are high [00:07:00] intensity lifting and high impact loading, i.e. Jumping. And these are things that have traditionally been avoided with people with osteoporosis, because the thought was that you're at risk of fracturing something. And again, with very frail individuals, you would have to be quite cautious about how you begin. But I think what's really interesting is that. In the research where they've trialed these programs on people with osteoporosis or osteopenia, there hasn't been any reported. Adverse side effects. So Belinda Beck, who runs a bone clinic, she just authored a paper this year in April. And she basically states in there that of the seven years they've been running the bone clinic, there hasn't been any adverse side effects , which is pretty good evidence to show that it's relatively safe.

So the recommendations are that people should be lifting 80 to 85% 1RM on compound movements, such as squat, deadlift, bench press, this type of thing. And that they should be including high impact moves like jumping. And that [00:08:00] over time they should get progressively harder. So moving from say, two foot jumps to one foot jumps. To jumping from height, multi-directional jumping and jumping with weighted vests. So I have managed to get some of my ladies in their late sixties, up to hopping with weights in their hands, multi-directional and from Heights, obviously, no, one's going to just start out doing that. It's a very slow progression over time. But it's interesting to see that this is what's advised. And the reason is because your bones apparently get used to cyclical things as in like running or cycling where it's this repetitive cycle very fast. So they need short, sharp intense bursts of load. And it has to be quite different, which is why the multidirectional comes into it. Unfortunately, swimming and walking, don't improve your bone density and running actually doesn't either. Because of that repetitive nature.

There's this article by warden and colleagues in 2021. And it [00:09:00] talks about this concept. It says basically that in order for your bones to remodel, you need to... It's about the mechano sensitivity of the bone. So I suppose that's the.. the sensitivity of the bone to a mechanical stimulus applied to it like an impact. So bones become, he says deaf to repetitive loading. . So basically, after a few minutes of running, that constant same load on the bones, your bones just get used to it and they don't get any stronger after that.

Another sort of interesting point raised in the article is that swimmers and cyclists have lower bone mass than other athletes, but they actually don't have a high risk of stress fractures because those sports don't have any impact associated with them. So while you might have poor bone health, you won't necessarily get a stress fracture because there's not that bony stress there. But if we're thinking about [00:10:00] longterm, Implications for those athletes. Then once again, we're coming back around to looking at trying to optimize bone health for the future and reduce the risk of osteoporosis. So. For people who do those endurance style sports. This is obviously a consideration that I think i s really important.

And I guess something else to consider with these sports is that. They're also not great for bone health because you also have a really high energy demand while you're doing them. And so your body needs energy while you're exercising and performing those tasks and it has to get that energy from somewhere. It's interesting that those sports where, you know, something like a triathlon where you might be doing all three of those things and exercising for four, six plus hours, it can actually be very hard for your bones. Again, that's why we need that heavy, short, sharp, heavy lifting, jumping, and I honestly think that everyone should be incorporating this stuff as [00:11:00] soon as they can. And again, in the Warden article, it does actually state that incorporating some jumping training or some plyometrics at a different time of day to the running could be quite helpful in the case of endurance runners. Indicating that this concept of multi-directional jumping and landing is consistent across lots of different types of research about bone density. It's not just for people with osteoporosis.

And just as a side note to that, for those people that do do running, in the same article, a strategy suggested to help manage it among other things is to incorporate a week off that repetitive sport one week out of every 12. I think it says just to give you a skeleton, a bit of a skeletel reset before you re-introduce the loading again. And it does talk about in the article about how people with a b ackground of heavy resistance training, [00:12:00] have a lower likelihood of sustaining a bony stress injury. So a few things to consider there as well.

So going back to the exercise for people who might have osteopenia or osteoporosis. And just for a bit of clarity around those terms, osteopenia is the precursor to osteoporosis. They're basically diagnosed based on your T score, which is determined by a DEXA scan. People often say, okay, I'll lift weights, but why do you keep asking me to lift heavier and partially it's because of the bones needing that new load that they haven't experienced before in order to continue to increase but there's another thing as well that i think is really relevant.

A concept that I think is quite interesting, the thought of a 1RM So. A 1RM a one repetition maximum. So for me, That would be going in a power lifting competition and lifting the max [00:13:00] weight I could possibly lift for one repetition. And I wouldn't be able to repeat that. that I wouldn't be able to repeat it on the day. I wouldn't be able to do it for two reps. I wouldn't be able to do it the next day. It would really tire me out. And the recommendation for this bone health stuff is that people should be lifting 80 to 85% of that, which means the amount you could lift five times, but then not six times. So it's like really heavy. And people might say, you know, why would you be getting older people lifting that heavy? And my sort of counter to that is... you've probably all seen an elderly relative. Try to get out of a chair that might be a bit low. And it might be close to impossible for that person to get out of that chair. And once they've done it, it's a max effort. And really, could they repeat it again straight after? Probably not. That person's doing a one RM to get out of their chair and they might do that multiple times a day. Imagine how exhausting it would [00:14:00] be to be maxing out your capacity multiple times throughout the day.

That's where I think these intense forms of exercise. You can really see the benefit because you are going to improve that person's capacity so that they're not maxing out day to day. Like for me, I only max out or come anywhere, close to maxing out my movement capacity at the gym. But day-to-day, I don't come close, so it's not going to have a huge effect on my energy levels. Whereas if you're going up the stairs, holding your laundry, sitting down on the low couch and getting out a few times, if that's almost max effort, you want to improve your capacity so that that's not a max effort anymore. So I think that's a really powerful way to see why it's worth doing more intense forms of exercise, even if you are an older adult.

If people are coming to gym classes or physio led classes or whatever you want to call them to improve their bone density. And in the [00:15:00] process, they're doing this heavy lifting. You can kind of tell how the benefits are deeper than just improved bone density, but there's also reduction in sarcopenia which is basically muscle wasting, age-related. And there's an improvement in strength, which is going to be worthwhile, not just for bones, but for fatigue levels. And to reduce risk of falls. , and to keep body mass muscle mass high, which I think is a really important marker of health as well.

One final thing that I thought was interesting from Belinda Beck's 2022 article was that sometimes bone mineral density alone isn't a great measure of bone health. I read an article that said it's only about 60% of the story, and it doesn't tell you about the structure of the bone, which is actually apparently quite important. And Belinda talks about cortical thickness. So my thought is that the cortex is like the. Outside of the bone and it's not the kind of lattice-y stuff [00:16:00] on the inside. Cortical thickness is quite relevant and the LIFT-MOR trial, which is the one the bone clinic is based on in that study the bone density didn't necessarily get that much better, but the cortical thickness of the femoral neck, so like your hip bone, improved. So just bear that in mind, that bone density is about 60% of it. But if you do embark upon some efforts to improve your bone density and you don't see great changes on that it's not necessarily the whole story.

Just as a final note to kind of recap what I've talked about here. You build most of your bone mass before your 20, you build 90% of it. You can continue to build it until your mid thirties. And from there things start to decline and I'm not a hundred percent on what that looks like if you're someone who does lots of resistance training or anything like that, this is just I suppose the average adult living in [00:17:00] average lifestyle., It's really important to take an interest in your bone health, because as you get older, that slow decline in your bone density over the years can present as osteoporosis or osteopenia as we get older.

And people are more at risk of this if they have certain health conditions, but particularly women are more at risk. With at least one in three developing osteoporosis in their lifetime in Australia. I think that s drastically under reported that statistic as well. And the risk of having poor bone density is sustaining a fracture from something that's not a very big incident.

This is often a fall in older adults. There are ways to reduce the risk of you losing your bone density. And the earlier you start it the better, because the more bone mass you can build or maintain the more you can delay a diagnosis of osteoporosis. So in order to build your bone density. And also just the health of your bones in general which [00:18:00] goes deeper than just the bone density. Heavy resistance training. That's very hard, 80 to 85%, one RM of compound movements. And multi-directional jumping is really important as well as other things such as adequate food intake. And avoiding things that mean you intentionally aim for a low body mass.

You can start this at any age. There's any number of ways you can start slowly and build up, but it's definitely best to do this under the supervision of a professional. So at my clinic, I run bone density classes. They are supervised three or four people to one physio. There would be many physios and exercise physiologists out there running these sort of classes. So it is in your best interest to find one of them and start improving your bone health as soon as possible.[00:19:00]

Thank you so much for listening to this podcast, I'm going to try and alternate between one episode where I interview somebody, I've got lots of Instagram lives to go back and convert into podcasts and every other one. Me talking about something. So. Hopefully that works out all right!

Women and Bone Density

Thu, 18 Aug 2022 05:52:15 GMT

What is bone density and why does it matter?

Fractures in post-menopausal women are a significant problem in Australia. Research shows that 1 in 2 women over 60 will sustain a hip fracture in their lifetime (Australian Menopause Society, 2019). Poor bone health and increased falls risk are two major fracture risk factors. To reduce the impact of fractures on the community, interventions should look to improve bone health as well as reduce falls risk.

Bone density increases until approximately mid 30s (Tu et al., 2018). It is thought that having a 10% higher peak bone mass (building your bones as much as possible!) can delay the onset of osteoporosis by 13 years (Santos et al., 2017).

In 2012, Osteoporosis Australia estimated that 66% of all Australians over 50 had poor bone health, with women impacted more significantly than men (Australian Institute of Health and Wellness, 2020). Fractures can often occur prior to an osteoporosis diagnosis, and sometimes a fracture is the first indicator that one has the condition (Daly et al., 2020). This presents a challenge, as many interventions designed to reduce fracture risk are available only to those with a diagnosis.

How can physiotherapy help?

Physiotherapy’s role in fracture risk reduction in women over 50 primarily involves exercise-based interventions which target bone health as well as reduce the risk of falls. Beck et al. (2017) present evidence-based guidelines for exercise in the management and prevention of osteoporosis:

Previously, high impact (i.e. jumping) and high intensity (i.e. heavy lifting) exercises were avoided in older adults and particularly those with osteoporosis due to the assumed risk of fracture it posed, however there have been no adverse events noted in recent studies using this type of exercise in participants with osteoporosis (Daly et al., 2020; Watson et al., 2017). Belinda Beck has also written a paper this year in 2022 reporting her in-clinic experience running the bone clinic since 2015 and has reported no adverse events across those 7 years.

What research supports these guidelines?

Watson et al. (2018) investigated supervised high intensity and high impact resistance training in patients with osteoporosis and the impact on BMD. Training was performed twice per week for a period of 8 months. This is the LIFTMOR trial, the program of which is run at the bone clinic. The high intensity group experienced improvements in bone density in the lumbar spine compared to controls who used 3kg weights at home, though these increases were modest, ranging from 0.3-2.9%. While there was no improvement of BMD at the femoral neck, there was a significant improvement in cortical thickness.

Daly et al. (2020) performed an 18 month trial of a multi-modal program including strength training as well as balance exercises. Results demonstrated an improvement of BMD at the lumbar spine and hip by 1%, but no reduction in falls, though a net benefit of exercise in terms of muscle strength and overall function was noted.

These are just two of many studies published in the last 10 years investigating the impact of exercise on bone health and falls risk. When looking at the influence of exercise on BMD, while results are often fairly modest, this statistic alone does not tell the full story. It is thought that bone density (the reading you will get on a deja scan) accounts for only 60% of the actual profile of bone fragility as it cannot measure changes in bone structure (Osterhoff et al., 2016).

The other point to consider is how beneficial exercise is in other ways. Not only can it improve bone health, but may also improve muscle mass, balance, power, cardiac fitness, body composition, confidence, and mental well-being. Less than 25% of adults meet the WHO recommended exercise guidelines for resistance training, which is recommended twice per week.

How can classes in particular be beneficial?

It can be challenging to encourage older adults to exercise in a gym. A group, as well as supervision by a physiotherapist, increases safety, reduces the cost and provides social support (Burton et al., 2017).

Another positive of group classes is the motivation the members gain from working with each other, and seeing other people similar to themselves pushing themselves to lift heavier or to try an exercise they have previously been fearful of. I see this time and time again in my classes.

Why can’t I just take the bone density medications instead?

While pharmaceutical interventions to improve bone density can reduce risk of fracture, they do not reduce risk of falls, and do not target other concerns for post-menopausal women such as reduced muscle strength and size (Daly et al., 2019). Additionally, pharmaceutical interventions require a diagnosis of osteoporosis. Bone density classes can improve bone health in women without requiring this diagnosis. (But you should liase with your GP about whether you need these.)

How often should people be participating in the class?

Research shows resistance training must be completed on an ongoing basis and a minimum of twice per week to be effective (Beck et al., 2017).

What are the costs and how is it set up?

The classes are one physio to 3-4 people. Cost is $40 per person and can be rebated on private health. Those wishing to attend a class are initially required to attend an initial assessment, in which we go through a past medical history, a physical assessment, and a discussion of goals. A program is devised according to this assessment and tailored to the individual.

