Doug Kelsey's Blog

Question From A Reader: Strength Training Without Weights

Hi Doug,

I'm a big fan of your blog and have another question for you. What advice do you have in regards to progressive resistance for someone who is limited to working out at home with minimal equipment. If I were at a gym I could incrementally add 5lbs, 10lbs, etc to consistently overload the muscle, but I find this difficult to replicate at home when I'm doing mostly body weight exercises i.e. push ups, squats etc. Any thoughts would be appreciated.

Thanks,
F

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Thank you for the question. It's a great one.

A couple of questions  to ask your self first are, "What's the point of my exercising? What am I trying to achieve?"

If the answer is to increase muscle size (this is often the goal for men; for women it usually is to lose fat and increase muscle tone), then you have to, at some point, use heavier loads.

Muscle hypertrophy comes from recruitment of mostly fast twitch muscle fiber (FTF). When you begin an exercise, for example a push up, the recruitment of muscle fibers follows a specific sequence from Slow Twitch to Fast Twitch. As the intensity of the exercise increases, you recruit more FTF. But, you have to train for nearly twenty weeks to get past a neuromotor learning phase where your body gets smarter at performing the movement before it alters the muscle fiber size.

Now, in the push up example, the very first time you try them, you might fatigue at 10 or 12, for example. And, then the next day or so, you might be sore. But, eventually, you'll no longer fatigue at 12 reps but rather at 30 or 40 reps which means you recruit fewer FTF.

At this point, you can increase the load of a push up by doing a few things:

• Place your feet on a chair to increase the effect of gravity.
• Use a weighted vest.
• Place a weight on your back.
• Wrap heavy resistance bands around your upper back and under your hands.
• Perform one hand push ups.
• Place you hands together during the push up.

You can also add higher speed, eccentric motions to the movement such as a push up - clap your hands - land in the push up position. The higher speed of contraction (catching your self as you land) increases the force (F = mass x acceleration). Higher force means more FTF recruitment but this may not deliver much change in muscle size since you're not recruiting as much FTF as you would during a very heavy bench press, for example.

For the squat, you can increase demand by:

• Using a single leg squat.
• Holding a dumb bell in the opposite hand of the single leg squat leg.
• In between sets of squats, hold an isometric squat position for 10 seconds or more. This increases the rate of fatigue and therefore increases the perceived load.
• Increase the speed of the squat.

You can develop significant strength though for daily life and recreational activities without significant changes in muscle size (and even in athletes in some sports this happens like the high jump).

I would first answer the question, "What am I trying to achieve with my exercise?" and then decide the best path. If you want functional strength, you may not need much in the way of additional resistance beyond dumb bells. If you're after size, you'll have to go to the gym or buy some weight / resistance tools.

DK

Elliptical Machine Loads

How much force goes into your leg when you use an elliptical machine? The device is praised by clinicians for being "low impact' but just how low is low?

I looked and looked but couldn't find any research about the loads delivered by an elliptical machine. Maybe some one knows. If so, please send it along. In the meantime, here's what I did to solve the problem.

I took a Lafayette Digital Muscle Tester and placed it under my right foot while on a Precor elliptical machine. I had to place a high density foam block under my other foot to make the pressure fairly equal under each foot (The digital muscle tester is a load cell. It records pressure applied to it.). I then set the resistance on the elliptical machine to a "moderate" level - between 8 and 10- and then used the machine for approximately ten repetitions.

When I got off the device, I looked at the force recorded by the digital muscle tester. It was 140 lbs. The muscle tester records peak force so this represented the maximum force that went into my leg.

I then repeated the procedure but increased the resistance setting on the machine to 12. This time, the peak force was 185 lbs.

I weigh 211 lbs. So, for me, this was 66% and 88% of body weight. The machine's resistance is a function of your body weight. If you weigh 150 lbs and exercise at the same setting and speed as I did, the load going into your leg will be a percentage of your body weight (probably close to 66% and 88%).

Of course, there are a few problems with my study. There was a "n" of 1. I didn't evaluate the relationship of load, resistance setting, and speed. The faster you move at any setting, the more resistance you get. And, I didn't have a continuous load curve to assess where in the arc of motion the load was the greatest. Someone with all of the right tools in a well equipped biomechanics lab could do this though.

