Dear Doctor

by Jonathon Sullivan MD, PhD, SSC | June 17, 2020

pulling at a starting strength gym

Dear Doctor:

Your patient, ________________, has approached us expressing an interest in barbell training for strength. Our initial consultation leads us to conclude that your patient has the baseline physical capacities to participate, has no significant contraindications to training, and will benefit from a strength program. Your patient will be coached in the proper performance of four safe and widely-used compound barbell movements: the squat, the bench press, the overhead press, and the deadlift. These movements are widely used in strength and conditioning programs by coaches and a growing number of physical therapists [1,2,3,4,5]. They are loaded expressions of normal human movement patterns that will allow your patient to lift the most weight by recruiting the largest volume of muscle through the longest effective range of motion [6]. The squat, press, and deadlift are performed standing. Thus, they are structural exercises that load the axial skeleton and stimulate osteogenesis of the spine and hips [7,8,9] while also training the critical faculty of balance. Moreover, these exercises impose powerful adaptive stresses on the posterior chain and the back, transforming the spine from a force absorber to a force transmitter. It is our universal observation that strong backs hurt less [3,4], and less often, than weak backs, and we frequently observe improvement in chronic mechanical back pain after just a few sessions. Because these exercises express normal human movement over multiple joints, they train and recruit muscles and supporting structures naturally and safely, and build what many like to call “functional” strength. We just call it strength. After an initial workout in which the exercises are taught and trained to a moderate load that is well tolerated and can be lifted with good form, your patient will begin training with a novice linear progression [6,10,11]. Two or three times a week, your patient will warm up from an empty bar through ascending weights to work sets consisting of 3 sets of 5 repetitions. These work sets will be performed each session with just  a little more weight than the previous session. This linear exploitation of the well-established principle of progressive overload and the stress/recovery/adaptation cycle stimulates a rapid but safe and controlled increase in strength. In the course of several months, progress will slow and your patient will be transitioned to a more complex and protracted intermediate program that will become increasingly tailored to the needs and capacities of the individual, and will allow strength to increase, albeit more slowly, over a very long time [6,10,11,12,13]. 

The extensive professional experience of barbell coaches who work with older adults is that this approach is far more productive and far better tolerated than the conventional wisdom of “lift light weights for lots of reps.” That approach, in our experience, leads to more soreness and tendon and joint problems, while also failing to deliver the training stresses needed to reverse sarcopenia and osteopenia [7] and promote the corresponding salutary changes in metabolism and insulin sensitivity. Your patient will perform repetitions under brief Valsalva, like the millions of other strength trainees who perform billions of repetitions under Valsalva every day without ill effect. This approach is essential for the orthopedic safety and efficient performance of the movements at any significant dosage, will be performed by trainees whether we coach it or not (it is a reflex response to loading), and has never been found in any definitive experimental or population-based study to contribute to the incidence of cardiovascular or neurovascular events. In fact, as you are certainly aware, a significant body of research suggests that the Valsalva is protective, by mediating transmural cerebrovascular pressures during effort [14,15,16,17,18]. 

Your patient will be instructed to adjust protein and carbohydrate intake to support training. Trainees enjoy the greatest progress and best recovery when daily protein intake approaches 0.75-1 g/lb. bodyweight/day (1.65-2.2 g/kg/day) [19] to overcome the general anabolic resistance of aging and promote muscle protein accretion. Most trainees will also need at least 200-300 g of carbohydrate a day, best consumed prior to and after training. This regime is well tolerated, even by those with insulin resistance or diabetes because, as you know, glucose uptake into muscle during exercise is mediated by muscle-contraction-coupled cellular signaling and is an insulin-independent process [20,21,22]. Moreover, this form of training is well-documented to improve insulin sensitivity, through both insulin-signaling system adaptations and by the simple increase in muscle mass, a principle target for insulin signaling and a major sink for glucose and triglyceride [23,24,25]. In the later novice phase or early intermediate phase, your patient will begin conditioning work best suited to their capacities, goals, and interests. Our default conditioning approach will involve intense intervals in the high power anaerobic or mixed aerobic-anaerobic range which, as you are certainly aware, produce adaptations in endurance and metabolic phenotype quite similar to those imposed by long-slow-distance training (running, cross-country biking or skiing, etc.), including oxygen uptake and aerobic enzyme expression, but without the attendant time commitment or protracted and repetitive stress to joints [26,27]. This is an exercise prescription ideally suited to healthy aging. It is safe – safer than almost any other form of exercise [28,29,30], in that it uses carefully titrated loading of normal human movement patterns on a stable surface in a controlled environment. It is the single most dose-able exercise medicine in existence, and has the widest therapeutic window of any form of physical exercise. It is comprehensive, imposing adaptations in every fitness attribute: strength, power, mobility, balance, endurance, and body composition. It demonstrates high specificity against the major drivers of unhealthy aging: sarcopenia, osteopenia, dynapenia, frailty, insulin resistance, and loss of independence [10]. 

Your patient has taken an important step toward control of their physical destiny. If you are aware of any well-established, evidence-based contraindications to training for your patient, please so advise us with attendant citations for our edification. Otherwise, we hope you will endorse your patient’s desire to grow stronger, more powerful, more fit, and more resilient. Your patient will join the growing ranks of older adults whose lives have been transformed by the single most powerful, effective, safe and efficient exercise medicine for healthy aging available. Thank you for your consideration. We look forward to working with you toward the health and fitness of your patient. 








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