In my classes, I create a 3 day rotating program, that usually starts with large compound exercises (bit movements that use lots of muscles ) first, and then moves to single joint exercises (smaller exercises working one area at a time), finishing with impact loading, core and balance work. Once each day of the program has been completed four times, I change to a new program.

Over time, people are progressed as they improve.

For example, a woman who has never done gym based exercise in her life time might begin with body weight squats, 5kg deadlifts, 3 sets of 10 light jumps holding a rail, and 2kg upper body weights. In 6 months, she may be up to 20kg deadlifts, 3-5kgs upper body weights, and 5 sets of 10 heavier jumping. At one year, she may be up to a 35kg deadlift using the hexagonal bar, bench pressing 20kgs, overhead pressing 10kgs, and performing 6 sets of 10 jumps holding a weight.

A final benefit of the class is that whenever a musculoskeletal problem crops up, as inevitably does, we can monitor and manage it during the classes. My clients who have had hip or knee replacements have been able to attend right up until their surgeries and come back afterwards, enabling weekly or twice weekly monitoring of their progress. If someone wakes up with a sore neck or lower back, we are able to change the class around the issue until it resolves, while monitoring the need for any additional care. This continuity of care and follow up over a prolonged period to me is really what healthcare should be all about.

References

1. Australian Menopause Society, https://www.menopause.org.au/ .

3. Beck, B. R., Daly, R. M., Singh, M. A., & Taaffe, D. R. (2017). Exercise and Sports Science Australia (ESSA) position statement on exercise prescription for the prevention and management of osteoporosis. J Sci Med Sport, 20(5), 438-445. https://doi.org/10.1016/j.jsams.2016.10.001

4. Beck, B. R. (2022). Exercise Prescription for Osteoporosis: Back to Basics. Exerc Sport Sci Rev, 50(2), 57-64. https://doi.org/10.1249/jes.0000000000000281

5. Burton, E., Farrier, K., Lewin, G., Pettigrew, S., Hill, A. M., Airey, P., Bainbridge, L., &

7. Daly, R. M., Dalla Via, J., Duckham, R. L., Fraser, S. F., & Helge, E. W. (2019). Exercise for the prevention of osteoporosis in postmenopausal women: an evidence-based guide to the optimal prescription. Braz J Phys Ther, 23(2), 170-180. https://doi.org/10.1016/j.bjpt.2018.11.011

8. Daly, R. M., Gianoudis, J., Kersh, M. E., Bailey, C. A., Ebeling, P. R., Krug, R., Nowson,

9. C. A., Hill, K., & Sanders, K. M. (2020). Effects of a 12-Month Supervised, Community-Based, Multimodal Exercise Program Followed by a 6-Month Research-to-Practice Transition on Bone Mineral Density, Trabecular Microarchitecture, and Physical Function in Older Adults: A Randomized Controlled Trial. J Bone Miner Res, 35(3), 419-429. https://doi.org/10.1002/jbmr.3865

10. Osterhoff, G., Morgan, E. F., Shefelbine, S. J., Karim, L., McNamara, L. M., & Augat, P. (2016). Bone mechanical properties and changes with osteoporosis. Injury, 47 Suppl 2(Suppl 2), S11-20. https://doi.org/10.1016/s0020-1383(16)47003-8

11. Santos L, Elliott-Sale KJ, Sale C. Exercise and bone health across the lifespan. Biogerontology. 2017 Dec;18(6):931-946. doi: 10.1007/ s10522-017-9732-6. Epub 2017 Oct 20. PMID: 29052784; PMCID: PMC5684300.

Watson, S. L., Weeks, B. K., Weis, L. J., Harding, A. T., Horan, S. A., & Beck, B. R. (2018). High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. Journal of Bone and Mineral Research, 33(2), 211-220. https://doi.org/10.1002/jbmr.3284

Talking scapula dyskinesis with Louis Savill

Thu, 07 Jul 2022 01:43:44 GMT

Here's the conversation i had with Louis earlier this year on IG live in text and youtube format for those who missed it!

Frances: [00:00:00] So may as well get started. So just for anyone that doesn't know me, first of all, if you’re on my Instagram you might have a little bit of an idea. I'm Frances, I'm a physiotherapist I'm based in Brisbane. And I am chatting today with Louis, who is my, I would say my friend these days. Who's also a physio in Brisbane. So Louis graduated UQ from UQ as I did just a few years after I did, uh, he works at Excel physio in Hawthorne.

He's CrossFit level one coach. And he is like me particularly interested in evidence based practice. So I met Lewis, I guess it was last year. Yeah, through the gram reached yes, through the gram. So Louis reached out to me over Instagram and just kind of, you know, brought up that he felt like we had similar ideas and whether we wanted to meet and chat and Louis is actually one of the reasons I started doing my masters because Louis could quote Research off the top of his head and I'm like, I wanna be able to do that. So there we go. And what we're gonna talk about today is [00:01:00] scapula dyskinesis after Lewis telling me that he sort of was having a chat about it in his workplace the other day. So I wanted to ask you first can you even define, or can we define what scap DySIS is.

Louis: Yeah, thanks for having me on Francis it's, uh, I'm very, uh, honored to be the first guest for your, your live video series. So, so I mean, scapular dyskinesis it's I, I guess, uh, a bit of a longstanding theory in the, the shoulder pain and, and rehab world as to being a, a source of shoulder symptoms. So it's sort of defined as like a change or deviation from the normal resting position or active position of the shoulder blade while moving.

Okay. Okay. And, and it's, this is proposed that it may be a source of shoulder pain by increasing load on the rotator cuff and the contents of the subacromial space, uh, while you move. And then, I mean, in, from a mechanistic perspective, it makes good sense, right? Like it's, it's very intuitive. Yeah. It's [00:02:00] certainly a big issue for people who have dramas with like a, a neurological injury to their long thoracic nerve or accessory nerve.

So that will cause some really funky movement of the shoulder blade off the chest wall. But it's also proposed to potentially be something that causes pain in just regular run of the mill rotator cuff, shoulder pain. Yeah, I. There's a number of issues with this though, despite the fact that it sort of makes good sense on a, a theoretical level.

Yeah. Um, and, and it's like many things in musculoskeletal medicine, I think like we have these ideas that have really theoretical and then we take them and run with it. But then when we actually do some research into it, it, it proves that it's not really correct or doesn't really bear out. Like we thought it would.

Yeah. So if, if, if we think about the anatomy of the shoulder, right, you've got your. Your scapula suspended in the thorax by 17 different muscles, anchoring it to your mid back neck ribs and arm bone. Yeah. Um, so I mean, that's, there's quite a lot of moving parts there. [00:03:00] Yeah. And I, I think to define abnormal, we first have to be able to say what is normal.

Yeah. And when you dive into the literature on that, it's, it's very difficult to say what is a normal resting position at the scap what's normal in terms of, of the movement. Yeah. We've seen that the resting position tends to vary based on your hand dominance. So whether you're left or right handed the shoulder blade may sit slightly differently.

Um, what kind of upper limb activity you do regularly and habitual positions you put the shoulder in. So baseball pictures as an examples, the scaffold and the dominant side has been shown to rest slightly more upwardly, tilted, and internally rotated, and also tilted forward a little bit more than their UN that's actually their opposite side.

Frances: That's interesting. My dominant hand, like for sure does that. And I definitely attributed my shoulder pain a few years ago to that, and kind of went down the whole, like trying to assess my own scapula movement thing. So that's an interesting point.

Louis: it is interesting. Yeah. AB [00:04:00] absolutely. Um, I think the other thing too, like we, we have this idea that there's like, I guess that general pattern of scap movement where we like raise our arm overhead and that's to, to progressively upwardly, rotate to posteriorly tilt or tilt backwards and either turn in or out a little bit. Yeah. Um, there's also this notion of scapular humoral rhythm, which is that for every two degrees of movement at the ball and socket, you'll have one degree of the shoulder blade turning up, cuz the socket is part of the shoulder blade needs to face upward to help get our arm up, up to him. so does, that makes sense. Uni,

Frances: like I never thought about it ever again since uni, but I can remember those lectures very well.

Louis: That's a good thing that you haven't thought about too much. Cause it's actually not really true. Like we can probably see that the rate actually varies anywhere between like six to one and two to one.

Frances: Okay. Yeah.

Louis: The rhythm and how much movement there is. There is again with hand dominance with how fast you move, how tired you are. [00:05:00] If you're in pain and if you compare like a constrained task, like lifting your arm to a more functional activity, like throwing a ball or doing a snatch, you'll also see differences in how the same person shoulder blade moves.

So, I mean, if you think about like having a physio look at somehow someone's shoulder blade moves when they lift their arm or just how it sits at rest. um, that may not be overly relevant for somebody who's pain, uh, occurs while they throw a ball or why they, while they press a dumbbell overhead. So I, I think it, it's very challenging to actually say what is normal scapular movement. And, and as we'll go over sort of soon, there's, there's a lot of like I guess, asymmetry and differences in how it sits and how it moves even in people with, without shoulder pain. . Um, okay. So I guess you've basically defined it as well.

Frances: Dyskinesis is abnormal movement of the scapula. That's how it's defined. And that's what I learned at uni. But I guess our question [00:06:00] today is whether, is that a real thing and you're sort of indicating not necessarily. And I guess that leads me to my next question, which is, can we accurately assess, I suppose, scapular dyskinesia or scapular movement? And I ask that because I know that in. Athlete screening tools and stuff. They might have it in there. I'm trying to remember if in my subjects at uni last year, if we talked about it, probably it's one of those things that's always just thrown in as like a, you know, a throwaway line, like, is there abnormal movement of the scapula? So yes. Do you think we can accurately assess it in any way? And should like, should we bother and should we put it in screening tests for athletes?

Louis: I think it's worth looking at, like, I think we should always observe how it moves. I, I think that visual assessment of just subtle differences in scapular movement has very poor reliability. So what that means is if you and I both assess the same person's shoulder and watch how the shoulder [00:07:00] vapors moving, we probably have very different ideas about. How well is moving or how much upwards rotation there is or whatever. So it's, it's certainly yeah, the visual assessment, scap movement has poor into rider reliability, but I guess the exception would. When you have cases of like long thoracic nerve palsy or neurological injury it's very obvious that something very funky is going on. So it's, it's always worth looking at, but I guess, I don't think we can make a really good in clinic assessment, just relying on our eyes alone.

Frances: Can I just throw something in? I noticed too with me that like once, you know, what's side, It's like your ability to assess it accurately is gone because you know, it's hurting. So you are looking for those changes and, well, this is me anyway, but I'm sure other physios do it. Then you're kind of looking for something to blame. And so your ability to assess it, even yourself, I feel like it becomes quite hard once you know that what side is in pain, let alone someone else coming in and you. [00:08:00] Anyway. Yes. Go on.

Louis: Absolutely. And, and, and I think that's, that's interesting because we've got another paper that was done relatively recently. And, and what they did was they took a group of, of patients who either did or didn't have shoulder pain. And they had a group of therapists assess how their shoulder blades moved. And the experiment was, let's actually not tell one group of people who hasn't their shoulder pain and tell the others who does. And, and what they found was that therapists were more likely. Label someone with dyskinesis, if they knew they had shoulder pain beforehand. Yeah. Whereas the same. Yeah. Whereas the same people, the same people assess why a therapist who didn't know that they had shoulder pain, they were less likely to pick up anything function going on. So I guess it suggests that the way we're trained through uni and maybe through. these courses that some people go on, like tend to biases towards finding this, this dysfunction, even when it doesn't exist. It's, it's kind of like, pareidolia like, for instance, you see Jesus in this piece of toast. Oh.

And now, and now all you can [00:09:00] see is, is Jesus in the, in the piece of toast. So I think sometimes we, we see what we want to see or what we think should be there versus what really is. So I think that that's certainly a visual assessment. I don't know that there's a lot of good value in doing that outside of the gross neurological problems. yeah, scap movement can be more accurately assessed in a oratory setting where you have like 3d data from magnetic tracking systems and fancy stuff. But general day to day clinicians and coaches, you, you don't have a lot of chance unless something really funky is going on.

Frances: Yeah. Okay. So you're basically saying that for like in athlete, screening scenarios, where they do have access to that stuff, would you, do you think it's worthwhile? I think you might have said last time we chatted that there was maybe some evidence that in like a. Sport there was potentially some relevance.

Louis: Yeah. Yes. So they've done some prospective research on overhead athletes. So, you know, following a group of people over time from baseline looking at yeah. Who [00:10:00] had like nobody having shoulder pain to begin with and assessing scap dyskinesia, and then following them over a period of time. And they've done this in baseball, tennis. Badminton volleyball, um, handle. Yeah. So for the first four baseball, tennis, badminton, and volleyball, there was actually no association between having a funky scap at baseline and developing shoulder pain in the future.

