Mentor Spotlight: Dr. John Rusin

https://drjohnrusin.com/about-us/

When I started this blog in November 2017, I mentioned a few mentors who I like to follow - you can find that here.  I've gone into some detail about how I found a new mentor here and have written about some of the courses I've taken with these providers in the past.  Here's another post about mentorship, because this is a topic that I find worthy of regularly discussing, and because one has been producing some really neat new content that I wanted to share.  This could be a valuable resource for student and new grad physical therapists and strength and conditioning coaches to improve their knowledge and also to observe some real life interactions between a clinician and a client.

I spend a lot of time learning from Dr. John Rusin.  John is a physical therapist and certified strength and conditioning coach who, from what I've been able to observe, does a thorough evaluation of his clients' movement patterns and then uses strength and conditioning principles which I've previously touched upon here to progress his clients to improved function, better strength, increased cardiovascular fitness, and overall improved quality of life and health.  He's incredibly smart and provides me - and all of his followers - with boatloads of content that are generally organized in an interesting and user-friendly manner.

I'm not here writing a blog or developing a brand where I'm creating new ideas and new content (at least not yet). You won't see me videoing myself demonstrating exercises I've created any time soon.  With regard to physical therapy, my blog is a write up of what I'm learning about from the experts and trying to synthesize their information so that I can use it with my patients. I've written about several other mentors and their impact on my practice, but today it's all about Dr. John Rusin and the top three things I've enjoyed learning from him.

First - John focuses his training around six key movement patterns: the squat, the hip hinge (deadlift), the lunge (single leg), the upper body push, upper body pull, and the carry.  Prior to reading and watching John's work, I was already a fan of squats and deadlifts - though I haven't been under a bar in quite some time.  I also focus heavily on single leg work in my own workouts and patient programs, though I wouldn't say I used lunges quite as much in the past as I have been more recently.  I never used loaded carries before coming across John's work and I didn't do nearly enough pushing and pulling myself or with my patients who weren't rehabbing from an upper extremity injury.  I've taken the time to read numerous postings from Dr. Rusin about his movement patterns and have found these patterns to be useful in my personal training as well as with the patients I work with.

Second - I know I had a Motor Control course and a Pediatrics course in PT school - but the carry over to application with actual patients somehow didn't really click.  Dr. Rusin does a great job integrating these primitive progressions into his rehab programs as well as the educational materials he diseminates and I have been giving more and more attention to the sympathetic versus parasympathetic nervous system and energy systems (conditioning) because of him.  Pay attention to the normal development of babies.  First - they breathe.  Second - they'll lift the head - the body follows the eyes, and the extremities move on a trunk that generally stays still because we need proximal mobility for distal stability and globally, the mobility and stability need to work in combination with one another.

The stability components are key.  We physical therapists and rehab professionals are too often working on mobility and flexibility when a focus on stability would have greater outcomes, according to John's work. One area in which I strongly consider this is hamstring flexibility and toe touching.  I often find that kids who can't bend and touch their toes don't really need passive hamstring stretching.  They more frequently need strengthening and motor control of those hamstrings so that the muscle releases its protective hold and the person can function more optimally.

Finally - Dr. Rusin has recently been putting out video footage on his work helping to "Rebuild Dave Tate."  This stuff is really cool.  Dave Tate is a  world class weight lifter and body builder who was dealing with numerous orthopedic injuries, surgeries, and deconditioning for which he reached out to Dr. Rusin. These guys got together and have been filming their interactions and posting segments walking you through John's subjective and objective evaluation components, the program he developed for Dave, and some follow up/progressions of the program.  This site has links to the 9 current videos they've posted, and they're not done yet!  This is an incredible resource for others and I have enjoyed watching (and re-watching) and also discussing the posts on John's Facebook with other followers that it felt essential to share this.

I haven't yet had the chance to meet Dr. Rusin in person yet since he operates out of Wisconsin, but he has numerous products available and I'm hoping to try some of his training options in the future when I finish my current plan.  I'm so grateful there are clinicians out there that put out intelligent, immediately applicable information, all for free, all for the greater good.