But, what I do have is better than guessing; better than assuming that an elliptical is low impact so it's ok for people with joint disease or joint pain. It's ok as long as the client's load tolerance is at least 66% body weight.

This may explain why some people with knee, for example, tolerate the device and some don't. If the client's actual load tolerance for a Single Leg Squat or Stair Step (the elliptcal machine is close to these motions) is only 50% body weight, there's a good chance that the ellipitcal machine will be too much load.

Good reason to test the Load tolerance.

Healing and Strengthening Tendon - Part II

In my last article, I explained how to find a client's Single Leg Squat Load Tolerance - the maximum amount of force that the person can generate without form failure or symptoms. This article explains how to use that information in designing a program for someone with patellar tendonosis by blending Pathology, Load Tolerance, and Staging.

Let's assume that our 44 year old, male weighs 180 lbs. The tests results indicate that his Single Leg Squat Load Tolerance is equal to the force produced by his body weight at Level 6 position on the Total Gym. The angle of Level 6 on the Total Gym produces ( ) % of body weight force for a person of 180 lbs. This is the maximum amount of force for the symptomatic limb.

In most cases, the test will stop due to pain. Let's assume that this is the case in our 44 year old guy. To determine the dosage (the intensity, frequency and duration) for the drills, we need to know one more thing: severity of the symptoms.

Nirschl developed a staging system for tendonosis that categorizes the severity of symptoms and functional impairment. He then prescribes exercise based on the stage.
        Stage 0: No pain or soreness
         Stage 1: Stiffness or mild soreness after exercise activity. Pain is usually gone in 24 hours.
         Stage 2: Mild stiffness and soreness before activity which disappears with warm up. No pain during activity, but mild soreness after activity that disappears within 24 hours.
         Stage 3: Same as above with mild pain during activity which does not alter activity, disappearing in 24-48 hours. Counter-force bracing may be considered here as well as mild anti-inflammatory medication.
         Stage 4: Mild to moderate pain before, during, and after exercise which alters the exercise or activity. ADLs are affected. Phase 4 is indicative of some level of tendon damage.
         Stage 5: Moderate or greater pain before, during, and after exercise or activity, forcing the patient to discontinue the exercise. Pain is experienced with ADLs. Usually reflects permanent tendon damage
         Stage 6: Phase 5 pain that persists with complete rest. Pain disrupts ADLs, many activities have to be eliminated.
         Stage 7: Phase 6 pain with disruption of sleep on a consistent basis. Pain is aching in nature and intensifies with activity.
Phase 5 or greater indicates some degree of tendon damage.

If the client is a Stage 5 or higher, Nirschl's guidelines are to use bodyweight resistance and isotonic exercise in a pain-free range of motion (his original article was for elbow tendonosis). I found this to be of little help in cases of patellar tendonosis. The motion was too limited and the loads were too light to produce any significant improvement. The program consists of 30 repetitions that the client can perform pain free. This is done daily. Once the client can perform 30 repetitions, on two consecutive days, the load is reduced but the stress to the tendon is increased by altering either the range of motion or reducing the mechanical advantage of the muscles. This process continues until the client reaches a Stage 4 then the frequency is reduced to three times per week.

The physiologic basis for this approach, according to Nirschl is "to promote a vascular response and increase endurance". However, my understanding from experimental research suggested that one set of 30 repetitions was not enough stimulation for a more avascular tissue like tendon.

Experimental models suggested much higher dosage - in the hundreds of repetitions. For example, one study, using a rat model, found that swimming counteracted the effects of aging and increased the tendon strength better than muscle strength training. The authors concluded that endurance training had an impact on tendon strength but that muscle strength training had little.  If this is true, and considering that the number of repetitions in swimming is far beyond 20 or 30, how can you perform hundreds of squats without overloading the tissue and making the client much worse?