Frances: do you know, and I'm really sorry to just ask you this, just in case you don't know the answer, but do you know how, how they assess it? Like, was it at rest? Was it with move? Do you know?

Louis: the, the two methods I've seen when I've read through the paper is either like this lab measure using that magnetic sort of technology to, to look at that. Oh, um, I've also seen it assessed using, um, Not so much with movement, but certainly resting position. They use like a tape measure to look at where the angle sits relative to the thoracic spine. And I think you've, you've probably seen this. And maybe when you raise your arm, then how far does it sit away again? But I think the better [00:11:00] papers tend to use the pretty flash 3d modeling to do it.

Frances: And do you think it's mainly, are they mainly looking at like lack of upper rotation or are they looking at it like, what's it called? "Winging" when it like sits.

Louis: Yeah, both, both they look at, they look at, does it, does it sort of internally rotate in the shoulder ways to lift off the chest wall? Does it properly rotate as much as the other side? Um, yeah. How much does it maybe tilt more forward or backwards? So, and they kind of all of the things, but yeah, all, they they'll look at everything, right. They tend to, because it has so many like degrees of freedom and obviously that much, that many muscles anchoring it to the chest wall. It's um, it's got, it's got a lot of potential movement available. . Yeah. So, um, so where there is some conflicting evidence is in high level handle. Okay. So we had, we had one study showing a small correlation, but another one sort of as like a replication study where there was no link.

Frances: Right.

Louis: So, I mean, potentially at the upper level of human shoulder function and maybe an argument that something being a little bit [00:12:00] off could be a risk factor. Yeah. But, um, it's, it's still a little bit ambiguous and I wouldn't say worth investing significant time or resources. We can actually prove that it is a problem for those people.

Frances: Yeah. Okay. And yeah, so that kind of covers whether we should screen for it in athletes, which to be honest is not the area I work in. So moving on to the area, that's more familiar to me. So considering someone who is already in pain do you think it is relevant how their scapula is moving?

Louis: I, I think it's, it's certainly worth looking at and I guess asking them about right. But I, I, I think again, the evidence doesn't really support that notion either. And it, it sort of speaks to a lot of these things that we've kind of deemed to. Dysfunctions in the body. I guess that are based on theory. Yeah, it's, it works in theory, but not really in, in practice as such. So there was a systematic review in 2013 that actually concluded that no physical examination test of the scapula was found to be useful [00:13:00] in differential diagnosing pathologies of the shoulder.

So it, can't actually like looking at those things in a clinic, can't really give you information about what's really going on with the, with the shoulder itself. And then the other thing that they said, and I'll have to quote this word for work, cause it's a great, great sentence. Scapular asymetry emotional position is not an indicator of shoulder dysfunction and is not limited to those with shoulder pathology. So, yeah, that kind of reiterates the point that some variation in asymmetry and how it sits and moves is actually really normal. Like it's not just isolated to people with shoulder pain. Yeah. I think where it may be relevant. And particularly when, like, it's not like a gross dyskinesis, but maybe it just feels funny to the person. Or maybe it looks a little bit funny to you. Like, I it's very hard to say, well, was that the cause? Or is this just something that's developed after they got sore?

Frances: Yeah.

Louis: So kind of like if you roll your ankle, you'll limp on it. Yeah. To take the pressure off. I think that it's reasonable to say that the muscles, the shoulder are gonna start to behave a bit differently when you're already sore. So it's kind of like a [00:14:00] limp. Yeah. So nobody, nobody looks at someone who's sprained their ankle and say, well, maybe if you weren't limping, you wouldn't have sprained it.

Frances: Yeah.

Louis: Like that's just, that's just bad reasoning. So, and, and I think it's kinda similar.

Frances: Yeah. I love, I love that idea because I feel like that's how I've started to really think about so many things. I see. The person comes in in pain. Cause that's what we usually see as physios. And then they're moving in this slightly abnormal way on that side. And then yes, we blame that and go, oh, that must be why, but exactly what you're saying. It could be that they're moving like that because of the pain. And so if you try and address that, it's probably not gonna get you anyway. So yeah, I love that thought and that, to me, out of like everything to do with dyskinesis is that's probably what speaks to me the most. In that, how can I trust what I'm assessing was there before? Um, and yeah, just something, I guess I noticed too, is that when someone's in pain and I'm, I know I do this, they're looking for something different to the other side and [00:15:00] attributing value, but they might have had that scap pattern forever. And then now that it's saw, you know, they're blaming that, but they also suddenly added lots of load and then, but they're blaming the abnormal movement.

Louis: Yeah. Absolutely. It's it's that, it's that whole thing around, like when we're sore, we, we go looking for answers, we go and try and find meaning and we be, we can sometimes become a bit hypervigilant. We sort of overanalyze what's what's going on here. Like, what is, what is the issue? Um, and we can pick up on some stuff that may have been there all along, but now that we're sore where we're sort of connecting the dots and they may be completely unrelated.

Frances: So my understanding is that there is some research that shows. That scap stability exercises do actually improve outcomes for people with shoulder pain. And just to clarify, like, what do you think a scap stability exercise would be? Like, I remember at uni, it was those weird lie on your stomach and do like lower traps. [00:16:00] And then I feel like, do you think those it, Y exercises, are they kind of scalability or what do you think?

Louis: Yeah, I think it depends on who you ask honestly. Right. But the idea is. If the scapular has to form a stable base for the glenohumeral joint to function on. Yeah. So if it, if it's not, if it's not set enough or not sort of absorbing enough force, then there's more load on the rotator cuff. But like I said before, the scap or the joint between the scapular and the rib cage is it's, it's quite a unique joint. And the only boney attachment between the shoulder blade and the body is by the collar. yeah. And the rest of it is just supported in, in muscle. It's like, like Jared Powell says it's suspended in a sling of muscle.

Right? So it's, it's not a very stable arrangement, right. It's just sort of on your chest wall anchored by muscle. So to call it stable. And if you look at how it moves, when we go there and it has to move around and turn up and down, it's not set in place. So no, I. When we talk about scapular [00:17:00] stability exercises, often we are talking about contracting those muscles or setting it in a certain position to try and take stress off part of the shoulder.

And, and I think these types of exercises have been proven to work for pain, but interestingly, that has nothing to do with changing the position of the scapula. Yes. So we, we've got a couple of RCTs. Now that show that you give the person a program and you watch 'em over a period of like six to 12 weeks and people get better and sometimes significantly better, but their scapular motion and timing of how the muscles work doesn't change.

Frances: yeah.

Louis: Despite the fact that that's, what's been emphasized, it's just exactly the same as, or a baseline. Yeah. Probably one of my favorite ones was done by Philip STR and colleagues in 2012. And it's one of the best described RCTs I've ever read.

Philip and these guys, they, they really went into a lot of detail about each innovation and they talk, they talk you through every step and like every progression and regression and how they told people to avoid pain and all [00:18:00] these things. Right. And so they had they two groups with shoulder pain and a possible dyskinesia, and one was assigned exercises with like a heavy emphasis on where the scapula sits and working those muscles. And the other one was given more general exercises for the rotator cuff and a friction massage.

Frances: Okay.

Louis: In this study they found that the scapular exercises seemed to help more than pain with pain, I should say than the other one. However, it did not change the rest of the position of the scapula, right. Or how the scapula moved.

Frances: And I'm like curious. Now did the rotator cuff exercise group have a lower total dose of exercise?

Louis: Yeah. I was about to comment on that. It seems though they didn't do quite as much work, which does make things that, that again is a variable that maybe control well, um, yeah. . I mean, it, it, it kind of shows that this stuff can work, right. It's not that we have to throw the baby out the bath water. We can do exercises targeting the shoulder and the, so the [00:19:00] scapular muscles, I should say, but we don't have to go with the narrative of we're correcting your position because we're not. Yeah. Like that's just not, that's not true. Yeah.

Frances: And I guess it's like, that's the whole can of worms with exercise as a whole, in that even saying, like, I know there's been lots of discussions about do, is, does it actually make you stronger? And these types of. And it's like those narratives, like we're correcting movement or we're making you stronger, which sounds so obvious. It's actually not happening. So exercise, but exercise still works. And like, I love, I love that idea. Like I feel it's given me so much more freedom with how I prescribe stuff.

Cause I'm like, ah, it's, it's doing, I it's not correct. It might be correcting, but it's loading the part that hurts or it's getting you doing something that you thought you couldn't do before or building capacity. Like, whatever it. Yeah, so, but those things of it's "fixing your position". And the reason I asked about the workload was just because it reminded me of, I did it's slightly different.

It was rotator cuff tendinopathy, but there was a systematic review, I think last year. Cause I [00:20:00] did it for one of my assignments that was trying to look at whether like dose was relevant. Rotator cuff tendonopathy, which is like in the ballpark of what we're talking about. And it kind of, it was quite, there wasn't that many studies, but the thought was that whether it was higher load is in like weight or higher volume, it didn't really matter.

As long as you were doing more like the higher, the work load, the better the effects, which I thought was really interesting too, which is that idea of find something they can do and do heaps, just like make them do it often. And so I like that. And it's probably scandalous stability exercises are quite low, not very provocative of pain.

I reckon people in pain. So there might be a good choice, but the way we phrase it might be different.

Louis: Yeah, definitely. And it's not that they're bad options, right? It can, it can work for people. It's just not working for the reasons that we used to think it worked. Yeah. And that's, that's fine. But I think we probably need to shift the emphasis. Just doing stuff that people can tolerate that builds their ability to do stuff they wanna do [00:21:00] versus correcting dysfunctions.

Definitely. So I just have one more question, which is, if someone does come in with shoulder pain and their shoulder blade is moving abnormally and like say they, you know, they might notice cuz now that there's YouTube and Instagram, people are more clocked onto.

Frances: What might be going wrong and they might say, oh my scapular, move's funny. I have winging, I have scapular winging. Like I've been trying to fix it. And it's, you know what would you do? Just a general.

Louis: . That's I could go on for a while about that, but I think I'll try and keep it fairly brief, but I, I think probably the more common scenario is that, like, there might be some very. Asymmetry of scapular movement that I think is probably just normal and normal variation, but often people, or some people can feel like something really funky is going on there.

They're like, I feel like it's not seen right. It feels like something's wrong, it's moving wrong. And, and I think that like altered sensation of scapular movement, [00:22:00] Maybe like just a bit of a compensation to something going on with the rotator cuff. And that's actually supported by some of the research.

I know there was one RCT that looked at like how the shoulder blades move and when people do and don't have shoulder pain and in that study, they actually saw that people with shoulder pain actually rotated their shoulder blades upward more than the people. which is interesting, right? Cause that's, yeah, that's almost countered to what people think they think.

Well, no, it's not moving up enough that in this group is like they would, they were doing it more interesting. And, and perhaps that's that limp we're talking about. Right. There's just that slight change in how stuff's working, because they're important to get your arm up overhead. Your cuff is overloaded.

It's cranky. It's not really doing it's job very well. And now. Changes the behavior and how it feels.

Frances: That makes sense, like a hitch, like the thing where we do that.

Louis: Yeah, totally, totally. So I, I think that, like, I tend to, maybe I I'll obviously not dismiss the thought out of, out of [00:23:00] hand or I'll have a good look at it and I guess validate the way they're feeling, but also explain that look, there's nothing too funky going on, perhaps cause the cuffs a bit overworked, a bit grumpy that these muscles are having to work much harder to get the up over.

Okay. And, and maybe by getting rotator cuff doing a bit more and desensitizing it through rehab, we can actually get those muscles working a bit more like they normally would, or take a little bit of a load off and shifted elsewhere. Yeah. And then I I'll, I'll always look at like, yeah, assessing a person's rotator cuff strength or tolerance to, to pushing hard or like endurance and those things and trying to give somebody something to focus on that I, I tend to go with.

That Joe Gibson approach to that, to be honest, which she talks about the, the scapular muscles and the, she talks about the scapular muscles and the rotator cuff muscles are like G and T. Okay. They should never be, they should never be separated.

Frances: Yeah, I totally.

Louis: So, yeah. So I think I will, I will focus on a bit of that, but I'm certainly not necessarily telling people that I, yeah, your, your shoulder blade's gonna fall off your chest wall or anything that that's, [00:24:00] that's not really supported.

Frances: Yeah. And I guess The idea that they don't work separately is obviously really logical as well. Because as soon as you lift your arm, they're both gonna work. Like you can't isolate them. It's impossible. No. So definitely strengthening one. You're probably drinking other and yeah, I was just gonna say that.