Stair Challenge!

Richmond Beach Park steps - Shoreline, WA

How is it almost June?!  That mean's it's time for the Shoreline Million Stair Challenge!  The purpose of this event is to have the community collectively climb one million stairs to increase fitness competing with neighbors. According to the site, last June I completed 11,444 steps!  The challenge was started in 2012 for community awareness of health as well as to bring more people out to the park near my house where there is a long stair case (188 steps) that can be broken down into portions as well as a smaller set of stairs nearby.  I use these when I train for my March stair climb for Multiple Sclerosis which I've previously written about here!

This year my goal is to complete 15,000 steps in the month of June.  That's an average of 500 steps per day or 3500 stairs per week.  I don't work out 7 days per week, so this seems like a lofty goal, but I'm excited to work towards it and spend more time outside.  Additionally, on the side of this blog, I've been tracking my miles walked and stairs climbed all year... and I'm a bit behind in my 75,000 stairs goal, so this should really help get me more on track!  Fortunately, the sun stays out a lot longer in June so post-work stairs will be in order!

I urge others to join me in this challenge and climb some extra stairs this June.  It might help you start a new exercise routine or change your daily habits.  Since I started training for stair climbs, I definitely notice myself taking stairs more than alternatives... and I've gotten stuck in a few stair wells for doing it! You can climb stairs anywhere and still participate in the challenge. We can motivate each other to train and get stronger and more fit!  I want to see photos of the stairs you climb - so if you sign up to join, I'll match your stair count (up to 1000 additional stairs!).  Seattle area friends, if you want to head to a local stairwell - there's a whole network of them listed on this website - let me know and I'll climb some stairs elsewhere! I won't race you - because it's not about doing them quickly.  It's about being active... and I'm slow!

Happy Summer and Happy Climbing!

More about PAIN

Last week I posted this blog introducing my recent studies regarding pain science starting with a few basics I learned from Explain Pain, by David Butler and Lorimer Moseley.  I also recently finished reading their 2017 edition, Explain Pain Supercharged, an awesome book, particularly in its use of easily understood metaphors and stories to help illustrate the concepts, but those underlying concepts are more complex than anything else I've ever read.  It made me think of first grade when the librarian was teaching us how to determine if  books were appropriate for us to read. She instructed us to select a book that might be interesting, ( I wanted to read the Boxcar Children), sit down in a quiet corner, open the book to any page, and read that page holding up one finger for every word we didn't know. If we didn't know five words when we finished the page, it was a little too tough for right now, but maybe next time back at the library it wouldn't be.  I still love the library and quiet corners.

This timing of my focus on pain science is intentional. I've mentioned that I've been working with more patients who are experiencing chronic pain - both at Seattle Children's and when I'm with the adult population.  The patient with chronic pain is interesting because they continue to experience pain long beyond the normal tissue healing time expected with injury and often to a degree that is not proportional to the injury that was originally sustained. Picture stubbing your toe on the corner of a table.  It hurts, but you keep going about your day, maybe hobbling a little bit, but then days later you're still hobbling and it still hurts, and then a month has gone by and now you're avoiding weight bearing at all. This progresses until you reach a point where you stop putting your foot on the floor entirely, switch to crutches or a wheel chair, become fearful of any possible touch to your leg, and consistently report high levels of pain.

For these patients, the nervous system has found a way to overprotect their body. It has gone from working a 9-5 job to becoming a workaholic where every increased responsibility at work just makes them more and more irritable - only we're talking about how the body works from the inside!  In the end, the principles to working with these patients are largely the same as any other patient - if you can understand the mindset of needing to unload the stresses on the nervous system and then progressively load that - rather than focusing on unloading other body tissues of the musculoskeletal system which we so typically target.  AKA - take a vacation, break the overwork cycle, read a book by the pool, have a pina colada, and then when you return, maybe take an extended lunch break or two to slowly get back into the swing of the job without it taking over life.