You have to alter the training environment. To alter the tendon, you need a high volume of training. This is where the Total Gym comes in. Let's go back to our scenario of the client who has a Load Tolerance of 70 lbs. Let's assume he's a Stage 5 on the Nirschl Scale (Moderate or greater pain before, during, and after exercise or activity, forcing the patient to discontinue the exercise. Pain is experienced with ADLs. Usually reflects permanent tendon damage). We know that at 70 lbs., the tissue is not yet overloaded but if we asked him to perform 50 or 60 or 70 repetitions, he likely would be.

At Stage 5 or higher, we're aiming for 300 to 500 hundred repetitions per session. Let's assume he can perform squats at a pace of about 20 per minute. That's 15 to 25 minutes of squats! Of course, we wouldn't ask him to perform all of the squats at once but it gives you the idea of the volume.

If we're asking him to perform, for example 5 minutes of squats, how much load should we use? Well, 70 lbs. will be too much; that's his maximum. You could use a bilateral squat which would then cut the load in half (35 lbs on each leg). That might work. But, we also need a little fatigue. We need to know that the muscle tugged on the tendon enough and the only way to know that is to achieve a certain level of fatigue. You could use a scale, 0-10 where 10 is extreme fatigue, and aim for 5/10 fatigue at the end of the set.

So, you could start at Level 6 on the Total Gym, bilateral squats, to no more than 90 degrees of motion, five minutes and assess the fatigue both during and after the set. You want to check during the set because sometimes the client, because he is not used to performing squats, will fatigue rapidly. I've had clients, like our example client, reach a 5 or 6 level of fatigue in under two minutes. Watch the pattern of motion - make sure it's well controlled - and inquire about fatigue. I ask,"What is your fatigue level? What number?" Rather than, "Are you fatigued?" Remember the volume: 500 squats at 35 lbs of load is 17,500 lbs of total force.

This process takes a session or two to find the right dosage. Once you have it, some clients will change stages on you faster than you might think. You have to adjust the training to match the stage for maximal progression. This is probably a common mistake - failure to "edge" clients as they move through the stages.

This leads into other areas of the session that I call "coaching". This is about how to get the information you need without being obvious, how to help people make decisions instead of you making them, etc. Staging has a large "subjective" component (which, by the way is not less valuable than things you measure but I digress) and to figure out what stage the client is in, you have to know how they feel. You need to know what the injury is doing to them and how they are reacting to it. For example, the difference between Stage 4 and 5 is mostly the severity of pain and the degree of impact on activities of daily living.There's only one way to find that out. You have to talk. What you say and how you say it is coaching.

Once you reach Stage 4, the program shifts. It moves away from the higher volume and lower loads to higher loads, speeds, and greater motion with fewer repetitions. I'll go over that next time.

And, of course, there are other elements to a comprehensive program including biomechanics, understanding segment links (like how the hip and ankle move, etc) and coaching. But, for now, all I'm focusing on is tissue healing.

If you know the Pathology (tendonosis), Load Tolerance (e.g. 70 lbs) and the Stage (e.g Stage 5), the program design is much easier. Try going through this case without any of this information and then pay attention to how confident (or not) you feel about your plan. I think you'll find that this combination of information makes a significant difference for you.

And, before I get emails about what to do if you don't have the tools, my answer is always the same. Good luck. I quit trying to "make do" a long time ago. But, that's another story. Tools are key. Remember, you have to match the environment to the person and that's what tools do for you.

DK

ref: (Simonsen, E., H. Klitgaard, et al. (1995). "The influence of strength training, swim training and ageing on the Achilles tendon and m. soleus of the rat." J Sports Sci 13(4): 291-5.

Healing and Strengthening Tendon

I mentioned in my last article that the type of training used for an injured tendon is different than that used for muscle or cartilage or other biologic tissues. And, I proposed that to accept my argument, you have to accept the premise that 1.) tendons respond both positively and negatively to physical stress 2.) that the stress required for healing is different than that required for muscle 3.) that you can actually do it.

Well, we know tendons respond to stress because you can injure them. Too much physical stress can create injuries ranging from very mild strains to complete ruptures. But, what happens when you reduce physical stress as in the case of immobilization or inactivity?