The time when I saw the most kind of extreme example of scapula dyskinesis was when I was working in the UK. I've talked about this before. People had these really hyper, like very unstable shoulders as in truly unstable sort of slipping out of the socket, just with little movement kind of level, and their scapulas would do this huge... You could see the inferior angle, like winging big time off at the back. And you could just tell intuitively , that's not the issue here. And Anju Jaggi, who is this awesome physio I worked with over there explained it really well, which was that like, if your shoulder is gonna sleep off the socket, your body is gonna do whatever it can [00:25:00] to keep it on.

And so your scapula is gonna get under there and try to get under that, that bone and try to hold it in place. And so she kind of agreed that like the muscles that hold the rotator cuff, the muscles that hold the bone onto the socket is your rotator cuff muscle. so you really need to strengthen those to hold it in place.

And then the scapular muscles are kind of secondary. So it's probably going with what you're saying that rotator cuff is where it's at. And I suppose, I mean, rotator cuff exercises, again, like every exercise is rotator cuff exercise. So the world is our oyster really!

Louis: Yeah, totally. There's lots of options. Hey, it's just about finding what's gonna work best and what a person responds best to, and that can be a bit of a process to trial and. .

Frances: Yes. Okay. Well, I feel like we've covered everything I wanted to say. Unless there's anything else you would like to add?

Louis: No, that's great.

Frances: So this was the best ever. Thank you so much. And I'm hoping that anyone watching next time you see one of those "fix your..." And then it's like scapular winging or something. Just [00:26:00] remember this conversation and that it probably doesn't really matter and just gets strong and that's it.

Louis: Cool.

Frances: All right. That's great. Thanks. Well, I'll see you soon and I will see everyone else doing another Instagram live in a few weeks.

Louis : Sounds great. Thanks Frances. Okay, bye.

Should you rest if you have an injury? Or push through some pain?

Sat, 02 Jul 2022 10:36:52 GMT

Something that comes up a lot during my physio consultations for someone in pain or for people in my group classes who may develop a niggle is this.

If you have pain, should you rest it, or work through it?

The idea that you need to rest if you are injured or in pain is a bit of an outdated one.

In my opinion, the idea of resting an injury is an incomplete sentence:

You need to relatively rest the injured area, temporarily , and then as soon as possible, gradually re-load it again.

Too often, people see a healthcare professional and are told to ‘rest’ - an ambiguous term with no real direction.

It is often taken quite literally, and the person may reduce their activity levels significantly for a couple of weeks, only to find they keep getting re-injured every time they try to get back into their old routine.

At the worst, this can lead people to giving up an activity altogether, thinking they are just “too old” for that now, or that their body just “isn’t suited to it” (unfortunately, ideas often perpetuated by clinicians they have seen).

The idea that if you just rest an injury it will heal is flawed. The tissues that are damaged may heal, but they also will lack the capacity to tolerate loading and use like they did before - firstly because they have suffered an injury, and secondly because there has been no specific work to restore them to their original capacity (or beyond, as the injury likely happened for a reason).

On the other side of the coin, there are also patients I see who have had an injury niggling away for months and months but have never actually tried reducing the frequency or intensity of the painful activity.

I get the logic - you want to be able to run, it hurts when you run, stopping running would be giving in and not really fixing the problem, so you haven’t tried it. But no amount of corrective exercise/ massages/ dry needling sessions will do anything if there’s a problem there that is triggered by load. Reducing that particular activity slightly, just so that you can tolerate the movement without flaring up symptoms, can be helpful.

Of course, it also depends on a few other factors, so here is a bit of a list of things to consider:

Whether the pain is made noticeably worse with use, and feels better with rest. (Usually a sign some form of load adjustment has to be made).
The actual diagnosis. Some things need offloading. Other things don’t.
How new or old the pain is. Newer and more acute pains or injuries are more likely to need some initial off-loading.
How severe the pain is - see the infographics below.
If you have been avoiding use of the injured part and it isn't getting better, it is likely to need increased use and there may be some discomfort associated with this that may be part of the process (this is an art!).

Some other things to consider:

If you need to pull back a bit, do not stop completely. There should be a way you can keep doing SOMETHING, as close as possible to ‘the thing’.
Avoid ‘the thing’ for the SHORTEST period possible and gradually get back to it as soon as possible.
Avoiding movement for a long time causes lots of problems, and can make non-painful and non-threatening movements start to hurt.
Your body becomes sensitive the longer a pain is present, and it can make pain signals become less trustworthy the longer you have been in pain.
Pain does not always equal damage, particularly once it has been persistent for a long time.
Loading an injured body part early can help the tissues to rebuild more effectively and more quickly than if you offload it, particularly in an area that is used to being loaded a lot (e.g. your lower limbs).

Of course, this can be really hard to figure out on your own, which is where my role as a physiotherapist steps in!

This is particularly true as I know people are often worried that they will cause permanent damage if they keep working through a pain. I actually think ‘permanent’ damage is extremely hard to do.

If you injure a tissue in your body, it can heal again. Pushing through pain may make something take longer to get better, but it is very rarely going to do anything irreparable. The human body is pretty good at getting on with things.

So much more I could say, but that can wait for the next blog!

Hopefully this has been informative and helpful and something you can consider next time a pain crops up.

Please note: though I am a physiotherapist, none of this is intended to be taken as personalised medical advice, and is intended to be generically educational in nature.

Outer elbow pain ("tennis elbow") - what it is and what to do about it

Fri, 13 May 2022 10:48:29 GMT

Tennis elbow is the term given to pain that is felt on the outside of your elbow.

This pain is actually coming from the tendons of the muscles that pull the back of your hand towards your forearm. So it is actually a Tendinopathy (this word means a problem with the tendon). It’s medical name is lateral epicondylalgia, which just means, truly, pain on the outside of the elbow.

The reason it is given the name tennis elbow is because it can be common in tennis players who can develop the pain as a result of gripping a tennis racquet and/or from the force going through the wrist extensor muscles with certain shots, particularly back hands.

So why does it happen?

Tendinopathies almost always happen as a result of a tendon being asked to do more than it is currently conditioned for.

This means, basically, that the tendons around your elbow (when pain free) are able to tolerate what you ask them to do day in and day out. Your tendons can adapt and learn to tolerate more load, however, this needs to be done gradually and they need adequate time to recover before they are exposed to the same amount of load again.

What your tendon can handle will vary depending on who you are, your history, age, etc. But if you suddenly start demanding more of your wrist extensor muscles you may find yourself in a situation where the tendon becomes broken down instead of getting stronger, which actually weakens it, and makes it less likely to be able to tolerate things that it could before.

Here’s an example:

You move house over the course of 4 days, repetitively lifting boxes etc.
When you get to work the next day, you notice sitting at your computer that your elbow hurts when you type.
Then, when you go to the gym later, you notice it hurts to grip the weights machines.
After a couple of weeks with no improvement, you now notice it starts to hurt even reaching to pick up a cup.
You start using it even less, trying not to move it, but then it hurts to type, or use it at all.

Here are a bunch of potential things that may lead you to use the muscles at the back of your forearm more frequently, and develop this pain:

Typing more
Typing more with your wrist in more of a bent back position (e.g. with your forearms hanging off the desk. This happened to me after a 2 x 12h day assignment effort last year)
Gripping more
Gripping something wider than you are used to (e.g. using a fat bar at the gym, changing tennis racquet handle)
Using your arm a lot more (e.g. moving house, gardening)
Lifting heavier weights
A weakness in your shoulder that may mean you are using this area more
A change in your technique of a particular exercise
And many other things potentially.. !!

The pain can honestly get pretty severe and it can be a pretty annoying issue to develop. But rest assured, there are things you can do!

What can I do?

Number 1: Figure out what has brought it on & do a bit less of it

The number one thing that you need to do for any Tendinopathy is to figure out what you are doing that is using it repetitively that it doesn’t like and reduce this. This is a bit of a delicate balancing act where you want to reduce the painful thing JUST enough to allow the tendon to recover a bit, but not so much you are doing significantly less than normal, otherwise you will lose strength and capacity really quickly.

It is ok if your tendon feels a bit sore sometimes when you are doing things, but anything that makes it very sharp or very sore for hours afterwards is probably too much.

It really depends person to person and how bad your symptoms are (hence why it is best to seek professional advice).

Here are some ways to reduce the load on the tendon:

Hold things in your other hand
Avoid having your wrist bent backwards when typing (e.g. put something small under your wrist)
Avoid things that require a prolonged, strong, or wide grip (at least avoid doing more than you normally would of this)
Avoid going lifting heavier things than you normally would
Avoid anything that means you need to repetitively lift your wrist or fingers backwards
If you do carry something heavy, try to do it with your palm facing upwards, rather than back of hand facing upwards, as this uses the muscles on the inside of the forearm more than those on the outside/back

Note: The reduction in load/use is TEMPORARY. They are simply to offload the tendon while it is a bit more tender, and then you can gradually re-introduce them again.

Number 2:

If you just rest, the tendon remains ‘unhealthy’, and will probably hurt again when you try to use it. The ONLY way you can get the tendon to be able to handle being used without hurting again is to progressively strengthen it.

Here are a few exercises you might want to add in to start to address the problem.

NOTE: NOT to be taken in place of medical advice and i advise you seek advice and guidance from a physiotherapist before starting these.

Start with isometrics for pain relief:

Progress to through range wrist extension:

Add in pronation and supination:

Note: these are best done under the guidance of a rehab professional, as it can actually be quite hard to get the dosage right. If you've tried these and it didn't get better, it is probably not that you did them wrong, but more that the dosage & other lifestyle modifications weren't quite accurate.

Should I have an injection or wear a brace?

If you have a cortisone injection, you weaken the tissues, and though you may feel better at 6 weeks due to the anti-inflammatory effect, the research indicates you are actually likely to be worse off at one year (1).

Other treatments like shockwave, ultrasound, dry needling, PRP massage, etc, will not make the tendon stronger again . Passive treatments (where something is done to you as opposed to you doing it) are generally not effective for Tendinopathy in the long term as they do not actually improve your ability to function and are often targeted at trying to heal the tissues, or reduce the pain, without actually improving the tissue’s ability to handle force, which is what the problem is here.

If you just do ‘rehab exercises’ but don’t address the ‘why’ it started, it might not get better.

Tennis elbow bands have no serious negative consequences, and may be helpful for temporary pain relief for some. If you are struggling and the pain is quite severe, and you find the brace helpful to keep you training, or to manage symptoms at work, there is honestly no harm at all, though it won’t fix the problem.

How long will it take to get better?

Tendons can be quite slow, to be honest. If you do nothing at all, tennis elbow is likely to get better on its own but it may take up to 18 months. Depending on how long you have had symptoms for, it can take quite a few months even with rehab, but the good thing is if you do rehab properly, it usually means you can keep doing the things you want to be doing to some extent, and progressively more as you stick with it for longer.

How can I prevent this happening again?

Maintain good strength through your upper body. Doing regular strength work for your entire upper limb is likely your best bet at preventing this sort of problem in future.
Avoid sudden dramatic increases in load. If you take up a new hobby, try to do it in a somewhat gradual way, with days off in between each use.

Additional note: sometimes, persistent pain such as that with tennis elbow can have other elements that contribute to why it has been sore for so long, such as your nervous system being extra sensitive, or involvement of the nerves close to the area, but that is beyond the scope of this post, and still addressed by the strategies outlined above.

Struggling with tennis elbow? Head over to the ‘book now’ page to make a time to see me either online or in person.

References:

(1) Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of Corticosteroid Injection, Physiotherapy, or Both on Clinical Outcomes in Patients With Unilateral Lateral Epicondylalgia: A Randomized Controlled Trial. JAMA. 2013;309(5):461–469. doi:10.1001/jama.2013.129

Health behaviour change: small, sustainable changes

Sun, 13 Feb 2022 11:41:44 GMT

While it can be tempting to want to go 'all or nothing' and start that extreme diet, or take up going to boot camp at 6am every day (when you normally exercise once a fortnight, and don't like getting up early...), in the long term, extreme approaches are not sustainable. Here are some tips that may help you make a behaviour change that lasts!

The "all or nothing" mindset is ever present in the health and fitness industry. It is a strategy that is destined to fail. It works on the premise that people just need to be more disciplined, and if they just had enough willpower, they'd be able to achieve everything they desire.

Except that this is not true. Almost no one can do things they hate, or make significant sacrifices on a daily basis, forever.

For example. If you go on a diet, inevitably, you will get hungry. Sure, you may be able to power your way around that hunger for a few days ...

(note: i do not recommend this, ever. Going hungry on purpose makes no sense. It is not a sign of willpower to intentionally go hungry, it is a sign of depriving your body of something it needs, which for some reason society marks as admirable, but I disagree. Check out 'Maintenance Phase' podcast if you want your mind blown on the extreme anti-fat bias that fuels the diet industry and doesn't actually care about your health! but I digress..).