In addition to the clinical utility of learning about pain, Lorimer Moseley was in Seattle this past week and I went to hear him speak at the University of Washington. I attended the event with a crew of fellow PTs who have been learning and teaching me about pain science, using the framework of the biopsychosocial model with patients. Who better to help me understand the impact of my words on the patients I work with?  Dr. Moseley's presentation was entitled "Seven Amazing Pain Facts that Could Change Your Life."  Here they are, with a few thoughts on each:

1) All pain is real, regardless of cause.
Just because there is nothing on an XRAY or an MRI showing that there is something wrong, does not mean there is no pain or that nothing is wrong. Pain does not correlate with tissue damage.  Sometimes people have major injuries without pain.  And doesn't a paper cut hurt like the dickens?  (I typed that - then had to look up the origin of that phrase - the dickens is used to represent the devil because some people don't believe in talking about the devil.  Fun fact.)

2) Your brain is like a jungle.
Everything is connected in a complicated ecosystem with interdependence between creatures.  A little bit of Darwinian survival of the fittest with regard to the more you use certain brain pathways - including a pain pathway - the more intensified that pattern becomes.

3) Your brain is looking out for you in sneaky ways.
Pain is normal as a protective mechanism for your body.  But like my above example of a stubbed toe taking over, sometimes the protective mechanism is overactive and needs to be re-trained.

4) Your brain uses all incoming data.
This is consideration for that biopsychosocial model I've previously talked about here. Pain is influenced by numerous factors - including the tissues of the body, relationships with other people, stresses at work, diet, nutrition, exercise - the list continues.  It is also influenced by the words we use with our patients to describe their pathologies.

5) Your brain uses all the data already stored. 
If you've previously stubbed your toe and recovered with a typical pattern of recovery, you're more likely to have a similar recovery pattern.  If this is the first time you're stubbing your toe and the brain goes into it's overprotective mode, it's learning this pain pattern.  The brain remembers what it has done for similar events in the past and uses prior experience to guide responses to recurrence of similar activities.

6) Our nervous system learns pain.
Just like I said above.  We're like elephants... we don't forget.  And the more the pain cycle continues, the more re-inforced it gets into your brain until you can break the cycle.

7) Understanding contemporary pain biology may be the missing link.
For some patients, educating them about how pain works makes it less scary and helps them to break their pain cycle to start the road to recovery.  I'm thrilled to report that my first attempt to use my new knowledge appears to have had positive impact on the specific patient I chose to use it with, and that my colleagues are also having positive outcomes using this framework.  But I'm currently operating with an n=1, so I need a lot more practice on educating patients about their pain, and I'm working on further organizing my learning on this subject so that I can better choose when to focus on this treatment pathway rather than what I've always done in the past.

This is the link to the video clip I've started using for kids dealing with chronic pain. The video isn't actually targeting children, but it's the best one I've found, and, at the very least it is entertaining and parents can help their kids to better understand.  Check it out.  Notice the resemblance between cartoon Lorimer Moseley and real-life Lorimer Moseley, and let me know what you think!  I actually asked Professor Moseley about using the video for children and he said it's on his list to make a new, updated version, that's more kid-friendly.  But for now, this version seems like a good place to start. I hope I'm not boring anyone with my repeated topic of pain - especially because I anticipate one more upcoming post on the subject in the near future!

Me with Professor Lorimer Moseley

Book Alert: Explain Pain

This lengthy post begins a series of posts exploring pain science based on my recent completion of Explain Pain, Explain Pain Supercharged, some articles on Pain Science, this TedX pain talk, and the upcoming visit of Lorimer Moseley to the University of Washington. If you're currently experiencing pain - or have ever had pain - buckle your seat-belt for this adventure.

Since my job change about a year ago, I've started seeing more patients with chronic pain - some diagnosed with conditions such as chronic regional pain syndrome (CRPS) or fibromyalgia - others coming in having had unsuccessful rehabilitation or where symptoms have progressed from something small into a loss of function.  While it seems that I'm working with more of these patients, the alternative perspective is that I've been spending a lot of time learning about pain, so perhaps I'm just recognizing things differently than before.  I can easily recall patients earlier in my PT career who likely would have benefited from pain education, but I didn't know it at the time.

