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David: Hi Claire. How are you?

Claire: Hi David. Yeah, I'm great, thanks. Thanks so much for inviting me on.

David: Oh, it's great to have you on. I'm looking forward to chatting all about strength and conditioning with you.

Claire: Oh, same, same.

David: Sets and reps are a common thing that people struggle with. They want to know what is the best reps for people to do, is it that 10 to 15, is it the 8 to 10, 5 to 8? What are we looking to achieve with our different rep ranges and what would you tend to use when it comes to especially rehab?

Claire: Yeah, that's a really good question and to be honest it probably one of the reasons why I started doing these courses in rehab for physios. It comes back to what's the goal? You have to start at that point. What is the aim of that intervention or that rehab, what do you want to achieve with that patient? And then from that point you can start to make some sensible decisions can have just plumping for your 10 to 12 reps, 3 times, 3 sets and off you go away. To be kind, it might be a little bit effective, it might do some good stuff very early on, but the effects of that would be very, very short lived. Particularly if you're not defining what determines exercise cessation. So if you want to be working on muscle strength, you've got to lift a heavy load, for a few repetitions.

So the load is so heavy that you are unable to do more than is required. If you want to improve muscular and endurance, then the number of repetitions you do is greater and accordingly the load will be lighter so which that you're able to perform those number of reputations required. And then you're thinking about the dose as well. So how often, you know, it's quite a complex question really. You know, you really have to focus on what it is you want to achieve and then structure your program to achieve that. So your strength training is to get optimal improvements in muscle strength. You're really talking three to five rep max and that means selecting a weight that you or your patient is only able to lift for three to five repetitions safely and with proper form obviously. And when all you know is clinically obligated to do that.

David: Okay. So three to five reps to that we're looking at your sort of strength range there. Claire: Yeah.

David: It's a really, really interesting point because three to five, yeah I know in the health population, in my own training that works really well for increasing strength. When we look at the studies, there are studies that show that you can get good strength gains with your sort of low reps and there's other studies showing you get good strengths range with your higher reps. So tell us a little bit about that. What's your thoughts there?

Claire: Yeah, definitely. You know, we look at the literature and there's so much, isn't it? There's a huge body of literature on reps, sets, loading, populations, dosing. The question is what's enough? So if you're looking at what the perspective that I come from is you've got a limited time with a patient, presumably most physiotherapists do. Certainly in the NHS it's probably limited again, so for me, I'm trying to say what is it that you can do to get the best input/output equation or the most bang for your buck.

So yeah, you could give somebody repetitions that are up to let's say eight to ten, eight to 12 repetitions and you probably will get some strength gain. But if you compare the strength gain that you would get from doing a much heavier load, fewer times, so your three to five rep max, then you can get a much greater improvement in muscle strength. So the classic study that shows us is, is the Campos study, 2002 it’s been replicated time and time again. But looking at what the strength gain was doing three to five rep max over a period of eight weeks. Then comparing to 8 to 12 rep marks and then over 20 repetitions maximum. So literally you're failing or that the weight is progressed as the participant gets better so that they're still achieving the number of repetitions. So it's a load that's been progressed, not increased, not the number of rep. And they're clearly showed that the strength gain in the three to five rep max was far superior than the intermediate or the greater number of repetitions. So that's something like it was 60 I think it's only 63% improvement in leg press strength compared to something like 20% in the other two groups.

So you think, fine. Okay. So what I did was just quickly pull up a study this year by Evangelista to look at again, is this still valid and tried to find a study whereby we're matching volume and type of exercise. So a resistance training program for the lower limb and measuring strength by a one rep max on the leg press. They did 10 to 12 rep max, pretty similar dosage so that the volume of repetitions performed is somewhere between three and 400 so very similar and yes, there was a strength gain in those participants who did the 10 to 12 rep max. It was around about 23% but when you compare it to the three to five marks, you look back at Campos at 60% then again for me, that's another reason for me because if you are limited by time, probably resources, maybe buy in from your patients.

If your focus is muscle strength for me, I'll be looking to try and increase that loading to get to three to five rep max because literally you're maximising the input output equation.

David: So 3 to 5 reps going to give us that maximal strength gains and these were performed in healthy individuals or who they performed in.

Claire: You're quite right. Most research is performed in healthy young males like your university populations.

David: Yep.

Claire: For obvious reasons. And then we, you know, if we look at all the populations, you know, the same thing holds true though the volume of research when we're looking at elite and looking at all the populations, probably slightly less actually is slightly less.

David: But I want to dive into, you know, how that applies to your rehab population shortly. So if we're looking at pure strength gains, then it sounds like using those lower rep ranges and heavier weights is what's going to get us there quicker or you know, over a certain amount of time you're going to get bigger strength gains from doing that. Those lower reps. So is there a role for high reps? Like when would you use more of that? You know, say eight to 10, 10 to 12 or whatever else?

Claire: Yeah, yeah. I mean, don't get me wrong, I'm not completely bashing the 8 to 10 or 10 to 12 or the submaximal loading. There's definitely a place for that. There surely is. And for me, the examples would be, or you've got a patient or an athlete whose novel to resistance training and you want them to stick with the programs. If you suddenly load them up three to five rep max, do a load of sets with them, they're going to get such big DOMS response.

You might never see them again. So you know, the higher repetitions can be quite valuable in eliciting that progressive approach to resistance training. Also getting people moving with a load that's not too heavy. Again, approaching a functional situation. So if the goal is function, the goal is kind of loading tissue to tissue to accommodate load, then yeah, definitely you wouldn't want to be loading them up in such a heavy way for that reason. So yeah, the lighter loads, longer repetitions for those reasons. And also for muscular endurance as well. If your goal with your patient or your athlete is to improve muscular endurance, then again you'd be looking at those higher repetitions. So greater than 12 rep max to failure to improve muscular endurance.

David: Basically you're looking at, you said building load tolerance or more like an ability to handle that load. How does that compare to strength? You know, what's the difference between those, what they're going to be able to do if say they've got increased strength from doing your lower rep sets to doing eight to 12 so they might not have gained as much overall strength. What's the sort of advantages there in their ability to cope with the load in that 8 to 12 reps set?

Claire: Yeah. So if the goal is to improve strength and you're limited in time, it fits within your periodisation model, whether that be in rehabilitation or in performance and return to sport, then these are the 3 to 5 rep max. If you want muscular endurance, 12 or greater, that middle rep range might be just useful submaximal. So way that I use it for example, would be if we're looking at, for example an OA knee and some daily activities, stair climbing, sit to stands are quite painful. So I'd be saying that first starting point is, you know, you're doing some sit to stands with them. It's a painful activity for them to do. You don't make it more painful by increasing the load on the joint at that moment in time.

You want them to get used to accommodating that load and almost down-regulate that pain response or that stiffness and they get used to it alongside your conversations you're having about pain.

So that's when I tend to use those middle rep ranges and if you're looking at potentially an athlete, then you can start look at that from a power perspective. So that the speed of force generation to get kind of eight (ish), I won't be going much more over eight for a power improvement, but you might want to do a few more when you come into the, what I call performance based activities or sensory motor activities where there you'd deploy in that capacity that you've built in terms of strength in a functionally meaningful way. So whether that be something like a jump plyometrics or a punch for example in an athlete or maybe it's something different that's more functional for the non-athlete.