There are a number of studies that demonstrate the negative effect of inactivity on tendon although tendon weakens more slowly than its' associated muscle. The density and size of the collagen fibers decrease as does the tensile property.  In the case of inactivity, such as cessation of exercise, the weakening process goes undetected. This is one reason why people, after living a sedentary lifestyle for a number of years, injure themselves and develop tendonopathies. The tendon is weak yet not symptomatic. The mind still remembers what it was like to run five miles or play basketball or tennis. Without a gradual strengthening of the body, the tendon is at risk of injury so in the excitement of getting back to a sport or activity they love, the sudden increase in force injures the tendon.

But, tendons do respond to physical stress positively. Exercise, low load training in particular, increases the cross-linkage of collagen fibers and improves the elasticity. The question is, how do you do it?

This is where having the right tools becomes important and understanding the Load Tolerance for the involved structures. Lets take the case of a patellar tendonopathy. Let's assume the client's knee hurts climbing stairs or squatting so much that it is interfering with daily activity. And, let's assume that this person is otherwise healthy, age 44, male.

The first thing I want to know is, how much load is too much? I would perform a Single Leg Squat Load Tolerance Test using a Total Gym to find out the pain threshold for squatting. A Load Tolerance Test is a psycho-physical test; the client must relay to you how he feels. This is an inherent weakness of the test and can result in either under or overstating the Load Tolerance. But, as with many tests, the protocol you use helps reduce the chance of this occurring.

I use a Total Gym because the load is a percentage of the client's body weight and it's easy to administer. Here's how I do it:

• I explain the test and what I'm trying to find out. “Today I will be performing a single leg squat load tolerance test.  This test will tell me the amount of weight you can squat without symptoms or a breakdown in form. Please tell me if your knee hurts at anytime during the test. I will ask you periodically. Please answer yes or no.” 
• Place the Total Gym at Level 5 (on a 10 rung machine). It is usually safe to start the test at 25% of the client's body weight.
• Push the sliding platform up and hold it so the client can get on.
• Ask the client to lie down on the sliding board and place both feet on the platform, near the top, about shoulder width apart. The client's legs should be straight.
• The client now performs a bilateral squat to about 90 degrees of knee flexion. This is to introduce the idea of how to perform the squat and to be sure the load level will not be too great.
• The client now performs five squats. Ask, "Did your knee hurt?" The answer should be quick and clear. Pain is all or none. Like a light switch. You may have a little but you either hurt or you don't. This is the step where a lot of mistakes can be made. A client who says, "Uhhh...well...not really...no I guess not...it's not that bad...." hurts. Get a clear answer. Don't be shy about re-stating the purpose. If something hurts, lower the level of the Total Gym until the movement is pain-free (and I can talk about what to do in the case of that not happening in a later article).
• Now that the client has performed five bilateral squats without pain and with good form, proceed to testing the uninvolved side. Repeat the instructions. The purpose in this phase of the test is for the client to know, to experience, "normal".
• Next, repeat the procedure with the involved limb. Five repetitions. Watch for deviation of the limb into adduction or the pelvis hiking or rotating. If that happens, even if the client does not hurt, you have reached Load Tolerance by a failure in form. If the five repetitions is not painful, increase the angle of the Total Gym one level and repeat. Give the client at least 30 seconds of rest. If the test is painful, at any point, lower the Total Gym one level and repeat.
• At some point in this process you will find either the Load Tolerance produced by pain or form failure or both. For example, let's assume that your test ends at level 7 on the Total Gym because the client's knee hurt. This means that Level 6 is the highest degree of force tolerated. You now know exactly how much force the injured limb can withstand.

From a client's perspective, this information is very helpful. Up to this point, all the client knows is that whenever he squats down for something like the newspaper or tries to climb a flight of stairs, his knee hurts. By identifying the Load Tolerance, you have tapped into something known as the Hope Theory. The Hope Theory states that hope is created by a clear goal and a map to get there. A Load Tolerance test gives you the most important part of the map: where to start.

Now that you have the data, what do you do with it?
That's coming up next.
DK

Kvist, M. (1994). "Achilles tendon injuries in athletes." Sports Med 18(3): 173-201.