Regardless of diagnosis or level of function - emotionally, I am sad for these patients, particularly when it's a kid.  A child who has had pain for months and has started to lose function or interest in activities because of their pain starts feeling hopeless about their future. This can be pain that has debilitated kids so that they cannot attend school or play their favorite sports or adults who can't tolerate their work day, ultimately losing income. Having recently learned about the positive benefits of teaching people about how pain works, I feel an obligation to guide these patients down the road of pain science.  This is a world that I am new to and have spent a lot of time learning about - only to discover that I have a lot more learning to go.   For example, I'm learning about the impact of the words I use to describe to a patient why they are hurting - and changing how you explain things is  a big challenge.  What I quickly learned was that physical therapy is the right place for people experiencing chronic pain, helping them find their way back to function even if it isn't their optimal level or their prior level of function.  One of my favorite things about being a physical therapist compared to most other healthcare professions is the regularity at which we interact with our patients and, because of this, the relationships we develop.

In my search to learn more about working with patients experiencing chronic pain, some of the themes I've come across are simple but vital:

1) These patients need to like their clinicians.  If we can't relate or connect, we'll have no impact on guiding them through their pain journey.  Fortunately, most of the kids find me funny... or at least funny looking... so they get comfortable working with me. On my neurological rehabilitation rotation in PT School, my clinical instructor sat me down and said "What you lack in knowledge, you overwhelmingly make up for with your personality."  She basically told me I was dumb, but that patients will like me because I can connect to them.  I like to think I've gotten smarter - but that my personality hasn't changed. 

2) Listen to the patient! They often tell you a lot of hints to help understand their pain experience so you can break it down. Also, many times, patients who have had pain for a long period of time have seen multiple healthcare providers and already know certain techniques that have not been successful for them in the past.  Why would you repeat that approach if it has already failed?

3) Based on the biopsychosocial model, pain is far more complicated than solely focusing on body healing processes, and if we don't give enough attention to the psychological components of pain, we're neglecting a major piece of the puzzle.

I've previously written about my interest in learning about chronic pain in relationship to the hip hinge course  as well as the chronic pain presentation I attended at Seattle Children's Hospital. I'm just touching the surface of my chronic pain learning. Today I'm focused on  this paper: A pain neuromatrix approach to patients with chronic pain - G.L. Moseley 2003 as well as his book with David Butler, Explain Pain.

In the journal article, Moseley describes assessment and treatment recommendations for patients with chronic pain.   He starts by defining "pain is produced by the brain when it perceives that danger to the body tissue exists and that action is required."  Studies have shown that there are multiple regions of the brain that release a pain signal, collectively referred to as the "pain matrix" but that these regions vary from person to person.  The brain holds an image of the body known as the "virtual body" which is constantly updated by interacting with the environment.  When pain persists, the virtual body adapts, often becoming more sensitive, so that less danger inputs are needed for the body to recognize threat level.

What do you do when this occurs?  The paper recommends treatment options with key focus on
"reduced input of threat," particularly pain education.  The more a person understands how pain works, the smaller impact pain has on their function.  If you have been experiencing pain, it may help you to learn more about how pain works.  Check out this entertaining Ted Talk for an introduction to pain science.  In the clinic, patient education using multiple forms such as pictures or metaphors or videos and not focused solely on anatomical considerations are necessary.  It is helpful to ask a patient what they think is causing their pain, and if they focus on an anatomical cause, to help them understand alternative narratives to explain their condition.

In addition, treatments need to toe the line of challenging the patient without overstimulating their pain matrix.  Body movement is beneficial, but the loading needs to be done in a progressive manner along with education.  The paper suggests finding the baseline amount of activity that is tolerated without increasing symptoms and making numerous small progressions rather than overshooting the level of tolerance.

