Hello everyone. A slightly less hectic week for me this week, how about you? So, did you manage to attend the MASSIVE Therapy Live conference last Friday? Jack Chew and his team did an amazing job of coordinating approximately 90 speakers to deliver sessions to 22,000 delegates. Yes, that’s right 22,000 people all online at the same time, watching the multiple concurrently running conference sessions. Phew. I was delighted to contribute to the programme and join the star line up of speakers. I received so many questions after my session I’m afraid I couldn’t get to them all, so I thought thought that this week I’d do a Therapy Live; 14 S&C questions answered session.

Thankfully, I screen-shot the list of questions so, here are your S&C questions answered. I’ve omitted names just in case you’re shy 😉

Hypertrophy

Hi Claire, what was the recent Hypertrophy paper again please?

I wasn’t quite sure where this came in my session, so there are a couple of potential answers.

1. The classic study by Campos et al (2002), which was the first paper to investigate the effects of different intensities of resistance training [Link to abstract].

2. I mentioned that the volume of work performed was likely more influential in the hypertrophic responses to resistance training rather than intensity. I’ve written a couple of posts specifically on hypertrophy, but I think this is the one (Here’s a link) where I refer to the recent Kubo (2020) paper that I mentioned in the talk.

Is Specificity Important with Novice Trainers?

Some evidence suggests that in patients that are novice to S&C training, that any prescription will offer improvement to an extent. Do you agree that a less specific prescription can be useful in some patient groups and it depends on their training experience?

Yes I agree, perform some novel exercise and you’ll likely get some adaptation across a multitude of parameters. I’d also argue that with novice trainers we’re trying to achieve buy-in and limit the chances of drop-out. Thus doing anything that facilitates a consistent change in behavior towards the desired intervention is useful. We need to make sure, however, that as patients adapt that there’s progression built into the programme, which includes increasing the overload consistent with the specificity of desired change. This might be a progressive approach to achieving 5RM.

Concurrent Training

If you’re looking for a balance of strength and endurance work, would you do separate sets of few reps and high reps, or compromise and go for the 8-10 reps?

Specificity is key. Strength and endurance (whether that be muscle endurance or cardiovascular endurance) require different intervention to optimise adaptation. The extent to which you focus on each will depend who your patient is. If your patient needs to improve their endurance performance and their muscle strength and they’re an elite athlete, perhaps coming back from an extended period of injury, in my view you need to give adequate and specific periodised attention to each element of performance to achieve the desired adaptations. This includes separating out strength and endurance sessions.

If your patient wants to return to ADLs, then you have a little more leeway as the demands and expectations are likely less. In this way, whilst you still need to have a specific approach to each performance adaptation, you might be able to include strength and endurance sessions in closer proximity to each other.

Progressive Resistance Training

Thank you Claire for this really insightful seminar. With your less active/sedentary individuals, the need to improve strength may be very important and specific to their needs and therefore lower reps to achieve that higher intensity may be better. In absence of pain on loading, how might you load this patient group appropriately (start with same strength principles, or start with higher reps initially to improve tolerance to load). If the latter how might you periodise this and what speed might you progress them to true strength principles.

Nicely put and great considerations here. A progressive approach is required here to get to heavy loading – and of course achieve the buy-in required. The extent of this progressive approach will depend on the individual and their conditioning status.

I run a 12-week programme for knee OA patients and the aim is to get them up to a 5RM on lower limb strengthening exercises, performed 2 x per week. Most people manage to get to the 5RM by week 3 (session 6) or earlier, however, some may take little longer, which is absolutely fine. They’re forcefully activating the musculature, which they haven’t done for years and causing positive adaptation – great!

You might need to think about exercise volume, this need a progressive approach too for novice and sedentary trainers. If the aim is to do 3 exercises for the lower limb 3-5 RM and 3 sets of each, that’s a total of 9 sets. 1 to 2 sets of each at a lower sub-maximal intensity might be required in the first session, progressing to the desired prescription by week 3, 4, or 5 depending on the individual.

Is Lifting Form Important?

Do you value form over weight lifted? e.g. If looking to improve strength, would you sacrifice good form to stay within to 3-5 repetitions? or would you look to get them lifting lighter with better form first?

Depends on complexity of movement. A very poorly performed, uncontrolled squat at 3-5RM could be a recipe for disaster vs. a well-performed isolation exercise at the same intensity. You can adapt and decrease the complexity of compound exercises to make them safer, for example leg press, to smith machine squat, to barbell box squat, to full squat. This technique training can be performed alongside the strength training isolation / less complex exercises.