David: When you're looking at trying to make the person comfortable with the move and just get used to those movement patterns and be okay with doing it, then you might not load them up quite so much into those heavier weights that are going to be needed for your 3 to 5 and you might use more reps to help them get comfortable with it, get used to it and learn that a bit of discomfort. Okay, but you haven't really loaded them up in this case, say with that OA knee.

Claire: Yeah, definitely. There's a different strategies with them to build a strength until the they're able to perhaps accommodate it in a truly closed kinetic chain way and we work around that by adapting exercise but from a functional perspective. Yeah, that's about it really.

David: What about your sets and so we're looking at that sort of rep range within our sets.

If say you're doing that, your lower reps, you 3 to 5, you're really looking for a strength improvement and you use those little reps, what sort of sets would you tend to use with that?

Claire: Yeah, again, another great question. So I've approached this from going to the literature and pulling out what I think is the kind of the best evidence and you know, checking the systematic reviews, metro analysis, and I've boiled it down to rather than set repetitions per muscle group per week. So if you’re on a strength training program or your patient's on a strength training program, how many repetitions per muscle group per week does that patient need to do to optimally improve strength? So when you boil that down, obviously there's a lot of heterogeneity between studies, but it comes in somewhere between 25 to 45 repetitions per muscle group per week, and that's based on your 3 to 5 rep max. So topside, that's five reps, they're clearly in an initial part of a resistance training program. You're not going to do all 45 reps in one session to that intensity.

So you are kind of dependent on the baseline capacities experience of those individuals, you know who you're dealing with, you adopt either slower approach or a more progressive approach to get to that or whereas you know, if it's an athlete that's literally just acutely injured and you can get there much more quickly than you can probably get there. As I say, quickly and get up to that. But yeah, literally 25 to 45 repetitions per muscle group per week for your untrained or moderately trained individuals.

When we look at the literature for elite athletes, as I said before, there's not all that much there by comparison to the other populations. So probably that is more like 25 to 50 plus. And again, it's a big range.

And anecdotally I'd say working with athletes, you probably who are habitually resistance trained, you probably are more like in that 50 repetitions per muscle group per week to continue to get that strength gain. And again, split over a couple of sessions there.

David: So if you took an example of an exercise or, so let's just imagine they were doing in this case, say squats for instance, and they're doing 5 rep sets, then they might, if they did squats twice a week, they might do them that you're looking at say 3 sets or 3 or 4 sets of five reps squats twice a week or so. Is that right?

Claire: Yeah, something like that. So again, you can use different exercises obviously to keep it, well a variety and whether you do compound or isolation and stuff, but yeah, so you mix it up. Do couple of, like you saying, the squatting, doing the extensions, leg press. So at the end of that line, so in my courses I can have people to program the out. So at the end of that line that week you will have achieved that number of repetitions for that muscle group and then you know clearly it's probably not going to be just one muscle group. So you incorporating in that program maybe the antagonist muscle as well and other bits and pieces. Alongside that you've got an idea of volume over the week and then over the month and you've got something then really quite objective that you can start to change and modify along with the, you know, assessments that go with that.

So if your patient's making the progress that you want them to, fantastic, you keep doing that. If they have achieved the marker for example, that you want them to achieve more quickly, then you can perhaps drop that down and bring into the equation the other aspects of performance or focus more on other aspects that you want to focus on there.

Or indeed, if it's not quite working and not quite getting there and you've seen that the dose isn't quite what you hope for, then you can at least modulate that and perhaps increase.

David: When you're looking at different muscle groups, so say you're looking at smaller exercises or is yes, you will join exercise or those sort of things. Do you tend to vary the rep range for that? So let's just imagine for instance, you're working on calves for instance, or for a tendinopathy of the forearm or something like that, would you tend to vary your rep range there being a smaller muscle group and or do you tend to use still that heavier weights and lower rep range if you're looking for strength?

Claire: To be honest, I'd still go with that starting point because in terms of the evidence that I'm aware of, the adaptability, yeah, you've got differences in generally slower twitch musculature versus fast twitch. But if you start from that point, then you can modulate from that. So I go with the same thing. So the goal is strength, then we have heavy loading, low repetitions rather which muscle group really.

David: And how do you decide whether your focus is going to be on strength or it's going to be on one of the other facets? Like let's just say we're looking at a rehab patient and we say we've got an OA knee patient and I think this is going to work well because you see quite a few of those and it's obviously an area that you're quite interested in. So let's imagine we've got that OA patient in and they're weak, they've got pain, and they've got some probably some, their movement patterns might not be great. They've got some avoidance, all that sort of stuff. So how do you decide what your goals are there as far as you know, whether it is strength or whether it's something else and how that helps you decide on your rep range and set range?

Claire: So I'm right at the front of my personal thoughts, this person, everybody that you see needs to get stronger. Usually they've had pain for so long, they've under sarcopenic and they've avoided physical activity because of the pain because they've not been educated appropriately. So you know, it would be very rare to see somebody that didn't need to get stronger. So it's then how you approach that. I wrote a chapter recently for Elsevier’s new sports medicine textbook, which hopefully will be out by the end of the year, which proposes a model for answering that question pretty much if you've just asked that there David, where what do you focus on and when? And it's like bringing in a periodisation approach into rehabilitation. So what's most important and then how do you then start to focus on that so that you're not doing too much all at once because we know there's not one fantastic magic elixir of an exercise that will bring about optimal adaptation across all aspects of neuromuscular, musculoskeletal function.

So how do you start then to a portion your focus and change it over time? And I think one thing that we miss a lot is the focusing on a muscle strength specifically. So we might think we want to improve strength, but we might (because we're strapped for time because it's easy, we might just) give out an exercise sheet that's already been pre-prepared. I'm not for one minute suggesting that anybody listening to this podcast does that, but lots of the people certainly that I see from an OA perspective. Well I did it with these sheets and I said maybe that's a good thing, you know, 3 sets of 10 to 12 reps just to get people moving, but we need to progress people. People generally fall by the wayside and they don't get progressed. They might increase the number of reps that they can do, but as we know that's completely losing any strength stimulus.

Strength gets forgotten I think so I would be looking initially to improve muscle strength that goes alongside or what first comes is the conversation, and just that fear of movement and trying to allay those fears. It's very individual as you well know. And then once they start to feel more confident in movement patterns in, you know, we'll do some sit to stand, some stepping, make a general assessment of their physical capacity capability, their mental state where they feel like they can go where they want to go. What their goals are, then we'll look at how to start to load them up. And as I said, I always put strength at the beginning of that program. Alongside then things like mobility, accommodating load, doing normal daily activities, progressing those, and the definitely either sensory motor performance or the balancing tasks. These people have, you know, kind of living in an avoidance bubbles. So it's trying to gradually bring them out of that. But the strength is just, we know it kind of correlates with pain a lot better off. So the more we can improve their strength, the more we see that the pain dissipates, the more that they are able to do. And we see this, and my team, say it quite a lot in these OA knee patients. It's just how quickly we can get there with those conversations.