The article (and some friends) ultimately convinced me to read Explain Pain, by Lorimer Moseley and David Butler.  Explain Pain is a book written to help the general population understand pain.  It is reader friendly and has cute illustrations that are helpful in simplifying the complexities of pain science.  Some key takeaways from the book:

1) The amount of pain you experience does not necessarily correlate with tissue damage.  It is possible to have pain without any tissue damage at all.  It is also possible to have extreme levels of tissue damage without having any pain.  Phantom limb pain - pain where a limb has been amputated and no longer is attached to the body - illustrates that pain does not correlate with tissue damage, as there is no tissue present to elicit a pain response.

2)  Pain depends on numerous factors and the brain decides whether or not something hurts, without exception.  Pain relies on context.  Signals go to the brain for processing and the brain weighs out these signals to determine if the body is in danger or not.

3) All pain is real.  All pain is normal.  It is a useful protector for your body.  As such, it should be respected - not feared.  It should be validated and considered in treatment programs.  And it should be considered an individualized experience where each person needs separate treatment to recognize their own pain response.

Once I read these resources, it triggered reading others.  More on them in an upcoming post.  For now, I hope that someone who is experiencing pain reads this and learns one thing that may help them with their pain.

Palm Trees and Tennis

Today I'm out of town on a quick adventure to the Bay Area of California for a UConn Athletics event, but while I was in town, I decided to walk around Stanford University.  I've never been to this campus and I always like to check out basketball arenas when I get a chance, but unfortunately, Maples Pavilion was closed.  I was so looking forward to a photo with the court wearing UConn attire, but I guess I'll have to come back for a game. 

On Stanford's Campus

Anyways, the campus is gorgeous and the sun was shining.  There are palm trees (and awesome Mexican food), something Seattle and Connecticut are both lacking.  I came upon the Taube Family Tennis Stadium, got in a few stairs to move around after my morning sitting in an airport from flight cancellations causing lots of waiting around.  Then the women's tennis team walked out to start their practice.  Opportunity!!!

I haven’t spent much time watching tennis live - a few matches in high school to support some friends and occasionally on TV when the big names are playing.  Beyond that, I've also only played a few times, so I'd be lying if I said I know much about this sport.  But I love to watch how people move and I have treated patients who played tennis so it's always good to consider the demands of different activities on the body and where injuries might potentially come from. Here's what I observed watching the first 15 minutes of their practice: 

First - I watched their dynamic warm-up.  I've recently been becoming an even bigger fan of the dynamic warm-up in my own training and also with my patient care.  I will admit that sometimes it becomes fairly routine and I'm not always creative - but sometimes the children I'm working with just need to get their heart rate elevated, get their bodies moving, and get some dynamic balance activities in before some more intensive loading.  I strongly believe that a warm-up has a functional purpose of getting you transitioned from the day to day tasks into the mindset of "I'm about to get to work" and also should serve as a primer for the movement patterns that are going to follow it.  It's also a good chance to include some rehabilitation activities or "activation" exercises, so when the tennis players started taking out their resistance bands to complete most of the "Thrower's Ten," my heart smiled. Shoulder Care in Tennis! I LOVE THIS!  They also put on sunscreen... which I appreciated.  Safety first Cardinal. 

Second - I was surprised to observe that all their players used two hands in their backhand stroke. I know I've seen players do this, but I didn't think it was used so commonly and for some reason it made me immediately Google if Serena and Venus Williams did the same.  I found this article which goes into detail about Serena's which is considered to be an old-school (traditional) back swing with an "unorthodox" stance and a "text book" follow through.  I guess Stanford's crew is not only on top of their prep work, but also on their use of two hands with the backhand stroke.  Photos popped up with Venus also using both hands.  Then I Googled Raphael Nadal and Andy Roddick- also using two hands.  Apparently I just thought everyone used one hand... and I was wrong. Ya learn something new every day.

I came across this article that discusses numerous hand grips for backhand in tennis and talks about how it mostly falls on player preference and the preference is usually based on where the most power can be elicited. It summarized 5 different grips!  There are pros and cons to each one, but the use of two hands adds stability and strength and can influence the spin on the ball.  Neat! 