As I was saying. Almost no one can intentionally go hungry, indefinitely, forever. Inevitably, you will get really hungry, and eat probably more than you need when you finally "give in" (hormones have a role here. Not my area, not going there in any detail.). This is not because you are weak. It is because people generally do things that feel good. We are humans. It is our human nature. Forcing yourself to do something that feels bad is not sustainable for most people.

The same is true for exercise.

If you hate getting up early, signing up for a 6am boot camp 5 days a week on some sort of intense discipline 'health kick', will not last.

Again, annoyingly, the internet seems to applaud early morning risers, as if they are somehow superior to the rest of society, and that all people who are fit and healthy achieve it by getting up at 5am. Please, ignore this rubbish. Everyone is different. Any statement that attempts to encompass EVERYONE (note: i try to keep my language to 'most' rather than 'all'. Feel free to correct me if I miss one.) and say that EVERYONE needs to do "insert health habit here"... then they are probably not someone who has successfully helped a wide variety of people achieve sustainable change. What has worked for one wont necessarily work for all.

So... what can you do to achieve long term behaviour change, like making healthier food choices, or establishing a regular exercise routine?

My top tips:

Start gradually & set small goals

My first recommendation is to introduce things GRADUALLY. If you make small changes, and set small goals that you progressively tick off before coming up with a new one, you will have a continual sense of success which can make it easier to make continual progress.

Avoid: for example. If you say, 'I'm going to the gym before work every day this week!' but then miss Tuesday and Wednesday, you're likely to write it off, and start again the week after. Then you might not feel like it that Monday, and promise yourself you'll start the week after... and then it never happens.

Instead: Pick something that is definitely achievable, and probably much less than your ultimate goal. So if you currently exercise once every 2 weeks, firstly set the goal to exercise once every week. When you have successfully implemented that for a number of weeks, and it feels almost second nature, then consider adding a second day. This way, you may end up achieving a goal of exercising 5 days a week, but you will gradually work your way there, figuring out strategies along the way that help you to keep up consistency.

This approach also allows you to cope with challenges, for example if you miss a few days, or even miss a week, because you are coming at it from a more balanced mindset, there's no need to 'get back on the wagon' as there is no wagon in the first place, just a continual gradual progression towards your goals.

Choose things you LIKE.

Avoid: deciding to take up running even though you hate it. Forcing yourself along to gym classes you don't enjoy. Pack yourself a lunch of chicken and salad that you don't like the taste of.

Instead: Honestly, not many people can stick to doing things they dont like, as i said earlier. Be honest with yourself. If you hate running, truly, there is no point in attempting to become a runner. It won't stick. FInd something you like, and start with that. I have found that if you get in a habit of doing a type of exercise you enjoy, you may enjoy the benefits of exercise enough that you are then willing to branch out into occasional dabbles into exercise you don't enjoy as much, but want to reap the benefits of. Same goes for food. Find healthy and nutritious foods you truly like the taste of, and stick to trying to eat more of those.

Avoid goals rooted in things you can't easily measure or directly control, for example: "i want to get more fit", or "i want to lose weight".

I want to get fit is not easy to measure. You might exercise every day for a month and not actually know if you are fitter or not. It can be hard to stay motivated when you cant see any results. It is better to quantify goals based in an actual behaviour that you control, for example, "i want to be exercising 3x per week by the end of March". Then you can know if you have achieved it or not.

Wanting to lose weight is also actually an outcome, not a behaviour, and seeing as it is VERY challenging to achieve, it can be extremely disheartening if you choose this as a way to measure progress. Weight loss depends on a whole host of factors. Again, you may successfully take up exercising 2-3x per week and manage this for a year, but not lose weight. Some may view this as a failure, if they are looking at it from a weight loss lens. Choosing an outcome as a behaviour change goal, rather than a behaviour you can directly influence, is destined to result in disappointment.

For the record as well, making changes to your health can happen irrespective of your weight. Weight loss is not the holy grail of health.

Schedule in your exercise

This is really important. If you wait for the right time to exercise, something will always come up. Exercise should be like an appointment in your calendar that is non negotiable. I know this won't suit everyone, but if you are serious about making a change, this is a big thing. I am lucky in that I can now schedule it into my work diary. It is blocked out and nothing is allowed to take it's place (urgent patients sometimes, but not often).

Once you have scheduled in the same exercise for a few weeks in a row, it is likely to start to feel like a routine, and feel weird if you don't go. This is how habits are formed!

My personal experience

I have exercised 6-7 days a week for longer than I can remember. I am not disciplined, or highly motivated all the time. That is not how i would describe myself. Even when I dont really feel like it, I will almost never take time away from the gym (though lets be honest it is quite rare for me to not feel like going to the gym). I also would say I eat pretty 'healthy', I don't do 'cheat' meals (no need for these if you arent dieting...) and rarely have fast food (because I honestly don't like the taste).

But this is not because I am on a diet, have lots of will power, or lots of discipline. Because I would say that I honestly just eat food that I love. I HATE being hungry. I do not eat food i don't like. I have made a conscious choice to find out what foods that are nutritious that I like the taste of, and eat these most of the time. I honestly look forward to every meal I eat because I love the foods I have chosen. I dont deprive myself of less nutritious things that i like purely for the taste, like prosecco or chocolate, but i definitely have them in moderation. I am lucky that I am able to do this, and i know it is not this simple for everyone, but I really object to all the hardcore diets out there that people suggest, indicating that this is the way forward. That is NOT what health is about.

I also am lucky in that i LOVE exercise. I really love going for a walk, training in the gym, doing Les Mills Classes. I got into the habit years ago of going to the gym almost every day, and as I said, it's now scheduled in to my diary. I do not even think about going to the gym, I don't 'make a choice' to go, something that would require consistent motivation and willpower, I just have it in my diary and I am going, and that's that. It is as much a part of my life as work is. I work towards goals which helps me to feel satisfaction time to time when I achieve something new, and sometimes I try something new to explore other options for the future. I hate the feeling of barely moving, and so I do what I love, which is to move. I do not think of exercise as a way to punish my body for eating food, or to change how it looks. I do it because I like how it feels, and I have grown to truly love my body for what it can do for me over the years. I have found this has been quite a helpful and positive mindset change.

One more thing. I hate getting up early. When i lived in Melbourne, I took a 6am Body Attack class 3x a week. So I got up at 5am, 3x a week, for 3 years. I gave it a shot. I hate it. The scheduled exercise I mentioned above? It's in my diary at 8am. Physios usually work til 7pm, so it works.

Since coming home, I have filled in one 5.30am Attack class for someone who had COVID as a favour, but that's it. I have successfully achieved 'regular exercise' , starting up and running a business, and doing a Masters mostly full time in that time.

All while (almost never) getting up before 7am.

This is not to boast, but to demonstrate a somewhat success story of someone that does work hard, but does not go on about how much willpower I have or that the key to success is to get up before 5am, etc etc etc. I also quite enjoy my job. I was 100% burned out working for someone else, and I worked overall much less than I do now.

How we feel really dictates a lot of what we can cope with, I think.

Hope some of these tips resonated! Here's a few more , in video format:

Too much, too soon... followed by too little

Sat, 12 Feb 2022 03:07:26 GMT

It's the new year. You want to make a change to your fitness NOW. So you've started going to the gym every day. But... 3 weeks in... and... something doesn't feel right. So you rest for a week and it feels ok, but as soon as you get back into it, it's back.

Sound familiar?

A "load management error" is one of the most common things I see in practice!

This is usually something along the lines of doing too much of something, too quickly, after a period of doing too little in the period before it. This can be problematic because the soft tissues are not conditioned to be able to handle that amount of loading, at that time.

If pain begins at this point, it can result in a period of total and prolonged rest (unfortunately often this is what is suggested by health professionals), which reduces the tissue tolerance even MORE.. making it impossible to get back to the desired task, even at a lesser intensity.

You may also have been advised that this problem is a result of a certain technique flaw, and if you just change your technique, your pain will go.

Sometimes changing this may address the issue. But in the case of rehab that just isn’t getting anywhere, it may not be the right focus, as changing technique only moderately alters how much you load certain tissues. If a tissue is irritated this may not be enough.

Bear in mind too we often move differently once in pain (think: limping), so “correcting” faulty movement patterns in someone in pain may not always make sense!

So if you have “corrected” technique but the pain keeps coming back, consider, have you also managed how much load is going through an angry tissue?

If you keep getting pain when you hit a certain point, or every time you come back from resting, this may be the issue.

Do a bit less, allow the tissues to recover, then gradually do a bit more.

It doesn’t mean you are copping out by doing less of the thing that hurts. You can do modified versions of it and you can also use the time to adjust those movement patterns you wanted to.

Try finding what you can handle (establishing baseline), do just a bit less than this, and do that more than once a week, instead of perpetuating the too much / too little cycle.

If your physio / doctor tells you that you need to just rest, do less, that you are ‘over-doing’ it, with no plan to find your way out of this.. time to find another one!

Get in touch with me now to discuss this if this has happened to you - see the ‘physiotherapy services’ tab, where you can book a free 15 minute phone consultation, send me an email, or book an assessment.

How does online physiotherapy work?

Wed, 12 Jan 2022 00:38:07 GMT

Don't you need to be able to feel my joints and perform manual techniques on me? How can you do that through a screen?

Not necessarily.

"Traditional" physiotherapy may be more along these lines, where you need to be manually assessed and a manual treatment performed in order to facilitate recovery.

But a more modern approach to musculoskeletal care does not look quite like this.

In 80% of cases, a diagnosis can be made from the an effective patient interview alone (Maude, 2014). A thorough, in depth discussion about your problem, can reveal a lot about why it may have begun. And to be honest, this is often done very poorly in practice, particularly if a healthcare provider is short on time. This is something that can be done very effectively, with lots of time available, through Zoom.

Sometimes, you may need a physical examination to confirm or rule out a condition, for example in the case of a suspected ACL rupture. This is not always the case however, and if a physical examination is required, referral to a local clinician with specific instructions about what to screen for can be made.

In terms of treatment, mostly this can be done remotely as well.

Two of the main recommendations for high quality musculoskeletal care are to:

- provide appropriate advice and education, about one's condition, and

- To provide active treatment strategies

(Lin et al., 2020).

Manual therapy is to be used as an adjunct to these treatments only, as recommended by Lin et al. (2020) in a systematic review discussing what constitutes best practice care for musculoskeletal pain. That is, it is an optional extra. Advice and education, on the other hand, is considered essential, though researchers have found that appropriate advice is given only 20% of the time in a primary care setting.

"Just rest it and take a few anti inflammatories, and go and get this MRI" sound familiar?

Telehealth physiotherapy can provide much more than this.

Here is what one of my Telehealth consultations generally looks like:

An depth conversation about the reason you sought out advice from a physiotherapist.
Identify what has led to the pain/injury starting, and come up with a potential explanation as to why.
Discuss what you think are the main reasons the problem has developed, and what you have figured out help so far.
Go through a physical examination (you doing certain movements) to figure out movements that trigger the symptoms, or that may be different on one side compared to the other..
Work together to come up with a plan, that involves
A. Education on why you may be in pain so you know what you can do to start getting back on track.
B. What you may need to do a bit less of for a period of time to let things calm down.
C. What you can do more of instead to make up for that.
D. What you may need to do a bit more of right now to build up your capacity.
E. Specific exercises to achieve these things, if necessary.

This can be done with no travel time, from the comfort of your home, and fit around your potentially otherwise busy day.

If you're interested, head over to 'physiotherapy services' page and book yourself in for a consultation. Or, a free phone call to learn a bit more about how I may be able to help.

References:

Maude, J. (2014). Differential diagnosis: the key to reducing diagnosis error, measuring diagnosis and a mechanism to reduce healthcare costs. Diagnosis, 1(1), 107-109. https://doi.org/doi:10.1515/dx-2013-0009

Lin, I., Wiles, L., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., Straker, L., Maher, C. G., & O'Sullivan, P. P. B. (2020). What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med, 54(2), 79-86. https://doi.org/10.1136/bjsports-2018-099878

How low back pain is managed can dictate its chronicity

Wed, 01 Dec 2021 13:02:59 GMT

Which of these sounds like you?

HYPOTHETICAL: NEGATIVE PAIN EXPERIENCE LEADING TO CHRONIC SYMPTOMS

Imagine this. A fit and active young person hurts their back. Feels a giant terrifying snap and extreme pain. Goes to the hospital, gets an MRI which shows a disc bulge. Told it isn’t serious, yet, but it could get worse, and could progress onto the nerves, causing pain in the legs which might require surgery. Is told to go home and wait for it to get better, and if not return to see a surgeon.

Person goes home and googles back pain. Learns that flexion makes the soft inside of the discs ‘explode backwards’ like a jam donut. Thinks this will happen and lead to needing surgery. Becomes petrified of bending forward. Takes to bed for a few days to help the extreme pain go down, as the intensity of the pain must be linked to the severity of the injury.