David: So tell us a little bit about some of that. Just talk about the education side of things. So you mentioned with these OA knee patients that, you know, they might be de-conditioned and they are… low strength, that sort of thing. But tell us about some of the key things that you're talking to them and some of those key points that you really want to get across to them when you're discussing the next phase of their rehab or getting them, you know, back to being able to do stuff.

Claire: So I ask them, well first of all, what they’re being told about the knee. What's their perception of where they're headed, what their prognosis is.

Most of them have been told they've got wear and tear, that the next step is a joint replacement. They've mostly been seen by either an orthopedic surgeon or most recently a physiotherapist. You know they're in their limbo. They've just waiting to have a joint replacement and there's no, nothing in between more physical, they're kind of in more pain and then the joint replacement. So we have a discussion about how the muscles around the joint act as the biological stabilisers. So some of these patients I fit with an off loader brace whereby they're able to, if the uni-compartmental that's causing the pain, each able to unload slightly that compartment. So that can be really helpful.

You would mitigate some pain. It makes the conversation about exercise so much easier. Those that don't have it, again, it's the same conversation perhaps just takes a little bit longer. So we talk about the function of the joint, we talk about that where always try and make it positively focused and get them to look forward about, you know, what they want to achieve, where they want to be. Some patients have said, I've been, I'll never run again. I've been told I can't do this, I can't do that and they've had all these restrictions placed on them. I try as much as possible to get them to reframe their thoughts to move forward because that then helps them with the exercising moving forward rather than you know that that hesitancy and feeling like they're going to do nothing but get worse.

David: So let's just say that have been told that they can't run again and that's been a big thing for them. What do you sort of tell them about, how do you address that? Claire: If I put myself in their shoes and somebody told me you've got knee osteoarthritis, it's wear and tear, it's not going to get better and you can't run anymore. Don't run.

I'd feel pretty annoyed really, pretty upset and I can imagine the psychological impact that would have on me so you know, unless there's something else going on where there is a very good reason clinically they can't run because something else going on. I say it's not for me to tell you whether or not you can run again. It's for me to explain to you how the joint works, how the musculature serves as your biological scaffolding. The stronger that scaffolding is, the better the joint functions in their terms and the better the pain should become. So I don't say you can't do this, you can't do that. And I try avoid that negative language where possible and just set them on a positive mindset. As I said, it helps with their thought process, their engagement in exercise. The engagement with, sounds quite deep really, but with life, even after about 3 or 4 weeks of going through this program, they look like different people generally, you know, they push themselves to doing things that they couldn't do, they viewed they couldn't do before or told they couldn't do and psychologically it's got a massive impact on them.

David: How do you address it if they say to you then, okay, I've been told I can't run but I really would love to run again, how do you address that?

Claire: Good question. Tell them it's not impossible. I'd say, well I don't know whether we can get there, but I'm not going to tell you that you can't do it, so I will help you to get into the best physical shape that you can such that you might be able to do that again, so it's not out of the question. I'm not going to tell you can never run again. A good example is a chap who came, he had bad knee osteoarthritis, uni compartmental. He was probably scoring about an eight out of 10 on a VAS, overweight and his passion was tennis and then he had a young kid, he couldn't run around and kick the football around with him.

You know, it's really having an impact on him psychologically as well as physically. So he joined the program, he had an off loader brace, but he stuck with 12 weeks of strength, or close rehabilitation and we progressed him.

So he wasn't able to flex in a close kinetic chain under significant load to start with. So things like press. So we adapted the exercise. So I changed the range of motion. We do isometrics or we do open kinetic chain progress that so at the end of 12 weeks his strength had increased dramatically and then he starting to think that I might be able to play tennis again. So he's feeling a lot better coming back with a smile on his face. Clearly this is all like dose. I have taken the psychological inventories, but he got back to playing tennis 16 weeks after he was really struggling to walk.

Now, there are other things to address that I still can’t quite, he is still quite overweight and he's probably movement patterns the best to play optimally for a long period of time. But that's what he wanted to do. That he got back to playing tennis, continue with the program and he's moving forward. He's feeling more positive about life and that he came in thinking I'm going to be having a joint replacement in the next few months and I don't want to, but what can I do? I'm kind of resigned to the fact that it might be the next option. Now he's back playing tennis. He's enjoying life a lot more.

David: For sure. And that's great. And it helps him to see that, you know, he's benefiting from it and he's more likely to, you know, carry it on in the long-term too, if you can experience that he is actually able to do some of those things that he enjoys doing. So that's really nice. And it sounds like you looked at his function and you know, at the start, so he wasn't able to do any closed chain work.

It was too painful for him. So you started with some isometrics and open chain work. So in this instance, I'm guessing it was what leg extension, leg curls, those type of things or what were you doing there?

Claire: Yeah, yeah. Leg extension, like curls, isometric and the leg press, a joint angle. There wasn't that symptomatic, you know, in some hip oven add up to work. Just anything really that that wasn't too that causing that much discomfort. And so what we see on the program is that we do take measures of pain at the start. So we were running this as a 12-week program, but encourage people to continue. We take a VAS of pain at the start and on a designating activity as well. So most people from that population anyway will probably say you know, the getting up out of bed in the morning, walking downstairs to make a cup of coffee. That's a real activity that that resonates with them it's painful. So we get them to do a VAS of their pain amalgamated generally over the past week on a designating activity 10 or before halfway through 12 weeks.

Then we also just pragmatically what we can include in assessment, we include a sit to stand in 30 seconds and so like kind of at six weeks this guy pain, and most people coming through you see that the function goes up before the pain changes, but at the same level of function, the pains decrease, if that makes sense. So they're able to do more. So their function of this guy sit to slammed, I think there was something like 14 in 30 seconds six to eight weeks. Here's like 24. So when I came out, okay I need to change, the task has improved so much and by the end, midway to the end, the pain scores are coming down as well. So it's like there's a bit of a latent effect before there's a real acknowledgement that pain is different, but they acknowledge and the functions different and then that pain kind of catches up to, they're doing more for less pain by the end of that 12 week period typically.

David: So that gives him a really nice starting point. And then you've progressed him basically moving back to that education phase of things. Lots of chat about some of the other things and what you're telling me about pain during exercise and that sort of thing as well. So can you cover some of that for us? Claire: Yeah, sure. So as you're listening to this that knows that there's pain generally provokes an avoidance of activity in that population OA knee population. It compounds the problem of the de-conditioning. So I explained it to them. the avoidance of doing an activity because of the pain is inadvertently making those muscles that control the joint, that make it more stable to get weaker and the apportion no-blame, because that's what we do as humans we avoid pain. But actually to say that it's not a bad thing, don't worry about it and do some basic exercises with them as I say, and just some of the things that they're struggling with at their activities of daily life. So they're not fearful. They know that they're not going to do any more damage by doing a step up or per a step down or a walking around for a period of time.

That's not going to cause your knee to degenerate more and mean you're going to need a knee replacement more, and in actual fact, if we can work on the muscles a little bit more than that, pain should improve. So it's all trying to put it in context in their language, but all the while explaining that pain doesn't necessarily mean that you're causing damage. It's in this moment isn't helpful to you. Lorimer Moseley’s explanations are fantastic in, you know, that paradigm. So he's obviously the best guy to it to explain that, but it's kind of bringing some of those statements into the conversation.