All this reading helped me to consider one more thing that was easily apparent during their volleying warm-ups I observed but that I often don't think about: timing.  I've previously read a few articles about the timing of the shoulders and hips with baseball pitchers so this concept wasn't new, but watching how they let the ball come to them and timing the swing and how they ramped up their distances from the net and the speeds of the ball was really neat and gave me some things to think about. 

Back to the sunshine... hope I run into Coach VanDerVeer!

What do Physical Therapists Do: Installment #3 - We Strength Train

© creativecommonsstockphotos - ID 96113980

In the first installment of "What Do Physical Therapists Do? We Look at Mechanics," I described an experience with a patient who came to Seattle Children's with doctor's orders to do a biomechanical assessment to clear him for return to sport and discussed how it is our job to be "movement specialists."  In the second installment, "What Do Physical Therapists Do? We Listen," I touched upon the biopsychosocial model and the importance of considering the psychological stressors in addition to the internal biological influences on pathology.

Today I'm back with the third installment: "What Do Physical Therapists Do? We Strength Train."  I don't mean that we necessarily pump iron... although I do like to lift heavy things from time to time. Earlier this week, for example, I carried my ~50 pound kayak overhead about 1/4 of a mile to put it into the water... some overhead pressing would probably make that a bit easier.  It would be even cooler if I could suitcase carry it - but so far I'm not able to.  Some of my PT coworkers lift. Others do yoga, or ride horses, or ski, or hike, or play hockey, or lacrosse.  In general we're an active group which helps us to better understand how the body moves.  I once had a clinical instructor tell me that I should try out (or at least watch) any activity available so I could best understand where frequent injuries in that activity could come from and see the things the body is capable of.  It led me to take a snowboarding lesson and watch sumo wrestling - talk about immensely different ways for the body to move!  But that's not what this is about... I'm talking about what we do for our patients.

A common (and essential) physical therapy treatment is exercise.  Exercise covers a wide variety of topics, so the focus today is on strength training.  I'm not here to debate whether or not soft tissue work improves mobility of tissues or has neurological effects or changes the chemical composition of body tissues.  I believe all of these things happen to some extent and know there is debate in the literature on this topic.  Regardless of how soft tissue treatments are applied and what is happening in the body, after some mobility work is completed we need to load our patients. Here's why this is a problem:

Physical therapists guide their patients in strength training exercises but, in my opinion, we barely touch on the basic principles of resistance training and we certainly did not apply them sufficiently in PT school.  Earlier this week, I passed the Certified Strength and Conditioning Specialist (CSCS) exam by the National Strength and Conditioning Association (NSCA). "Certified Strength and Conditioning Specialists are professionals who apply scientific knowledge to train athletes for the primary goal of improving athletic performance."  Some of my patients are not participating in athletic endeavors, but all humans are athletes and all athletes are humans - so we need to treat them as such.  (I can't remember where that line came from - it's not mine, though).  So physical therapists serve a similar role as strength coaches in many ways.

While preparing for the CSCS exam, I was overwhelmed by how much I didn't know. When checking the literature for articles about physical therapists and strength training, I came upon this 2016 article entitled "Periodization and physical therapy: Bridging the gap between training and rehabilitation."  The paper also presented the basics of resistance training and the similarities and differences between physical therapy rehabilitation programs and strength and conditioning programs.

Both physical therapists and strength coaches apply the General Adaptation Syndrome.  "Physical activity is better described as a physiological stressor... when physical activity is properly dosed in individuals who possess the physiological capacity to respond acutely, homeostasis is restored."  The idea is that the body has a baseline set point that it normally operates at and a threshold beyond which it cannot properly recover.  Exercise is one type of stressor following which the body moves away from its set point, towards a threshold, and needs to have processes available to return to baseline.  There are baseline settings for numerous things in the body, all of which can be influenced by exercise including: fluctuation in blood pH, stimulus of hormonal changes and immune responses, changes to the cardiovascular and respiratory systems, altered hydration status, potential tissue damage... the list of is extensive.  The body is generally amazing in its ability to adapt and respond to this variety of changes to return the body to its resting state.   However, if the stresses are too high, injury, illness, or death (at extremes) can occur.  The goal from physical therapy and from strength training is to operate within the boundaries of applying stress so the body can adapt to and recover without over-reaching.