While lying in bed, person becomes deconditioned, which happens rapidly if you stay lying down a lot. The person finds even any tiny forward bending hurts and is petrified that means more damage is done. Stops bending forward. Back starts to hurt all over, all of the time due to being super stiff and rigid, and now hurts even to stand up, as has lost strength to stay up for long periods against gravity.

Back still hurts 6 weeks later, when it should have healed. By this time this person has had the whole time off work, unable to tolerate sitting up at a desk and having been told sitting is bad for disks. Has quit the gym as knows lifting will make the disc bulge more. Has started to feel depressed and isolate from friends, telling everyone that they have ‘totally stuffed up their back’ and starting to panic about maybe needing surgery.

HYPOTHETICAL: POSITIVE PAIN EXPERIENCE REDUCING RISK OF CHRONIC SYMPTOMS

Now imagine the same person from the scenario I posted a few days ago. A fit and active young person hurts their back. Feels a giant terrifying snap and extreme pain. Goes to the hospital. Is advised that there are no ‘red flags’ and that while the pain is severe, the injury is unlikely to be anything serious, the pain is related to inflammation. Person feels relieved, and pain even feels a little better knowing that there is nothing serious going on. Person is referred for physiotherapy to guide them back to movement safely.

Physiotherapist tells the patient that it is safe to keep moving as normal, even to bend and twist, as avoiding these movements is likely to make the back even more sensitive if it is to move in that direction. The patient is advised to try to stay active and avoid trying to sit up excessively straight, or hold their back rigid, as these things can make the whole back feel sore due to muscular fatigue.

The physio also shows the patient all the movements at the gym that are still ok to do, even in the acute phase of low back pain. The patient does a few of her usual gym exercises, gets some endorphins, realises she isn’t ‘broken’, and feels optimistic!

After a few days, the acute inflammation is less, and while the patient feels a bit stiff, she can still do 90% of her gym workouts, which helps her to feel strong and in control. After a few weeks, she gradually starts introducing the exercises she was initially told to avoid, and finds that after a few weeks of this, she is back to normal.

Obviously these are invented scenarios and the second one is very “textbook”. But both things happen. The EXACT same injury can literally end up as polar opposite as these two presentations at 6 weeks.

Does this resonate with you? Feel free to leave a comment or get in touch!

Why does the front of my shoulder hurt with bench press and push ups?

Wed, 01 Dec 2021 12:14:36 GMT

Pain at the front of the shoulder is a common complaint with bench press, push ups, and tricep dips. But why?

When you do certain things like push ups, dips, or bench press, there is a lot of pressure on the structures at front of the shoulder. This includes the biceps tendon, shoulder capsule, acromioclavicular joint, the end of the collarbone (clavicle) itself, and the rotator cuff tendons. This is ok, and safe, and your body can get used to it in most cases (people with significant instability and history of dislocations may need more targeted advice). But this may take time, and during that time, you may feel pain.

There may be reasons why your shoulder may be moving more than normal in the socket, causing it to put more pressure on these structures. This may happen if you have slightly stretchier ligaments (hyper mobility), slightly less strength or stiffness in the muscles, a history of repetitive micro trauma which stretches out the joint (e.g. gymnastics, bowling, pitching, swimming), or even just are born with a slightly different shaped bone structure that means the joint moves a bit more than in other people.

You may notice your shoulder crunches or clicks a lot if this is the case , which in itself is not dangerous, or harmful, it just means that the shoulder is moving around within the socket and causing these sounds. None of this is necessarily a problem. It may just mean a little more focus on improving the stability of the joint is required, to reduce the amount of movement of the ball on the socket with movement.

What does this mean? 2 things.

One: Gradually get your shoulder used to pressing in the direction that is painful (horizontal pressing): bench press, chest press, push ups.

How?

Start with horizontal pressing movements that don’t hurt. This may involve reducing the range in some way, so doing a push up halfway down only, doing a bench press to a block. It may also involve reducing the load, so doing push ups from the knees, or doing bench press with a lighter weight.

People are often hesitant to do this, but it is ONLY TEMPORARY , and it is better than pushing through and never getting better, or stopping all together and resting!

You may also need to reduce how much of these you are doing, for example, only do these movements twice per week, and relatively low sets, perhaps 2 exercises, 3 sets of 10-12 each, twice a week. So a total of 12 sets of reduced load/range horizontal pressing movements per week to begin with (as a suggestion).

Two: Keep your shoulder strong by doing other shoulder exercises.

You will be able to find positions and movements that don't hurt. Back exercises or pulling exercises such as rows, lat pulldowns etc often feel fine. You may also find that overhead press feels ok, but only on a certain angle.

Note: not to be taken in place of professional healthcare or medical advice.

Why is my shoulder stiff reaching overhead?

Sun, 28 Nov 2021 02:44:58 GMT

Question: why does my shoulder always feel stiff when I try to lift my arms all the way up overhead? I have been told it is because I have tight lats (muscle under shoulders) and that I need to stretch or foam roll more.

Answer:

Firstly, we must look at what is muscle tightness? My understanding is that muscle tension is a feeling that’s controlled by the nervous system. So, if your body feels it needs to protect something, an increase in tension in the muscles surrounding a joint may be part of this.

Massage, needling, foam rolling etc can temporarily tell the nervous system to “relax”. But this is temporary only. If we know the tightness sensation is protective, then let’s consider why!

To answer this specifically for the shoulder, we should first consider the anatomy of the shoulder joint.

The shoulder is a ball and socket joint. The socket is called the Glenoid fossa and it is not really a socket at all it’s quite flat , though it is made deeper by the labrum, a thick cartilage layer that creates more of a socket shape. This socket is located on the shoulder blade (scapula).

The shoulder joint on its own isn’t super stable. It needs ligaments, muscles, the labrum, and a soft tissue capsule (think glad wrap or cling wrap around the joint) to make it so. When you try to reach upwards, your scapula needs to rotate upwards too, as the ball is sitting on it. To remain stable, the ball needs to be centred right in the middle of the socket. This requires the muscles controlling the ball on the socket (rotator cuff muscles) to do their job, as well as the muscles around the socket (scapula muscles) to keep the socket sitting underneath the ball.

If the ball isn’t sitting securely in its socket, the muscles all around it may work extra hard to try to make sure it is stable. This may be the muscles around the ball and socket joint trying to hold it in place OR it may be that the socket on the scapula moves to try to stay under the ball, which can make all the muscles around the shoulder blade feel used or tired or “tight”.

If we stretch or foam roll or dry needle the tight muscles, though it may feel immediately looser and better to reach, it is unlikely to last as this is not addressing the root cause of the problem.

So how do we do that?

Generally, building stability in all directions the shoulder moves in, through full range, should help. You can try really REACHING to facilitate upward rotation of the shoulder blade, which may help.

In particular, if reaching overhead feels stiff and difficult, overhead press (OHP) may be a good option.

OHP forces the scapula into upward rotation and the socket is then facing upwards, so the muscles around it don’t need to work as hard to control on a sloping downwards surface, which maybe helps the sensation of tightness to ease.
OHP does not cause as much direct pressure on the font of the shoulder, but allows the muscles around it to work hard which may give the feeling of stability, again allowing the muscle tension to ease.
OHP puts the lats in a lengthened position so naturally may feel like it’s “loosening” them.

Some other ones I like are long lever shoulder side elevation (abduction) and forward elevation (flexion). The long lever (having the arm extended so the load is far away from the joint) challenges stability. Focusing on really REACHING can help facilitate the muscles around the scapula to lift and elevate the shoulder blade as necessary to get your arm all the way up.

Note: this is not intended in place of medical advice. Seek a professional opinion for your personal problem as everyone is different.

Having a disc bulge is not as scary as you think

Tue, 21 Sep 2021 13:13:25 GMT

" I hope I haven't done a disc!!!"

The most common thing I hear when I see a client with a painful lower back is, ‘I’m really worried I’ve done a disc’.

The idea of a disc bulge or herniation being correlated with a terrible injury is one of the most pervasive fallacies in the musculoskeletal realm, considering up to 50% of people aged 30-39 who have NEVER had low back pain have a disc bulge or herniation on imaging (Brinjikji et al., 2014). This number increases every decade.

In fact, there is evidence to show that people who receive an MRI early after feeling low back pain have a WORSE outcome and end up spending MORE money than those who don’t (Webster et al., 2013). This is potentially because being shown a disc injury on MRI is scary and worrying. It is often combined with being told that you have ‘slipped your disc’, and being advised that this can require surgery or lead to life long problems, which can cause the negative decline in function and self worth.

MRIs do have a place in the management of low back pain, and this role is to rule out sinister pathology. There are very rare instances in which there is an emergency that requires medical attention and in these cases an MRI is necessary to bring it up; however, there are specific red flags that indicate this is required. In the absence of red flags, it is NOT best medical advice to receive a scan. This is supported in the UK’s National Institute for Health and Care Guidelines regarding low back pain best practice management. It is not simply my opinion!

Your ‘diagnosis’ does not define your presentation

Someone with multiple disc bulges all through their lower back can be perfectly pain free, deadlifting heavy, and doing as they please. Someone with no disc injuries can be unable to cough, sneeze, or bend forward without pain. Whether or not you have ‘disc-like’ symptoms is unlikely to be related to the findings on your MRI.

The idea that a disc injury is lifelong, leads to problems later life, needs to be treated extra carefully, requires avoidance of heavy lifting and running, is INCORRECT. While there may need to be modifications made in the short term to aid someone to feel better, there is no reason this needs to spiral out into a long term problem.

Acute low back pain is PAINFUL and feels TERRIFYING

The reason this whole situation is so common with low back pain in particular is because low back pain is PAINFUL. The true 10/10 pains I have seen in my career have been those poor people bent over and hobbling in as a result of their sudden onset lower back pain. I have had it myself. The stereotypical ‘pop’ with instant severe pain across my back so bad I nearly passed out, with leg pain and pins and needles in the weeks following.

And it took all my mental energy to reassure myself that what I was going through felt MUCH worse than what it really was!

It is very easy to understand why someone with 10/10 pain walks into their GP’s office crying, and walks out with an MRI and a fear that they are ‘broken’. However, this pain is usually because of the inflammation associated with low back pain (and probably all those other things that affect our experience of pain listed earlier). Most of the time, once the inflammation has gone, the severe, acute pain is much less.

I understand it can feel negligent to not have a scan when they are in such pain, however in the VAST majority of cases, you will get an MRI and be told to ‘wait and see’ if your pain gets better. If it isn’t better in a set timeframe, then more treatment may be warranted. This ‘wait and see’ approach is likely to happen whether you get the MRI or not. The scan does not change the treatment path in the acute phase of low back pain. Considering MRIs are expensive, and associated with worse outcomes, and don’t actually change the treatment in the short term, it doesn’t make sense to get one in those first few weeks of low back pain, in the absence of any red flags.

So what can you do?

With an acute episode of low back pain, understanding that it is scary but probably not dangerous, and knowing that you are likely to feel better within 6 weeks can be reassuring. Finding a healthcare practitioner (physio or exercise physiologist) who will guide you through movements that you feel safe to do is probably your best option. Often, people rest completely while they are recovering and then find they keep re-hurting themselves when they try to get back to regular activities. Everyone needs a different level of support, but don’t feel afraid to reach out and find someone who can help.

I offer online consults as well as in person in Brisbane, Australia. Please don’t hesitate to get in touch!

Also, check out an upcoming blog “exercises for acute low back pain” for some movement ideas, but remember tailored exercises are always best.

References:

Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A.,. Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American journal of neuroradiology, 36(4), 811-816. doi:10.3174/ajnr.A4173
Merskey H, Bogduk N. Classification of chronic pain, IASP Task Force on Taxonomy. IASP Press; Seattle: 1994
NICE (2020), https://www.nice.org.uk/guidance/ng59/resources/low-back-pain-and-sciatica-in-over-16s-assessment-and-management-pdf-1837521693637
Webster, B. S., Bauer, A. Z., Choi, Y., Cifuentes, M., & Pransky, G. S. (2013). Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine, 38(22), 1939-1946. doi:10.1097/BRS.0b013e3182a42eb6

Strength training for osteoporosis

Tue, 21 Sep 2021 06:46:32 GMT

Have you been told that lifting weights is dangerous?

One of my clients this week told me of an encounter with a specialist doctor regarding weight training with osteoporosis. Upon showing her doctor footage of her performing a heavy deadlift, the doctor expressed shock and concern, and advised her that she was at risk of fracturing her spine doing this.

So lets be clear here: A woman with osteoporosis, a condition for which has demonstrated proof that heavy lifting can improve, told her doctor that she was engaging in said health activity in order to improve her condition, and was met with shock by the doctor who then suggested that she may fracture her spine doing so.