It really helps them, I suppose consolidate the thoughts about that and be open to doing a little bit more and then they quickly realise and they quickly, you know that those pain responses for the same level activity are quickly modulated and come down.

David: Yeah. You're looking at that function and going, it's improving. And so do, if they ask you, is it okay to have any pain while they're doing their exercise? What do you say to them then?

Claire: So again, it's a bit of a finger in the air job, isn’t it? so I explain it like a 0 to 10 so that on their VAS. So they used to filling out that, although we don't put the numbers on it, if 0 is no pain, 10 is the worst pain imaginable. When you doing an exercise, I'm kind of like about the three to four stage. That's going to be okay. As long as when you stop exercising it doesn't get any worse and it gets better. And if you know the next day that your knee is not, you know, again, more painful than it was the prior days. So if it is, we'll just back off a little bit, and if it's not, then that's absolutely fine. And if it is a little bit more painful, again that's no problem at all. We can just tweak things. And so just them being used to having that discomfort, enduring discomfort anyway, and that's what I explained to them.

You know, you're in discomfort all the time, especially when you get up and when you walk the dog and some of these guys maybe cycle 200 miles a week in no pain, but when they get off the, you know, they're in pain walking around the house or their work so that they used to have in it. It's just reframing what that means and then when the understanding that they are in something that should be beneficial for pain ongoingly and they understand they're not damaging themselves, then kind of, as I said, he puts it into context for them a little bit better and they feel more comfortable with that. And probably the thought process around that probably down regulates that process doesn't it?

David: They can have some discomfort because they've got discomfort sounds like all the time anyway. And then you're saying it's like that's okay as long as it settles after the exercise and then the next day it's not stirred up as well. If it's a bit stirred up then you might back off their load a little bit and just adjust that. But if it's not and they're all okay, then you can keep progressing it.

Claire: Yeah.

David: And so that gives a really nice example of how you might tie that in with your, you know, in this case at that advanced OA patient. So, and we'll come back to that fair bit as well. So anything else, any other sort of education key points that you want to cover with them?

Claire: Really no. Pretty much said it all. Just trying to get them to understand that the role of the muscles, what's happening to muscles when they avoid exercise and then what can happen when we intervene and improve muscular conditioning, their stability and how that will influence pain and function. And even if they are on a trajectory for a joint replacement, pre-operative status determines post-operative outcomes. If they're in a very, very poor physical state before a joint replacement, then their rehab journeys is going to be much longer, much harder, probably more painful. So even if they go back to the orthopedic surgeon and they need a joint replacement, I would still say this, you know, if it were me, I'd be doing this, improve the function of the level and the strength of the lowering the capacity. It's like the fuel tank and you know, I can't see a negative effect of doing that.

David: Are you looking to progress it? Let's just imagine this guy here and he keeps, he decides he's going to keep going to the gym or whatever and he's going to keep doing strength and conditioning work. Are you looking to progress to a close train activities with him or what were you sort of goal activities and strengthening exercises?

Claire: Yeah. What we typically see actually is the get there quite quickly, albeit or if they're, they're are able to do it, the range improves. So we'll get quite big gains in the initial stages in terms of being able to push them. And I think some of that's a learning effect, some of that's being comfortable with pain and discomfort and there's an adaptation as well. So I'm yet to see anybody that we can't get into a closed kinetic chain situation and load them up so that they do get there. Some of them will be full range, some of them will be maybe partial range, but generally get, most people there.

David: I really want to dive into some of that, how you would decide whether you're going to work in a limited range. Where are you going to lower the weight down. So this might be a good time to look at it. So let's just imagine we've got someone that's a bit younger that's got some early OA that still got pain and they're a bit limited in their range and they've got pain with say squatting. Would you tend to limit their range first or would you tend to decrease the weight that you might use? Just say if they get pain when they squat with the do a one leg squat, where squat with say 50 kilos or something like that, what would you tend to do first? Back the weight off or back the range off?

Claire: I do both as in I'd focus on strength in a comfortable range. And then the second bit wouldn't be a strength focused exercise. It's for function. So we'd pull the weight down and get them to be, it's almost like learning the technique isn't it? But for them it is accommodating, load in a different range and through range.

So probably I'd probably do that towards the end of the session. So we'd pull the weight off and we're not going for strength, we're going for kind of technique and we're going for a range and we are going for mobility, etcetera. So I do both really. So we still keep that strength focus, but we're looking at function as well.

David: So you're finding a range that they're comfortable with and you're decreasing the weight so that they're, rather than loading them right up to that 3 to 5 rep range in this case, if they've got pain with certain range in weight, your back the range off and you back the weight off as well so that they can cope with both. And then after they're comfortable with the range, then you'll start to build up the weight. Is that how you tend to do it or what do you look at there?

Claire: Yeah. I mean we'll still try and get that 25 to 45 reps per muscle group per week in the strength zone in activities, exercises that are, you know, comfortable. So we don't have such a pain response. Concomitantly would include some exercises that would be more functional. So like you're saying, take the weight right back and go for range and if we have to do that in the same session, we'll do that towards the end so that the focus of that wouldn't be strength. We would have done all the strength work first. But like you said, you know, we want to improve range, we want to improve, ideally accommodating a bit of load through a closed kinetic chain situation. And so we would do it that way.

David: With these OA knees in particular, do you have any sort of favorite exercises? We've talked about a few of them that you're particularly looking at your open chain stuff initially and you mentioned their leg extension leg curl, you're looking at the hips as well, abduction, adductors and calves and those sort of things.

Any particular exercises that are some of your favorites in the early stages with your more say advanced OA to start with? Claire: Isometrics are great really. So if you think about what's in your tool bag or in your tool box depending, which you carry around and if you're struggling for, you know, in those first few sessions your struggling to get a full range -

David: Isotonically?

Claire: Yes, isotonic contraction and you can limit the range there, but also isometrics are fantastic just to get that person accommodated to activate in the musculature in the least uncomfortable position. So that I love using isometrics for that reason. And as well it's got great efficacy as well in bringing about strength gains. So if you can get them up to a maximal contraction, particularly along the muscle lengths, then you've got a transference across to shorter muscle lengths in terms of strengths gain if you were just to do a strength training program and isometrics. And also there's a transfer to concentric strength as well, particularly those longer muscle length. So there are really good often overlooked exercise than maximally and that can really help with that initial activation. And you know the starting then of that concentric, eccentric patterning of activation through range and or partial range.

So yeah, I love those and I love to get people doing deadlifts as well. And so once we've got the ... They're comfortable in it being in the environment because that's a whole another thing as well. So literally it's a handheld approach. Bring them in into the gym. It can be quite intimidating. So we need to get as much as possible. So once they're comfortable being there, they're comfortable lifting and their comfortable with the program, then we're seeing the strength gains or pains going down, most of them are never done a deadlift before and again it's one of those things that it seems so far beyond them. They'll never do that. I love to introduce them to it because again, it's just a brilliant win for, it's a psychological boost, being able to pick something like that off the floor, it doesn't have to be massively heavy, but then we can actually use that with these patients. So yeah, won't getting them to do those when, when it's appropriate. So it's another good thing.