How do you structure this into patient/client programs in a way that makes their threshold improve so they can do more work or lift more weight over time?  Both Physical Therapy and Strength Training use the concept of progressive overload described in Essentials of Strength Training and Conditioning as "progressively placing greater-than-normal demands on the exercising musculature - applies to training to increase bone mass as well as training to improve muscle strength."  For example, we start with a movement pattern such as the squat, and we train it as a movement with just body weight and then progressively load it with dumbbells or barbells and we fluctuate the variables of our training volume and intensity so that the body has time to adjust and adapt and learn.  This means that the homeostasis set point and the thresholds from the general adaptation syndrome are flexible and can be improved with the possible exception of someone who has reached their full genetic potential.

With consideration for progressive overload, strength trainers design training programs for their clients.  In my opinion, based on my observations in numerous clinics over the past 3.5 years, this is where the two fields diverge and physical therapists don't use the same principles.  When planning for resistance training, we can consider four target outcomes: 1) strength gains, 2) improved power, 3) muscle hypertrophy, 4) muscular endurance.  Programming for a specific target outcome means varying the volume (reps/sets), the load (percentage of maximum able to be lifted), frequency of training, and rest breaks.   To target these outcomes, those variables have been studied and summarized as follows:

Target Outcome	Reps per set	Sets	Percentage of 1RM	Rest
Strength	< 6	2-6	> 85	2-5 mins, full recovery
Power	1-2 or 3-5	3-5	depends but >75	2-5 mins, full recovery
Hypertrophy	6-12	3-6	67-85	30 sec - 1.5 mins
Endurance	> 12	2-3	< 67	< 30 sec

Also important to consider is Matveyev's model of Periodization which considers the preparatory phase (basically off-season), transition period (changing over from off-season to in-season), and competition periods, but the preparatory period is broken down into three more sections: hypertrophy and endurance early on, moving into a basic strength phase, and then more of a sport specific strength and power phase.  So understanding how to vary the volume and align it with time on the field or court is essential.  But in the PT clinic, we don't usually program or progress in this manner.  We may consider similar rep schemes and progressive resistance, but we don't typically use loads of this magnitude because we're rehabbing people who either can't or should not yet be lifting loads of that intensity.  At the end of the day, we're all loading up our patients/clients.

Lastly, consider teaching a person a new task such as a squat.  At first, regardless of reps and sets selected, the initial changes that person will experience will be the brain learning how to squat.  This is the same for any activity - your body needs to learn the pattern and get the neurons linked together before you can experience significant muscle gains, improvement in function, and changes in strength.  They may feel stronger or that the task is easier, but these initial changes are neuromotor.  In the context of pain, people move differently and their neuromotor patterns change.  So, since about 99% of the patients I treat are in pain, I'm basically coaching them to make neuromotor changes and as they go through that work, their symptoms resolve, and they're done with physical therapy (because insurance dictates this).  Thus, they have so much remaining potential for strength gains, endurance training, hypertrophy, power, agility, and all the physiological benefits that remain for a strength coach to guide them.  I'm a little bit jealous that I don't generally get to observe these adaptations in my patients, but I get to see them in my own training.

SNF Side Hustle

I've been working my way through Eric Cressey's older blog articles (as well as a collaboration he did with Mike Reinold called Optimal Shoulder Performance) and came across this post written in 2005 in which he debunks weightlifting myths.  In the post Eric recalls: "Dr. Jeff Anderson, Director of Sports Medicine at the University of Connecticut, said to me once: 'If you live your life the right way, you'll likely find yourself in an orthopedist's office at some point. If you live it the wrong way, you'll likely end up in cardiologist's office instead.'"  "Doc A" unfortunately passed away last year, but he was a great physician and all-around nice guy.  Reading his quote reminded me of my experience observing this in real life.