To the doctor’s credit, I have read numerous studies that state a flexed position under load (bending forward and picking something up, particularly while twisting) can cause a vertebral crush fracture in those with osteoporosis, and should be avoided. But as often is the case with these claims, it was not quantified (how much bending is too much? How heavy is too heavy?), or backed with evidence. I find these blanket statements telling people not to move to be incredibly problematic. What if a lady with osteoporosis lives alone and needs to pick up her cat, or bag of cat food, or heavy handbag, or grandchild? Are we truly telling her never to do any of those things lest she fractures her spine? I understand being aware of risks is important, but when it means making people scared to move, and in this circumstance, scared to load their bones - the one thing they absolutely need to be doing! - I feel frustrated.

Who decided that our bodies are fragile and we need to treat them so carefully? If we were that fragile, how do people play rugby? Box? Survive major traumas such as car accidents? If we used to hunt and gather and catch our food, why would we have evolved to need to wrap ourselves in cotton wool and avoid lifting anything more than a 2kg dumbbell?

I understand that a rugby player who batters himself so much that he is hobbling around by the time he is 40 isn’t a great example to use here, but considering most of us are doing MUCH LESS than that, the point still stands. I think a lot of it stems from the idea that we ‘wear out’ and ‘too much exercise will wear us out’ (not true, the opposite is actually true, the more you use your body the stronger the tissues in it become (all of them). Think callouses on hands.). It also stems from a fear that there may be a ‘no turning back’ injury, like if you just move wrong one time, you will be condemned to pain forever (highly unlikely, and if so, it is rarely (almost never) because the injury is extremely severe, but often due to a complexity of other factors I have discussed in other blogs). The body is very good at healing itself and getting used to what it has been dealt. We are amazing creatures!

But back to the osteoporotic women and spine fractures.

There are SO many barriers in place to exercise. The WHO suggests that more than 80% of adults do not do enough exercise. Let alone women exercising, let alone middle aged and older women, let alone doing exercise heavy and strenuous enough to promote real strength, balance, and bone density changes required to create a positive impact on their health. I’m going to go out on a limb here and suggest that a doctor telling patients that lifting may fracture their spines is a pretty substantial barrier here!

It would be irresponsible of me to claim that it is actually safe to lift heavy weights with osteoporosis without any evidence to back it up. Luckily, I have just that.

A study completed in 2017 compared high impact, high intensity training with a low intensity home based program for women with low bone mass. The high intensity program included barbell back squats, deadlifts, overhead press, and jumping chin ups with a focus on a ‘stiff’ landing. The lifts were performed up to 85% 1RM, which basically means they are lifting HEAVY - a weight that they can only complete for 5 repetition (note: it takes practice to work up to a true 85%/5RM effort). The home program was a low intensity strength program with a maximum of 3kg hand weights. Results showed a significant improvement in bone mineral density in the high impact group compared with the conservative home program group. There was essentially no improvement in the home group. And, importantly, NO adverse events (i.e. no fractures).

This is very interesting. When I was at uni, in one of the first few subjects I did (in 2007 or 2008) we learned it was not possible to increase your bone density once you reached a certain age. But this was obviously just because no one had really pushed people to lift heavy enough to make a difference! Now, we have research indicating that we can actually make a difference, even in those already with osteoporosis. And it is SAFE to do so. Provided you learn appropriate technique and are guided as to your weight selection.

Let’s try to reduce the stigma around movement, particularly around weight lifting, and help get ourselves and those around us moving and lifting and maximising our health!

Reference:

Watson, S. L., Weeks, B. K., Weis, L. J., Harding, A. T., Horan, S. A., & Beck, B. R. (2018). High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial [https://doi.org/10.1002/jbmr.3284]. Journal of Bone and Mineral Research, 33(2), 211-220. https://doi.org/https://doi.org/10.1002/jbmr.3284

Health behaviour change: Establishing new habits

Tue, 21 Sep 2021 06:42:08 GMT

Making health related changes are HARD. And it is not because you are lazy. It is because often there are lots of tiny little valid reasons that you haven’t been doing something.

Figuring out what these are and addressing them can help push you over the line to make real changes.

For me (and mum) we found buying these cordless stick vacuums made us both vacuum nearly every day (me at work and mum because there’s a dog eating things and leaving a mess on the floor ��) because it was so much easier to get out than the vacuum with the long cord that you had to plug in and lug around.

Putting physical things in place that make it easier to do what you’re wanting to change can make making that choice all that much easier.

This is one component of many. But could relate to how much of a difference this concept made to me with vacuuming that I had to share!

How could this relate to making other healthier choices? Eg eating more vegetables (have them pre cut in the fridge), doing more steps (have comfortable walking shoes)...

One of the best ways to motivate yourself to exercise is to find something you like that makes you feel GOOD. Motivation is inherently tied to emotion. If you enjoy something and it feels good, you’re more likely to do it.

If you honestly hate all exercise, tie it to something you like so you get that positive association. Do it with a person you like, in a place you like, listening to something you only listen to while exercising... etc.

Forcing yourself to do something when you don’t like it is destined to fail and it isn’t because you’re weak or lazy, it’s just human nature!

If you have a health or fitness goal, you need to make it specific if you actually want to make any progress towards it.

Ambiguous goals like, ‘I want to get fitter’ are not clear enough. They are also ‘outcome’ driven: getting fitter is an outcome. It is not a ‘guaranteed’ /immediate/easily visible effect of changing your behaviour. As such, it can be very easy to get demotivated if you take up exercise and after 2 weeks are not ‘fitter’ in the way you hoped.

However, if you choose an action or behaviour as a goal, and make it clear, you will be more likely to achieve it - and know that you have.

I.e. “I want to run 3x a week for 20 minutes every week for the next 4 weeks”. At the end of 4 weeks you will know if you achieved this or not. You will necessarily know if you ‘got fitter’ or not.

Make the goal - Specific, Measurable, Achievable, Realistic, and Timed. This sounds cliche but it is a well researched way to design goals that are actually likely to then be completed.

Make sure it is REALISTIC and ACHIEVEABLE. Often people set incredibly lofty goals for moving more - like, choosing to do 6am bootcamp 5 days a week when they aren’t a morning person. This is destined to fail. Choosing something that feels like punishment and is extreme is not going to work.

Make it small enough that you can achieve it. It may even be something as little as a step goal 1000 higher than you currently do, or doing an online yoga video 10 minutes a week. Whatever it is, start there, set a timeframe, achieve it, and use that as a one step towards a larger goal.

Start small and gradually build on your achievements.

"Do you actually even do 'physio' any more?"

Wed, 07 Jul 2021 00:53:36 GMT

I have been asked this question a lot in recent years, since changing how I practice. What my sessions tend to look like (lots of talking, moving, not much lying on the bed receiving treatment) is not seen as ‘physiotherapy’ by most.

Physiotherapy to me = getting people back to doing what they want to be doing. Being able to do activity that is meaningful to them, and what they enjoy.

It is teaching people to understand better how to manage their situation.

This may involve looking at lifestyle factors, activity levels and coping strategies, and helping patients to develop confidence end self-efficacy by taking an active role in their rehabilitation.

It may also, and often does, involve some sort of exercise as a step towards building enough capacity to return to full function.

While these things may sound unimportant, it is often these seemingly small factors that lead to a poor outcome.

A common story is someone suddenly doing too much, and becoming injured; pulling right back, and doing very little; trying to do what they could before once the pain is gone, and the pain returning; assuming the injury is very bad, becoming even more inactive; developing more subsequent issues.

The missing link here is the graded return to activity, something which may need to be managed quite carefully.

This is made more complex in the way that people are often managed by the healthcare system, as they are often told to ‘be careful’ ‘look out for their back when lifting’ ‘avoid bending’ ‘stay away from jumping’, to name a few.

These unhelpful narratives lead to a fear of movement that tends to serve people poorly in their recovery, despite being well-intentioned.

It is not actually helpful to tell people to be extra careful about how they move , though that may sound counter-intuitive! Research has found people with back pain move more rigidly and more carefully than those without pain.

This ‘hyper-vigilance’ and fear of movement is completely understandable but unfortunately often a barrier to recovery.

The missing link in a persistent injury is rarely that the person hasn’t found the right manual therapy intervention, acupuncture, dry needling, joint cracking, perfect exercise, etc, but more likely that a more holistic view of their situation is missing.

If you feel you may benefit from this approach, please feel free to get in touch!

Knee valgus. Is it wrong?

Mon, 17 May 2021 01:33:59 GMT

A dynamic knee valgus occurs when the knee flexes. The femur internally rotates and adducts relative to tibial external rotation and abduction. This will look like the knee “going in”. A knee valgus with movement isn’t necessarily bad, at all. It depends on context and person.

We know that once someone has pain, they tend to have weakness in their glutes and hip external rotators. It isn’t predictive of pain, but it is likely once pain has begun.

It is true that a knee valgus force combined with 30 degree of knee flexion (small knee bend) may rupture the ACL. It is true that some studies have linked landing with a knee valgus with a higher risk of ACL injury (and other knee injuries/pains). That said, the research is inconclusive, (some studies have and some studies haven’t linked it) and the “why” may not be what we think it is.

Some research has found that ACL injury prevention programs are VERY effective at reducing risk of ACL injury, but don’t necessarily change landing mechanics. So the person lands the same way, perhaps in a valgus, but is less likely to damage their knee.

Why? Could it be that muscle strength increased enough to mitigate forces going through the knee, something which we can’t actually see with our naked eyes? Is it then effective to categorise athletes into low or high risk of ACL injury based on how they land when how they land may not visually change, but their injury risk has?

I really think that a LOT of what goes on with the human body is unable to be visualised because there are internal forces going on that we can’t SEE with our eyes alone. We try to make sense of what we can SEE , not recognising the body is way more complicated than that! But also way smarter than us, in a good way.

The ‘why’ matters, because if you just blame VALGUS, and direct all treatment at trying to stop that, when in many cases it is not possible (I am case in point), then you may be missing the point.A dynamic knee valgus occurs when the knee flexes. The femur internally rotates and adducts relative to tibial external rotation and abduction. This will look like the knee “going in”. A knee valgus with movement isn’t necessarily bad, at all. It depends on context and person.

My advice? The best way to reduce risk of ACL injury is to do strength training that also includes jumping and landing based exercises, in multiple directions. That way, you increase your quads' ability to absorb force, which may mean you land in a greater degree of flexion, and absorb more force in the frontal plane, avoiding the shift of force to the staggital plane, thus causing less of an adduction and internal rotation of the femur. Training in this way also increases the muscle's ability to absorb force, so will take more force to exceed the capacity of the knee if the muscles are strong.

Reference:

Cronström, A., Creaby, M. W., & Ageberg, E. (2020). Do knee abduction kinematics and kinetics predict future anterior cruciate ligament injury risk? A systematic review and meta-analysis of prospective studies. BMC Musculoskeletal Disorders, 21(1), 563. https://doi.org/10.1186/s12891-020-03552-3

Low back pain exercise options

Thu, 28 Jan 2021 00:50:50 GMT

Before trying these out, please read my post about low back pain; my posts about acute low back pain here and here, and try these acute low back pain exercises here first if you are really struggling.

PLEASE seek medical advice if you are injured , these are NOT intended to take place of proper medical advice or assessment. (Though if they rush you off for an MRI, make sure you ask if you really need one, as the over servicing of imaging for low back pain is an issue, as mentioned in my post here.

LOW BACK PAIN MYTHS

Sun, 29 Nov 2020 00:55:55 GMT

MYTH #1: YOUR IMAGING FINDINGS ARE INDICATIVE OF YOUR PROGNOSIS, OR SYMPTOMS. E.G. MY MRI SAID I HAVE A BULGING DISC!!! I WILL NEVER BE ABLE TO RUN OR LIFT AGAIN!!

Fact: MRI findings in PAIN FREE populations:

At 20 years old:

37% had disc degeneration

30% had a disc bulge

29% had a disc protrusion

At 80 years old:

96% had disc degeneration

84% had a disc bulge

43% had a disc protrusion

(Brinjikji et al., 2015).

MYTH #2: HAVING A DISC BULGE/HERNIATION/RUPTURE/EXTRUSION/TEAR IS BAD NEWS.

Discs have a bad rep. It is common for someone to present to me reporting that they have a disc bulge, or herniation, and as such need to be very careful with lifting or jumping. The person may believe they have damaged their back forever, or that they have a potentially serious condition.

I think the most IMPORTANT piece of information here is that IMAGING FINDINGS ARE POORLY CORRELATED TO LOWER BACK PAIN. To the extent where having an MRI of your lower back is associated with WORSE outcomes, because of the fear that is linked with seeing what are actually NORMAL findings (Webster et al., 2013).