David: Come back to those isometrics that you mentioned. You said you'd like to use maximal and especially length and range. Do you tend to have a certain time target that you're going for with these and you know, reps of isometrics or how do you target your exercise prescription with those?

Claire: Yeah, stick to the same kind of dose I explained before and up to about five seconds of maximal contraction. So beyond that might be more certainly approaching the 10 seconds you're going to be in that fatigue range and you don't want that to intrude on subsequent contractions and the efficacy of adaptation. So about up to five seconds is probably enough. Bearing in mind as well is they're probably not going to be explosive in that those early stages of a strength training program, it might take them a little time to ramp up to maximum, which is absolutely fine. Is it as long as they get, so in total about five second contraction or like for a couple or another five and then just do that within the three to five rep max, we take them to doing five in a set, two minutes break, five and a set two minutes break. So same as the other much concentric/eccentric.

David: Yeah, and I'm just picturing this, so imagine you mentioned before leg press that you might do it in a leg press that there they've got a range that's comfortable and they're doing holds in that range. So I'm guessing they put the platform down onto the pins at a range that you're going to be close to using and then they lift it up off the pins that are how it works with your leg press?

Claire: Yeah. Yeah. Depending on what kind of kit you've got. I suppose clumped into place or loaded up in such a heavy way that they'd never be able to push it and move it. And at that joint angle that's, that's not really that symptomatic as well. So just picking that the longer the muscle length the better. But if you're really kind of getting into pushers and looks in significant pain is probably not going to be that useful. So just at that comfortable range for them.

David: Any other exercises that you to use isometrics with particularly for these populations besides the leg press for your OA knee, say you're looking at using these isometrics with them, are there any other of your favorite exercises that you'll tend to use isometrics with besides leg press?

Claire: Oh yeah. Yeah. So like knee extensions, definitely those are probably the main two because flexion doesn't tend to be that symptomatic or the probably just limited on range. So yeah, definitely the knee extensions, open kinetic chain and a leg press as well.

David: Leg extension, knee extension often get a bit of a bad rap in all sorts of different circles, whether that's physio circles or personal training circles, any of that sort of stuff. What's your thoughts there?

Claire: There are evil. Oddly they invoke fear ocus in to the joint, but what do we do when we walk and run? I don't think they're a bad exercise at all and I actually really liked them because you can, they’re open kinetic chain and in populations whereby you've got pain during compression of joints, like in a closed chain situation. It enables you to get…a leg up in getting my strength gain to get them into those positions that you might not be able to achieve because they are so painful. I really like them. I'm yet to see any research that says they cause injury or they're good. I like them.

David: For sure. I do too and it's just that there's a fair bit of probably an opinion, I suppose would be the best way to sum it up that people, people don't like them for various reasons. In the early 2000s there was lots of theories thrown around. They did put lots of sheer stresses on the knee and you know, that doesn't really seem to be the case practically. And they can be a pretty useful exercise, can't they?

Claire: Yeah, definitely. I mean it wouldn't, it's clinically not advocated to do that. So if you think about ACL reconstruction and open kinetic chain quality particular joint angle immediately post op, although we're starting to question that now, then you know that's probably a decent reason to question that. But in a population whereby there isn't that clinical consideration that you've got, I can't see a reason for not using them. They, you know, you're conditioning the musculature, they’re noncontractile in series. So yes you might get some shearing force in the joint, but you do get shearing force in the joint during sprinting, walking, lots of activities. So if we're conditioning the tissue to accommodate more force in those positions, then surely it's going to be a more robust system.

David: Definitely. And in a lot of closed chain exercises too. If they are, they are a bit quads deficient or you know, they haven't got the strength through their quads, then they could use the glutes, all the other muscles and it can be harder to target that to get those quad strength up.

Claire: Yeah, yeah. It's great isolation exercise. Yeah.

David: I like if some really good practical ideas of how people can start to address the strength and so you're looking at with those isometrics, you mentioned they're open chain stuff and then your isometrics and then you're looking to your often targeted with that strength range that you mentioned before. Looking at 25 to 45 reps per week per muscle group and your this population using your lower rep ranges, is that right?

Claire: Yeah, yeah. Yeah, definitely. Unless you're going for something different, function or endurance, definitely still stick with that rep range, three to five rep max.

David: What about your frequency how often are you getting people into the gym in general health and did you recommend for, it could be for OA patients, could be for any other patients. Tell us a little bit about the frequency of training. How often do we want to get people training for strengthen or move control, that sort of thing.

Claire: So we deal with humans, we don't deal with robots or machines. So we've got a, like you said before, there's a conversation about pain and you know the older the valid concerns that they've got. And then there's also a consideration of conversation about logistics and how much time they perceive they've got in their life. So some is better than none. Absolutely. And what we want to do is that with anybody who doesn't do this habitually or absolutely loves it, which I don't think he's either you or I who really enjoy it, but it's establishing a habit. And with some people it might be that you only get them to do a small bit of what you really want to do with them. Just to make it palatable for them and to get them into a routine. Once they're there.

So to be fair, most of these patients, the QA patients we've been talking about they're pretty motivated to get better as in improve their symptoms. They are trying to avoid a knee replacement and they want this apart of the conversation. What's their motivation? What's their why? Where do they want to be? What do they want to achieve? So is it playing football with a kid? Playing tennis? Is it being able to take their beloved dog on a walk on unstable ground?

So that's what their goal is that they're headed to. So most of them are put it in that context of pretty motivated. So then looking at their life and trying to solve, or help them solve that logistical equation. I like them to come in or do this twice a week, such that we're able to get that dose of strength. And we're able to do some ancillary things around that too. That's not to say they can't do it three times a week.

Definitely they can and one or two might do. But I think with this population, probably twice a week is something that they see as doable. And if you're thinking from a dosage perspective, that's probably about right when you're looking at trying to achieve that volume of repetitions for the muscle groups that you're working on. Again this periodisation approach with OA knee patient who has got goals of activity of daily life compared to then your elite athlete who has a high performance goal and they do that for a job. It's a very different consideration. So in terms of frequency, it might be that you're trying to crowbar their stuff in without overloading them.

So I had an example, I had a conversation with some of the rehab team last year for the then BMC Tour de France cycling team. I think that they’re now CCC, they were asking questions like you were saying, how often do they need to do this? And then approaching the equation of actually we've got an a need to at least maintain a certain level of cardiovascular fitness during this rehab time, but we also need to improve, for example, strength power in the lower limb. How can we put that together? How can we dose them without one conflicting with the other? And completely overloading them and having that interference effect. So the frequency, really kind of depends on, I guess, who you're dealing with. So trying to cram that, that dose into that schedule.

David: Yeah, it's a little different isn't it? They've got all the time, but they've got to make sure they get the recovery that they need. And also that they actually can complete their normal training and make sure they keep the actual cycling fitness up in that case as opposed to your OA knee that might be, if you can get them into gym twice a week, you'd be happy because I've, you know, managed to tick the box and start to get their strength up.