When I first graduated from PT School, alongside my job in outpatient orthopedics, I also worked as a per diem PT in a skilled nursing facility (SNF).  (#sidehustle). I was mostly scheduled to evaluate patients who arrived to the facility on a Friday and, because of insurance mandates, needed a weekend evaluation for admission. I regularly observed Dr. Anderson's statement, but it is only now, reading the quote, that it seems so much more simplified and realistic.  A day at the SNF would have a patient schedule of about six patients, an hour to 90 minutes for each one, often looking like this: 

1) Frail lady with osteoporosis, 82 years old, who fell and broke her hip.  Many of these patients would also present with a urinary tract infection and confusion. (primarily orthopedics)
2) Type II diabetic, obese, sedentary man in his 60's who just had a total knee replacement (orthopedics with cardiology risk factors/co-morbidities).
3) Man, 76 years old, life-long smoker, worked a manual labor job for his whole life, who recently had a stroke or a heart attack. (cardiology or neurology)
4) Younger woman, early 20's, detoxing from drug overdose. (could fall under several categories - I'm not exaggerating, here.  I really did see a lot of patients who were either detoxing or recovering from an overdose or had an accident that involved drugs or alcohol.  The first time I saw track marks left an impression.)
5) Overweight woman, 55, using supplemental oxygen with debilitating back pain and depression. (orthopedics with cardiology and psychological co-morbidities)
6) Homeless person who is malnourished and recovering from pneumonia. (also a variety of categories)

If the patient had been newly admitted to the facility, they may not have been out of bed for several days.  This 2007 paper outlines the effects of bed rest on the cardiovascular system, the muscular system, and the skeletal system but a basic summary is that everything gets worse when you stay in bed for too long.  What the paper doesn't explore is how self aware people are when they have been on bed rest.  These patients had frequently walked themselves into a hospital or were brought via ambulance within the past two weeks.  They sometimes have lost a little bit of sense of time, but they were able to walk not too long ago, so of course they can stand and walk.  I'd estimate about 25% ultimately weren't able to hold up their weight requiring me to hold them up when they got lightheaded from orthostatic hypotension or when their knees buckled from disuse of their quads.  Want to know another awesome benefit of standing and getting out of bed for the first time in several days?  The gravitational effect on your gastrointestinal tract! That's right, many of these patients would stand for the first time in several days and take a few steps and would need to be at the commode in under 14 seconds.  I was pooped on 1 out of every 2 shifts I worked. 

I would finish my day, exhausted from lifting people to help them transfer in and out of bed and onto the commode.  More than physical exhaustion, I would be a wreck from the intense emotional drain of trying to motivate people suffering from pain and limited endurance to go for walks and exercise.   This type of work really got to me.  The gains were small from day to day and I was only there once or twice a month so I never got to see the patients improve.  I had only worked there for a few months when I found myself finishing my day, sitting in my car, unable to get going because I was too busy wondering what the end of my life could possibly look like. 

According to the CDC, heart disease was the #1 cause of death in the USA in 2015 accounting for 23.4% of deaths that year.  When broken down by age, unintentional injuries/accidents was the most common cause of death in people younger than age 45.  This includes a fall as a cause of injury in addition to numerous non-orthopedic accidents such as drowning or smoke inhalation.  I don't think Doc A was referring to death in his conversation to Eric, but that's how my brain got here, and I like the idea that if you use your body so much that you develop orthopedic issues, you could be preventing some of the co-morbidities associated with cardiovascular pathology. 

The world really isn't so black-and-white and these outcomes aren't so dichotomous.  There are very active people running on a regular basis, who die unexpectedly from a cardiac event.  Can you lead a lifestyle that decreases your risk of cardiovascular pathology?  Yes, and it doesn't inherently mean a future of orthopedic issues is coming your way.  Can you take good care of your body with exercise and prevent arthritis/bodily breakdown?  Yes and it doesn't dictate you're going to have a stroke.  What does this mean?  It means try to eat a healthy diet and exercise regularly because in the end, we only get one life to live and one body to use, so we should make the best of it!