Heinemeier, K., H. Langberg, et al. (2003). "Role of TGF-beta1 in relation to exercise-induced type I collagen synthesis in human tendinous tissue." J Appl Physiol 95(6): 2390-7

Kubo, K., H. Kanehisa, et al. (2003). "Effect of low-load resistance training on the tendon properties in middle-aged and elderly women." Acta Physiol Scand 178(1): 25-32.

Load Tolerance versus 1 RM

Should a client perform a squat exercise if the squatting motion hurts, for example, the client's knee?

Well, some people might argue that if the pain is mild, then squatting is ok. But, generally, if it hurts to squat, squatting is probably not such a good idea.

Unless you know the client's Load Tolerance.

What's Load Tolerance? Load Tolerance (LT) is a testing procedure I created to find the maximum amount of pain-free force a person can produce for a given movement without a break in form*.

That may sound familiar to you. It sounds a lot like the definition of a 1 Repetition Maximum (1RM) from the world of athletic training and fitness. 1RM is the maximum amount of weight a person can lift or move through a defined range of motion one time.

So how is Load Tolerance different from 1RM? Load Tolerance includes the entire gravity spectrum from less than body weight to above body weight and is typically 5-10 repetitions. 1RM is traditionally limited to above body weight loads and is one repetition.

Trainers and athletes often use the data from the 1 RM test(s) to define the upper limit of training and to determine training loads. For example, strength training is often performed at 85% of 1RM. So, if your squat 1RM is 250lbs., your training load would be around 212 lbs. (this varies based on the intent of training, the rep range, etc.). I, and other similarly trained therapists and trainers, use the data of a LT test(s) for the same basic purpose: to idenitfy physical upper limits and determine trainning loads. The difference is in how we use it.

1RM data is used to determine muscle training loads only. LT test data is used to determine all joint tissue training loads: muscle, tendon, cartilage, muscle.

At this point, some people start scratching their heads. Are you saying that you can train tendon? That you do that somehow or in some way differently than muscle? Yes. Think of it this way. Normally, a healthy tendon is somewhere around 2 times stronger than its associated muscle which makes complete sense*. About the last thing you would want is an arrangement where the tendon is weaker than the muscle. Of course, this is exactly what happens in the case of tendonitis and tendonosis. The tendon is now less capable of withstanding the tension created by the contracting muscle. The result? You hurt.

So, let's take an example. Let's go back to the squat. Your client's knee hurts over the patellar tendon and let's assume she has patellar tendonosis. She tries to perform a single leg squat but can't. It hurts. So, you now also cannot (or at least shouldn't) prescribe any muscle strengthening squatting drills since the force would exceed the client's tolerance. What do you do? You could wait. Just skip the drills and wait for the tissue to become less irritable and the try the drill again in 10 to 14 days. But, what happens if, after 10 days, you get the same result?

This is when practitioners start soft tissue techniques: myofascial release, massage, Graston, etc., to relieve the pain; to have something to do until the client can tolerate the drill. Or, concerns about biomechanics become primary. Sometimes abnormal biomechanics are a source of overload. Nothing wrong with that either. But, the problem is that drills are often aimed at muscle when the faulty tissue is tendon. Why not find the LT for the squatting drill, dose it for tendon, and not only relieve pain but improve the tensile quality of the tissue?

To accept my argument, you have to accept the premise that 1.) tendons respond both positively and negatively to physical stress 2.) that the stress required for healing is different than that required for muscle 3.) that you can actually do it.

But, that's coming. I'll go over all three arguments in the next few posts. My point in this post is to raise awareness around the concept of Load Tolerance Testing; to think of the tissue that's injured, find the LT for a movement that involves that tissue and then design drills using that data. I'll explain how to do that with selected tests in future posts.

DK

*
Kelsey, D. D. and E. Tyson (1994). "A new method of training for the lower extremity using unloading." J Orthop Sports Phys Ther 19(4): 218-23.

Elliott, D. H. (1967). "The biomechanical properties of tendon in relation to muscular strength." Ann Phys Med 9(1): 1-7.