Specificity In Group Training

How do you best apply specificity in a group setting?

This can be tricky, especially when you have varied abilities.  Identify the goal of the session or the exercise (specificity). Set up the exercise(s) to achieve this (overload) and give patients instruction and autonomy to adjust the overload to complete successfully.  For example, the repetitions maximum (RM) is a great way to relativise loading to individual capabilities – a 5RM will be a load that a patient can only lift 5 times – clearly safely and with proper technique.  You may need to consider constraining the variability of the exercises such that they can be competed successfully. This will take some trial and error by the patients too.

RPE for Resistance Training

Do you have any suggestions/thoughts on use of Borg perceived exertion in strength training?

Hmmm, it has been used in resistance training (RT), and there’s even been a RPE developed specifically for RT, often to judge repetitions in reserve (another topic). I’m personally not a fan to use it to anchor resistance exercise intensity to as it’s so subjective and its accuracy is highly influenced by the RT experience of the individual. You could use it to help buy-in but I’d personally got with more objective measures.

Repetitions Maximum

Could you possibly clarify on Rep Max continuum slide – why is hypertrophy red in 7-12 but large text in 2-6?

For sure, here’s a link to a post that explains it.

How Much Strength Is Enough?

How can we be specific about how much we might want to increase our chosen parameter by (e.g. strength). why would we conclude that the patient needs to get 20% stronger?

Great question! How much strength is enough is something that I don’t think we can really answer with any certainty. From an injury avoidance perspective, the can’t say, for example, ‘knee flexor strength of 3.7 x body mass will protect agains an ACL injury’. Then there’s the limb symmetry index (LSI) – by how much does the left differ form the right and can we ‘correct’ that? But to rely on ratio data can be risky as we’re not looking at absolute performance.

Then there’s ‘population norms’, but this differs greatly between populations, sexes, sports, activity status and it could be argued that we need to aim for levels that exceed norms if we think that it’s protective.

Here we’re looking at correlation and retrospective data – if weaker individuals are more at risk of …. or performance on a specific skill is worse. We can make some estimations, however by considering the loading of commonly performed tasks, performance or otherwise. For example, if activities of daily living can induce loads of up to 6 time body mass in the calf complex, then clearly we need to be at least this strong to function properly and mitigate injury risk.

Rest Between Sessions

How important is prescribing rest/recovery days in rehab. Many patients despite only stating 3x a week are of the belief the more they do the better and tend to try and do their exercise very frequently

Another great question. Rest is imperative as this is when adaptation from your training occurs!   I wrote a couple of posts that discuss these considerations a while back. See here.

Assessing 1RM

How to test/estimate 1RM on patients with pain in order to prescribe appropriate load/intensity?

In patients it might be prohibitive to elicit maximal contractions, so how can you assess the right load? Well you can use the RM principle, as I describe above, or you can use prediction equations to estimate what the absolute loading might be. Check out a post I wrote here that answers this very question.

Resistance Training At Home

How do you make the intensity specific when patients don’t have access to the gym?

How apt is this question given for current climate?! It’s at least another 2 weeks until our gyms open here in the UK. Overload is key, you’re right. If the goal is to enhance muscle strength then we need to think creatively and perhaps accept a little compromise. Here’s a detailed answer to that very question in a post I wrote about staying strong in lockdown

Does Strength Training Benefit Endurance Performance?

Would working solely on muscular strength training, carry over onto muscular endurance, without having to actually train in the muscular endurance range?

I love this question. I’m actually covering aspects of this in this year’s amazing conference organised by Tom Goom (link). It depends on how you’re measuring muscular endurance. If it’s high intensity endurance – the ability to sustain repeated high-intensity contractions, then probably. The improvements are unlikely to be as great as elicited by a high-intensity training programme if for example the assessment task is relative to a % of maximal contraction, but nevertheless they are likely to occur. And they certainly will occur if the challenge of the assessment task remains the same pre- to post-training. Read the sit-to-stand bit here in this article.

Is Strength Important?

Quite a few patients will show as weak on strength testing but if pain is eliminated strength deficits are markedly less or even absent. Strengthening can seem like the right answer but is always answering the right question?

Great question, or point here. Being strong is not an elixir, a solve all solution to everything and we need to be cognisant of that and of the multitude of contributing physical and psychological factors that influence pain, behaviour, interpretations etc. The skill of the therapist is to recognise where strengthening may play a role delivered via specifically-designed interventions and importantly to be able to assess and judge its effectiveness, or not, commensurate with valid and reliable assessment methods.

Phew, there we have it. I hope your question was answered. If you have more, please get in touch 🙂

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