Claire: Yeah, exactly. Exactly. Yeah. So then you've got different, you know, with the professional athlete, you've got a different consideration and your thinking about the interference effect of concurrent training and like you're saying, the recovery and alongside rehab and the maintenance of the fitness, at the very least, maybe there's still limits or improve so those are different physiologic things.

David: Yeah, definitely. And on that note though, while we're chatting about the elite athletes and how that might tie in, we were talking before about your five rep max training or you know, three to five for that strength. How does that relate to your endurance athletes? For instance, you will cyclists, or your runners or those sort of things. Do your lower rep strength training, does that apply to those endurance athletes or do they need higher reps or how does that tend to work?

Claire: Yeah, they do. I mean probably, again you'll come down to what the sport is and their performance requirements are, but in terms of whether or not endurance athletes should do strength training or not, then I think there was generally the fear wasn't there the way back where you know, runners will become slow, they become really muscular and lose mobility. And I think we've got enough evidence now to say that's not them doing a strength train is actually an official for endurance performance such as running economy and maybe a time trial, a distance if many do the way. And then also there's the other things like resilience and dynamic joint stability as well. So not only does it not make you slower, it can actually improve your running economy. And if we think about the musculature around the joint being it’s biological scaffolding, some of the performance characteristics of the musculature is in the strength. So it helps maintain that more functional joint or being able to be more resilient against imposed dynamic forces.

I don't think there's a valid reason for saying no. Maybe the volume of which they're doing in terms of throughout their competitive season would be slightly different to certainly a strength athlete, but there's definitely the need to make sure that it's considered at some stage within their program throughout the season.

David: Yeah. And the lower reps suitable for endurance athletes?

Claire: Yeah. For strength gain for sure. Though, if you are wanting to improve, for example, high-intensity, muscular endurance, then you did some things separately, different time, which would involve those, those higher repetitions still to failure alongside. You know, your cardiovascular fitness or your other types of performance based training. But yeah, there's certainly to have a strength focus at some point within that competitive season will be a benefit for, there's no negative effects. It's been shown as long as you properly manage that and you know it has been shown to improve running economy or distance covered for a certain day or two. And also then we think about the stabilisation of joints and resilience and robustness to fend off or be more resilient against some poor dynamic forces and joint injury. So yeah, I think there's a strong rationale for that.

David: Yeah. Okay. Fair enough. So it's not necessarily, you know, in the old days of people sort of thought, well if you're an endurance athlete, you want to do higher reps and if you're a strength athlete then you want to do your lower reps sort of thing. But there's a benefit from going with the lower reps for your endurance athletes, they're going to have more better running economy and greater strength, that sort of thing. Whereas your high reps probably not going to get the same strength gains that they might get and that you probably not even in the same rep range are you? Like, you know, you look at a tendon, even if you did 20 reps, it's no, we need the 10,000 steps or whatever you might do in a run. So you're not really looking at a similar type of a rep range at all for specificity, but you, you're going to miss out on some of those strength gains that you get with your low rep range. Is that right?

Claire: Yeah, exactly. So again, it's looking at that input/output equation and you said the word there. Specificity. So for you know, think about you don't have to put as much time and undo the resistance exercise for as long to get actually better benefits in terms of their output in terms of strength, the show by doing that three to five rep max. So, as I said, strong rationale. And you know that specificity fit for strength training is definitely there.

David: What about when you're looking at that specificity in inverted brackets, functional exercises. So what are your thoughts on that? If you, you know, people want their exercise to look sort of like they're playing the sport. So what's your thoughts on making exercises functional?

Claire: Yeah, so functional training is quite the fashion right now isn't it?

David: Yeah, yeah.

Claire: And so I'm not going to poo poo it at all, but from a functional perspective, you probably not going to be able to load up in a way to elicit strength gains. So as in yeah, accommodate or get a load that represents three to five rep max in some functional situations that's not going to bring about the strength gains that you want. I look at functional training in inverted commars within this paradigm of periodisation and I label it as kind of performance based training or performance-based sensory motor performance, depending on who you're dealing with. And for me, that's deployment and utilisation of those capacities that you've already built. So in a rehabilitation plan that would probably come towards the end stages of that return to function, sport, whatever it is that your patient does.

And that would be then training them or them to be able to train themselves to deploy the newly formed neuromuscular capacities that they've got. So improve strength, improve power, speed of activation in a functionally relevant situation. So whatever that is for the sport. So mimicking some of those movements with load but not a load that clearly that you can develop strength with, but achieving those recruitment patterns that you now able to elicit because of the ground work you've done in the strengthen in the power phases of that rehabilitation programs. So functional training I think has a role when you're looking at that return to sport and using the just said that the new capacities that you've developed in that functionally relevant situation.

David: So you've used more of the strength exercises initially to get that strength and then later on if you want to you can incorporate some of that other stuff.

Claire: Yeah, that's how I view it from the perspective of developing capacity.

I don't think you can do it very well on certainly not optimally in a functional training situation, but when you're looking at performance base and utilisation and training to use capacity that you've already built and then it might have a role I think.

David: What about power and developing power train ... whether it's for your athletes or your non-athletes, when do you tend to include any sort of power training?

Claire: It starts to look at that. Then once we've started to develop a decent capacity or strength capacity, again, if you look at a rehabilitation phase, so in that diagram, that model or the, when you're establishing the hierarchy of importance of different things, if you were to focus principally on development of muscle power in a weak athlete, then it doesn't really make sense because if you think about the strength being the fuel tank, you know that's the capacity. If it's pretty empty, I don't have that much force to give. Then arguably if you're training to produce force quickly, it's a bit of a moot point because you don't really have that much. So if you focus on strength development first and top up that fuel tank, do you know that nice full levels, then for me then the utility of power training can be enhanced because you've got a lot more force that you can literally play with.

So I'd be looking at power production, performance and training once you've developed that capacity. So way people are non-resistance trained or maybe quite low in functional incapacity or their de-conditioned, then you might spend quite a bit of time developing that strength adaptation before you start to consider power and just know as well that some of the heavy loading three to five rep max can bring about power changes as well. So you're not completely ignoring it. But then you know if you've got an athlete who is really well conditioned, you're quite happy that you don't need to spend, I don't know, 12 weeks on developing purely strength. It might just be a two or three weeks there where you can have re-engaging those recruitment patterns and quite quickly you move on to that power training.

David: And what are some of your favorite ways of developing power?

Claire: Again, I follow that approach where it's that hierarchy of importance. So looking at weightlifting derivatives, the key thing about power is the intention to do something quickly. So that's the difference between strength training and power training is that explosive performance, that real kind of mental drive to lift or to perform with an explosive capacity. So could be, for example, let's say pick a, I don't know, a deadlift, it might be quite heavy and maybe approaching your five rep marks so you're not going to lift it off the floor very quickly. So externally when you're viewing it, the speed of the movement of that weight probably won't be all that great by comparison to if you, you know, half the weight, but as long as the intent is there to lift quickly, then that can really help with those recruitment patterns and drive to develop muscle power.