This doesn’t mean we don’t know how to treat someone with low back pain if we don’t know exactly the structure that is implicated, because we treat the PROBLEM not the finding (e.g. Person has pain to bend forward, which may be the case for someone with nothing on an MRI as well as for someone with a herniated disc on MRI).

Being referred for imaging for lower back pain in the absence of certain “red flags” that warrant further investigation is AGAINST best practice guidelines. And yet! Evidence shows 54% of people in the US are referred for imaging of their lumbar spine when they present with low back pain to the emergency department (Foster et al., 2018).

I understand why, because back pain is incredibly painful, and people must feel there is something horribly wrong with them when it comes on. But that’s the thing. The VAST majority of the time, the bark is worse than the bite.

MYTH #3: MY DISC HAS SLIPPED AND MY BACK IS ‘OUT’. I KNOW BECAUSE IT KEEPS GETTING STUCK!

Truth: Acute low back pain can be extremely painful. Pain is the body’s alarm system. It is an evolutionary survival mechanism. A pain signal is sent in the presence of actual or PERCEIVED threat to our tissues. Our discs are very close to your spinal cord. It is likely that any strain or stress to these structures will produce a large pain response. Couple this with the idea that many people have a fear of badly hurting their back, which is likely to turn up the pain signal.

Pain is often poorly correlated to damage (think how much paper cut, hot water on sunburn, or stubbing your toe hurts when none of these cause actual damage). Inflammation and local swelling around a disc hurts like CRAZY, and if this inflammation and swelling contacts one of the spinal nerves that are right next to the discs, it can give you symptoms down your leg, often called ‘sciatica’). This high degree of pain, however, does not mean that the injury is necessarily severe.

Most of the time, acute disc-y pain eases within a few days, and you’re left with some residual pain and stiffness. Over time this gradually eases as well. Pain that persists for longer than the time you would expect can occur due a host of factors that I’ll discuss soon. It is rarely because you have something ‘really wrong’ with your back.

MYTH #4: BACKS THAT KEEP HURTING, OR KEEP ‘GIVING WAY’ AND ‘GOING OUT’ ARE THE SMALL % THAT ARE REALLY BAD AND MUST NEED SURGERY. THE REASON FOR PROLONGED PAIN IS BECAUSE OF EXTREMELY BAD DAMAGE.

There are so many reasons back pain can keep coming back, or never quite go. I do think that it is mainly the response to the episode of low back pain that will dictate this longer response: see the blog "Patient experiences may impact the chronicity of their back pain".

Reference:

Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., . Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American journal of neuroradiology, 36(4), 811-816. doi:10.3174/ajnr.A417

Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., Maher, C. G. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet, 391(10137), 2368-2383. doi:10.1016/s0140-6736(18)30489-6

Gugliotta, M, da Costa, BR, Dabis, E, et al.Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study. BMJ Open. 2016.

Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L., Genevay, S., Underwood, M. (2018). What low back pain is and why we need to pay attention. Lancet, 391(10137), 2356-2367. doi:10.1016/s0140-6736(18)30480-x

Shamrock AG, Donnally III CJ, Varacallo M. Lumbar Spondylolysis And Spondylolisthesis. [Updated 2020 Sep 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.

Webster, B. S., Bauer, A. Z., Choi, Y., Cifuentes, M., & Pransky, G. S. (2013). Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine, 38(22), 1939-1946. doi:10.1097/BRS.0b013e3182a42eb6

The 'mystery' of low back pain

Wed, 07 Oct 2020 01:00:02 GMT

Key points:

Chronic low back pain is often a result of biological, psychological and social factors, rather than an 'incredibly bad injury'
The medical system is quite bad at managing low back pain and looks to purely physical treatments (injections, surgeries, manual therapy, etc) with LOW evidence base and poor outcomes
Exercise and cognitive strategies provide patients with some control over their pain & some self-efficacy over their situation
As a physiotherapist, I do not believe passive therapies (lying on the bed and having things done) is the way forward for low back pain

LOW BACK PAIN: What's the story?

Probably the most common complaint I have seen in my career as a physiotherapist is low back pain. My understanding of this presentation has changed drastically over the years, and I aim to share some of my thoughts with you, in the hope that you find them useful.

First and foremost: pain is complex

How we feel pain is dependant on many factors, only some of which fall into the purely biological domain. Pain is impacted by our beliefs, our past experiences, our surroundings, and many other things.

Pain is our body’s alarm system.

The International Association for the Study of Pain has outlined the definition of pain as “an unpleasant sensory and emotional experience associated with actual or POTENTIAL tissue damage, or described in terms of such damage.” (Merskey & Bogduk, 1994).

This means that we can experience pain IN THE ABSENCE of damaging stimuli . This idea alone gives weight to the idea that pain does not equal damage. You can be in a great deal of pain, and have no visible tissue damage. The opposite is also true, you can have a terrible looking MRI scan, but be in no pain and have no loss in function whatsoever.

A real life example to help you to consider this concept: Imagine you are doing something you enjoy, like skiing, or swimming in the ocean, or at a music festival. You might hit something accidentally, and sustain a cut or bruise that you find later and have no idea how you got it. Compare this to when you are having a really bad day, and nothing is going your way, and then you stub your toe; the amount of pain you feel is likely to be drastically different, despite the amount of soft tissue damage being equal.

There are numerous extreme examples of circumstances where people have had immense physical trauma, and no pain, or vice versa.

This it not saying that pain is ‘in your head’.

Simply that pain is a product of our brain, and so how we feel it is dependant not only only what is going on at a soft tissue level, but also what is going on in our brains, and in our surroundings. Often, the advice given and words said to people in the early stages of acute low back pain (e.g. you’ve slipped a disc; you might need surgery; you have the spine of an 80 year old; stop going to the gym; stop playing sport; etc) can have disastrous consequences.

This is not only because of the psychological component of pain, but also because we are likely to move and act differently if we believe we have done major ‘damage’ to ourselves.

We are likely to stop moving as much, for fear of doing more damage. We are likely to quit exercising, or sitting for prolonged periods at work, or lifting up our children or grandchildren, because we are worried it might be bad for us. We are likely to become hyper-vigilant about posture and pain, in the belief that we need to be this way in order to protect our backs, when in reality, the opposite is the case.

Often, it is exactly this series of events that leads one to be in chronic pain.

An injury occurs, the person is told they have damaged their back and may make it worse if they do it again. They quit doing things they love, grow more anxious, become less active, lose confidence in themselves and their abilities, lose their sense of control over their bodies, and feel they are simply ‘waiting’ until their back gets better, which often, in this scenario, doesn’t happen.

While their initial soft tissue damage has likely already healed, the pain persists. In these cases people are often sent on an endless cycle of trying to find out ‘what’s wrong with them’, which never yields a result, as the original catalyst for the pain has largely healed, thus creating the challenge of managing chronic pain.

This is often exacerbated by the fact that the neurological system becomes sensitised in those with chronic pain, meaning that the pain signals are ‘turned up’, or amplified, by their body’s pain feedback system. This is a challenging condition to manage.

One of the many drawbacks of our health care system is that despite this being fairly common knowledge, interventions directed at predominantly physical findings for those in chronic pain (e.g. prescription of pain medications, injections, massage, joint mobilisations, even exercise) is fairly near sighted. I will discuss possible management strategies in future posts (within my scope of practice as a physiotherapist only) but I will say that my bias is towards exercise, despite it being a physical modality directed at a biological cause, primarily because it gives the patient back some control and self efficacy, and is less invasive than other treatment options .

A simple treatment option with potentially complex mechanisms by which it may be effective.

Check out my other blog posts on chronic pain & low back pain if you are interested by what you've read above, or if this resonates with you. Feel free to get in touch, if you want to chat a bit more specifically about it.

Reference:

Merskey H, Bogduk N. Classification of chronic pain, IASP Task Force on Taxonomy. IASP Press; Seattle: 1994

Chronic low back pain does not mean there is something terribly wrong with your back

Tue, 25 Aug 2020 01:59:59 GMT

The idea that long standing low back pain means there must be something severely wrong with your back that requires more invasive treatment like nerve ablation, injections, or surgery, is flawed. If this was true, there would be strong evidence suggesting good outcomes from these interventions - however, no such evidence exists.

Pain is complex, particularly when it has become chronic, and can rarely be attributed to a single structure as it’s cause.

Pain is not always indicative of damage; sometimes it is your body sending a warning signal to protect against anticipated danger. This system can become hyper vigilant for many reasons (fear around pain and future prognosis; having long standing pain; etc).

Often, rehab programs are underloaded and too heavily focused around immediate pain relief and addressing a single structure, rather than addressing a whole person.

Bottom line: pain does not correlate well to “damage”. Long term pain is complex. Surgery is not necessarily (very unlikely to be) the magic fix. A lot of what is traditionally advised for back pain (scans, rest, stopping activity) actually is associated with worse outcomes.

References:

1. Harris, I. A., Traeger, A., Stanford, R., Maher, C. G., & Buchbinder, R. (2018). Lumbar spine fusion: what is the evidence? Internal Medicine Journal, 48(12), 1430-1434. doi:10.1111/imj.14120

2. Maas, E. T., Ostelo, R. W., Niemisto, L., Jousimaa, J., Hurri, H., Malmivaara, A., & van Tulder, M. W. (2015). Radiofrequency denervation for chronic low back pain. Cochrane Database Syst Rev(10), Cd008572. doi:10.1002/14651858.CD008572.pub2

3. Webster, B. S., Bauer, A. Z., Choi, Y., Cifuentes, M., & Pransky, G. S. (2013). Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine, 38(22), 1939-1946. doi:10.1097/BRS.0b013e3182a42eb6

REDUCE STIFFNESS FROM SITTING DOWN AT YOUR DESK

Wed, 29 Jul 2020 01:59:50 GMT

Les Mills Body Attack: Foot, ankle and calf pain

Mon, 09 Mar 2020 00:46:23 GMT

Note: This is in no way affiliated with Les Mills, and is not to be taken in place of medical advice. I am a physio and an Attack Instructor so it is purely just some advice from my experience!

First of all, there is no evidence any footwear is better than any other in relation to injury prevention , as indicated by multiple papers posted in the BJSM. People are likely to self select the most comfortable pair and that is the best predictor of what is the most appropriate shoe for them (go figure).

However if someone is new to Body attack, has hypermobile joints, weakness in their leg or foot muscles, or has developed lower limb pain already, or any number of other things, they MAY benefit from more supportive shoes initially to at least keep them going while they get used to it.

Improved strength over time should allow for more minimal shoes. I have gone from asics Kayanos (super supportive, 10mm heel, arch support) down to Nike frees (minimal, 6mm heel, no arch support) over the years - however my FIRST EVER injury was shin pain when I started body attack and swapping from my cross trainers to kayanos at the physio suggestion basically fixed it.

Time - place - person specific, but my opinion is ideally the goal should be to be able to tolerate less supportive shoes, as that is an indication of soft tissue capacity / strength / tolerance.

If dropping to a less supportive shoe, do it GRADUALLY, as suddenly swapping to barefoot/minimal shoes IS linked with injury risk! Build up gradually eg stand in them, walk in them (not every day, a few times a week and not for hours) before trying them in a class.

CALF, FOOT, OR ACHILLES TENDON PAIN ARE ALL REALLY COMMON IN BODY ATTACK. BECAUSE THERE IS SO MUCH JUMPING, IT CAN TAKE A BIT OF TIME TO GET USED TO.

This isn’t because impact isn’t bad for you, you just need to condition your body to be able to handle it.

Here are some tips.

��Gradually increasing the amount jumping you to is probably the most basic / useful thing you can do. The more running / jumping you’re used to, the easier you can get used to it, but if you haven’t done much recently (in the last 4 weeks) then you may need to gradually build up.

�� Allow time to get used to your first class; don’t do two days in a row to start.

�� Get used to the bouncing before adding bigger Plyometrics like jump lunges and jump squats.

��e.g. your first week you could do 30 mins only, twice in the week only, and leave out jump squats and jump lunges.

THOUGH YOUR CALVES MAY FEEL STIFF OR TIGHT, IT ISN’T BECAUSE THEY NEED TO BE STRETCHED, IT IS PROBABLY MORE THAT THEY NEED TO DEVELOP CONDITIONING.

Aside from gradually building up to it, you can also do some exercises to strengthen up your feet and calves.
These exercises are organised approximately from easiest to hardest, though it will depend on the person. Bent knee calf raises are often neglected but are particularly useful. I am more about training movements these days, but bent knee calf raises potentially do activate more deep calf (soleus) muscle which is particularly important in Achilles or plantar fascia problems.

2-3 sets of 10-15 is a good start for the exercises, starting easier and progressing to harder.

Additionally, make sure you land your heels during the class . As in, land on your toes first, then put your heel down like I do in the video. This also helps!

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