So you can play around with weight and you can play around with, with speed. So some of the good exercises to do, if you know, the athlete has got capacity and like weight lifting derivatives or part of this power and strength lift through to them because you can really load up on those exercises and really focus on development that faster motor unit capacity three, two then you know that if we're looking at lot functional activities like your plyometrics, I guess that's coming back to the performance space, different functional training.

So for me, you know that can develop power as well as doing it in an environment that is perhaps more replicable of your sports. If you're an athlete that is, I know basketball or volleyball or involves jumping a lot, then you know some of that initial heavy power capacity work will be done probably with, with quite heavy weights. So you can load up but then you know, explosive performance. Then translating that into performance, doing with the plyometric stuff and the, the box jumping, etcetera.

David: So you're looking at it more in that later phases, develop their strength first and then you're building into more of that speed and power work. And then you have possibly your plyometrics and that sort of thing. And so you mentioned there the weightlifting through safety might use things like your power cleans or your power snatches or snatches, that sort of thing?

Claire: Yeah, there's quite a bit of evidence of that as well. An interesting, some of those movements, and there's a few studies out there have been shown that actually they can help develop let's say vertical jumping ability just as much, if not possibly in some cases a bit better than plyometrics, which initially you might think that's counter intuitive. But then if you think about what plyometrics involves really it's just body weight, isn't it? Plus gravity, maybe a weighted vest. But beyond that you can't really load up safely on a box jump or something like that. So when you think about power involving fast-twitch motor unit recruitment and fibers and you know really trying to target those, then you know that's what actually strength work does as well. So those heavy loads. So it does start to make sense if you think about it physiologically and the determinants of power.

David: And you definitely got a jump pretty hard to get a heavy power clean from your hips up to your shoulders. So yeah, there's a lot of force there and a lot of speed and propulsion that's got to happen there. So it makes sense.

Claire: Yeah.

David: Yeah. I'm interested to talk to you and get your opinions on a few different exercises. And you mentioned there before deadlifts and deadlifts are a great exercises, big fan of them. When your training, say for instance, you mentioned that before you'd like to get OA knee patients doing deadlifts, what sort of instructions, are you fairly particular in the way that you teach them and how you'd like your patients to do them or are you happy for them to do them any old how? Claire: I try and avoid overloading them with information to start with. You can confuse people quite a bit, particularly if they've never done one before or really not seeing very many people do them. So I'll demonstrate it for them and then just maybe give them first of all, a couple of key points like look forward rather than down, drive through the heels and that can correct quite a lot of suboptimal movement patterns and can help them do it better. So avoid them tipping forward. I suppose kind of coming up on the heels can sometimes help with, you know, the shoulders or the just look a bit more stable. So avoid, as I said, giving too much information at the start. But certainly those two things. That would be the first type of level of instruction that I give them.

And then, you know, I'm not too overly bothered with them kind of having much too much, too little kind of lumber flexion for example. And again it depends on who it is and what their capacity. So usually we're doing these to learn the techniques to start with so it won't be loaded all that heavy.

So we'll just getting them to do it a few times. And then maybe the next session would just kind of then talk them a little bit more about putting the chest forward a little bit. Everybody's different, but I'm not really panicking if they don't look very elegant first few times of doing it.

David: Yeah. Yeah. So you're happy for them just to start getting a feel for it. You've given them a few cues, like pushing through their heels or and looking forward and not down. And then you starting to get them, you know, deadlifting then you starting to change a few as they get going, but you're not really focusing on it. It happened to be absolutely perfect.

Claire: Yeah, exactly. Yeah. Couldn't say it better actually. Yeah. Just as long as they're I suppose lifting the weight off the floor, it looks half decent and the driving through the heals, they are looking up, then they might make a few tweaks and to be fair, it will take them a good all while in a, you know, a strength rating problem to get actually to a five rep max. So there'll be a few sessions of learning first and then being comfortable with it too.

David: For sure before they can actually push hard enough to get to that, to something that they can only lift five times.

Claire: Yeah. It will be more like submaximal loading first and then maybe going up to you know, this is where you can have middle ranges. So you learning the technique, you learning to, you know, sort of very strange thing to do I guess, isn't it kind of, if you've never done it before, what would be their closest thing? The them have been done that maybe if they're shopping bags off the floor. Yeah. So which maybe make the holidays a bit easier when they're running for the plane.

David: Yeah, for sure. Then there's a lot of discussion about this. You know, there's a lot of people that say it doesn't really matter how you do it, you can do it any old how.

And then you sort of go to the other extreme and you look at say power lifting, where they're really focused on the technique. How do you balance, especially when people are sort of starting to get to those up towards the five max where they are pushing a bit more weight. You're looking at the technique and how do you balance creating a fear of the sort of moving wrong, you know, in inverted commas, or getting them stronger and that sort of stuff.

Claire: Yeah, that's a really good point because exactly that you don't want them to have a fear of or you don't set them back psychologically in the, you know, the strength training program, resistance training program that does have suddenly fear of heavyweights now. As I said, I try and avoid a lot of that instruction and quite hands off, but once they start to lift more than you can start just tweaking the technique a little bit more. As I said, I'm not massively worried about having particular angles of knee and hip and you know the back and as long as it looks fairly decent so maybe the shoulders aren't kind of slouched forward tremendously as long as they drive them through the heels, you should be getting some decent glute activation.

To be honest it tend to kind of get there. I mean it's not, as I said, it's not the most elegant in everybody, but it doesn't look too bad, to be fair. And I don't want to start rushing in there and going, Whoa, that looks awful. And then like you said, there's some fear to do it. If I'm struggling to think of a situation where I've been worried like that it might be, and some people we start with the hex bar to do a dead lift.

David: Like a trap bar dead lift where you stand inside it yeah?

Claire: Yeah, exactly. So it's like a square on its axis on this triangle and you've got your loading up from the side so you step into it. So it is a bit more like lifting shopping. So you're lifting the weight from the sides, so literally holding the bars. Either side of you just probably slightly wider than shoulder width apart and you'd get them stood inside that trap bar. Yeah. So you can then, if they've got an issue or they've got bit of a problem and trying to activate the glute, so you've seen that, you know, I don't really want them to be pivoting from their hips. That's something I probably would intervene with. And then let's move them actually onto that, which really does help them engage the glutes because you lifted in a slightly different way. It still got that whole body benefit.

David: Any other favorite exercises or any exercise in particular you are a big fan of and you'd like to include in your rehab if possible?

Claire: As I said, I like dead lifts because of psychological impact has gotten some of these patients as well?

David: Yeah.

Claire: Oh cool. Quite a lot though. You know, the isometrics is a really good, quick win. Those are my favorite actually.

David: Great stuff, and so what about anything you see often in the gym that you make might be one of your pet peeves or something that you sort of go, ah, it could be an exercise or a program… area that you sort of think, eh, you know, that's something you you'd like to or that you hear information about that you'd like to change?

Claire: Well, one thing that maybe is closed mindedness. Does that make sense? So people adhere to or subscribe to one particular way of doing things and there's absolutely no room for consideration of other things. That does slightly annoy me because that implies there's a right way and there's a wrong way for in this context rehabilitation. And I don't think that's the case. As you said, we're humans and different people respond to different things and they will respond differently to one another as well.

So like functional training is a great example. You know, some people all about functional training, we shouldn't be doing anything else when, you know, I don't think that was the case, but probably does have a place within a rehabilitation setting and performance setting. That doesn't mean to say it's the right way to do it. Likewise, I'm not advocating that strength training and power trading using resistance is the only way to rehab.

Yeah, kind of close mindedness and that does annoy me a little bit. And then I suppose I found it upsetting is seen a lot of these OA knee patients. There's a campaign if you like, a movement in the UK called Versus Arthritis and it's trying to bring together people who suffer from arthritis in groups to help manage this condition better. And I've done a couple of talks for them recently and the lack of education that people have got about their condition that I find that upsetting. That's a pet peeve. So even though my background is neuromuscular physiology and muscle activation and conditioning, I probably spent most of my time talking to people, validating their pain, saying that they were normal, that translating and trying to shift their mindset from being what they'd been told, which is negative, negative, negative, negative, negative. You're not going to get better. And to try and shift that, you know there is a possibility that you can improve your symptoms. So that's a big pet peeve of mine. I think we can do so much better. And that's not even involving any resources such as gym facilities and it's just delivery of information in a slightly different way, which I think can be hugely beneficial for patients who are suffering with this in constant pain all day, every day.

David: Anything. You know, if you've got the earlier OA, like say you know that 45 year old patient that had just started to get into the OA, what sort of education might you give them? Claire: That's really where we need to be focusing on. But it's difficult to sell prevention to any stakeholder really. So yeah, for them maintenance of activity, the recognition perhaps that they've recognised they have got pain. But again coming back to that knowledge of the role of the musculature in mitigating that and maintaining joint stability, maintaining joint function. So the people I see who are kind of in that arena feel like, are mainly be like squash players, badminton players, people that are active. So they are already motivated to do something about it. These are motivated people but they haven't ever really engaged in any form or resistance training. So this starting to become, to be honest, it's probably more like 50 to 53ish people I've seen, so they're starting to become sarcopenic as well.

So just education around that in a positive certain mindset framed in a positive way, but just that you can probably mitigate some of that pain. You can probably go on playing squash for longer and just make yourself feel a little bit better if you were to do a bit of resistance training like this. So that would probably be the couple of key things I'd offer up for them.

David: Had there been any studies looking at that, looking at outcomes of doing strength training in OA patients, that type of thing?

Claire: Yeah.

David: Any references particularly you'd like to mention?

Claire: I can send you a list of that.

David: That'd be great.

Claire: Certainly bashed the NHS in proposals with these in terms of how they, resistance training can, as we said before, on a research level, can improve pain, improve function in some cases, You know, that then might translate into a delayed decision making for joint replacement surgery as well. And then if you think about other ancillary benefits of being active and I and my systemic level, then obviously their there as well. Yeah, I'll pull up those references for you and send them across.

David: Awesome. Well I think we've covered a lot of great stuff in this chat. I've really enjoyed it. It's been great to have a chat about strength and conditioning and a really dive into OA particularly, which is great because we've had tons of questions coming in about how can you rehab OA patients, how can you incorporate this and see if OA has been one of the really popular questions that people have asked. So great to get your insight into that because you do such a lot of that and you know, you've had such a great background in S&C and show us how to incorporate that. So yeah, lots of great stuff there. Really enjoyed having a chat to you about that. And so tell us a little bit about where people can find out more about yourself and you also did a recent webinar for us. Just give us a quick outline of the stuff that you chatted about in the webinar and then tell people where they can find you as well.

Claire: Sure. Well it's been great to chat and time does fly. Yeah, I think the thing to say is just don't be afraid for loading up older patients and patients with OA. You know, it can be hugely beneficial if done in the right way, which leads me into, you know, the webinar that they've done for you that the couple is in two parts. So the first part is understanding and get a mastering what we understand to be muscle strength. So there's often a misunderstanding of what that might be. And then looking at the physiologic determinants a little bit, we're not going to too deep, but just getting comfortable with muscle strength, why it's important. And then the second part, we start to then look at how we can develop muscle strength optimally in rehabilitation programs.

So I spoke before about periodisation. You know, that's a common S&C term. You know there's a way in which we present that there. There's the way that you know we've discussed just today about dosing, about reps, about sets, about frequency, about adaptation and how you can fit that into a resistance training program. So as we said, there's not a single magic exercise that will bring about optimal adaptations across everything. So it's far better to, if you think you're strapped for time, which most people and most of us are, it's better to do one thing very well than many things very poorly. And for me that starts with the consideration of muscle strength in a rehab program. So we really get to grips with that and give some examples about how you can incorporate that into a rehab problems for OA knee and another athletic population.

And also I've done some videos as well about progressions and regressions. How you start then to instead of changing the load, what other variables that you can manipulate to maintain that strength focused so you don't want to drop the load because then you lose the strength focus, but how then can you keep the load but make sure that that person is able to do the exercise. So one, it's not too technically challenging or two, you're not evoking such a pain response that even if they did want to do it with generate inhibition and kind of losing the effects of that. So that's the couple of webinars that we've done, which are great fun as well.

David: Yeah. Lots of great info in those.

Claire: Great. Yeah. I really enjoyed doing them. So to get in touch with me, I have a website, www.getbacktosport.com. You can also tweet me @claire_minshull. I also have the profiles get back to sport on Instagram and Facebook. And as I said at the beginning, I run in-person courses on these matters strength and conditioning, neuromuscular conditioning for rehabilitation.

So check out the, you know, in the UK or Canada in September, I'll be running some courses in the second half of this year. Also, I'm about to launch an online course. So that's a six week course on pretty much, you know, most of the things we've covered here going into more detail about strength and conditioning for physiotherapists. How do you start really to embed that detail into your rehab plans? Looking at, as I said before, progressions, regressions, what strength is dose responds, different populations, periodisation, etcetera. So if you want to know more about that, tweet me. Also, you can sign up to receive a download on my website or on any of the blogs as well you see on my website and you'll be automatically informed as well. So any questions please just get in touch with me.

David: Beautiful. So your twitter handle, Claire. So is C-L-A-I-R-E-M-I-N-H-U-L-L?

Claire: That is correct. It's got an underscore between Claire and Minshull.

David: Perfect. Okay, that's great. Well get on there. Let Claire know what you enjoyed about the podcast. Anything you sort of want to sum up before we leave everybody or mention or other things?

Claire: No, it's been great fun. Thanks so much for inviting me on. I'm in the presence of many great people on this podcast, it’s great. And I think just the, as I said before, just let's try and avoid the automatic assumption. And if we're talking about OA and old people that we should avoid heavy weights because for me strength adaptation and strength training becomes more important as we get older, even in asymptomatic populations because of that sarcopenic effect. And we know how strength relates to quality and the quantity of life.

David: Well that's a great way to wrap it up. Well, thanks for coming on and sharing all that with us Claire it's been great and yeah, get on and say hi to Claire on Twitter, follow her, let her know what you've enjoyed and any questions I'm sure she'd be happy to have a chat to you about it too. So thanks for that. And yeah, we appreciate your time Claire.

Claire: My pleasure. It's been great to be on. Thanks so much.