Starting Strength Weekly Report

March 14, 2016

Training Log
  • The Squat - Training the Elderly - Beau Bryant takes Dan, a 72 year old new client with no prior strength training experience, through a modified teaching method for The Squat.
Starting Strength Channel
  • Ask Rip #22 - On Star Trek, the FM radio voice, post-workout meals, palliative sacral trailing and the reading material in the WFAC bathroom.
From the Coaches

Under the Bar

ludwig dinh squats Ludwig Dinh trains in Vietnam and uses chains to incrementally load his squat. [photo courtesy of Ludwig Dinh]
nick hammer 578 lb squat Nick Hammer squats 578 lb at the February 100% Raw NC State meet. [photo courtesy of Nick Hammer]
kris presses 92.5 lb triples Fivex3 Training member Kris presses 92.5# for triples. [photo courtesy of Emily Socolinsky]
cesar pulls 315 Cesar M. hits his first three-plate-pull at Horn Strength and Conditioning in Los Angeles. [photo courtesy of Paul Horn]

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Best of the Week

PPIs and Acid Rebound
Greg C

Background: four years ago, I went to the hospital with chest pain that was telescoping to my arm. Generally considered a good plan. After the normal admittance, EKG, follow on stress test etc, the Cardio determined my ticker was just fine and a subsequent (and I now believe terribly faulty) diagnosis of acid reflux was made. The ER and my primary doc prescribed Nexium at the time, which seemed to correct (mostly) the issue, although I still had the occasional recurrence, which I simply attributed to low dosage. Four years later, I had transitioned to another PPI - protonix. Due to some side effect concerns (reduced calcium and B12 absorption as well as copius gas!), I had run an experiment to see how I reacted to coming off the meds, which went well - side effects stopped and no incidence of heartburn...

Until a week later. Holy crap, major reflux and tasting acid all day. Got bad enough I took the protonix again twice, which eventually (about 24 hours) quieted the reaction. Turns out this is not uncommon - called acid rebound and evidently is a result of the body continuing to produce gastrin (which signals the stomach to make acid) due to the lowered levels in the body (production of which is blocked by the PPI). Remove the block, and the elevated gastrin has the obvious (and uncomfortable) effect.

Turns out a taper and/or a switch to H2 blockers (Pepcid AC< Zantac) as a half step is highly recommended to help control the rebound (which I am doing now).

A couple points for the folks out there:

  1. Pull the string when your doc wants to put you on meds. I failed this here miserably, and I'm now confident for numerous reasons that my initial issues were purely stress related and I should never have been on PPIs to begin with.
  2. Educate yourself about meds and medical conditions continuously - the info out there changes. Docs initially thought there were no issues with PPIs for either short or long term use. Surprise - there's new info after a period of time.
  3. Talk to your doc (if you can and have a good one) before playing around with your meds. I didn't, and probably should have. This was pretty dumb in hindsight, but I got busy and didn't consider that there might be such significant issues and didn't research first at the minimum.
Mark Ripptoe

There are 2 separate issues here. Let me preface by saying that I'm just a guy on the internet, and that I'm not a doctor. I wouldn't normally even comment on something like this, but I have personal experience with it, so here goes:

First is the misdiagnosis of acid reflux in the clear presence of angina. Chest pain that radiates down an arm is angina. If they find a normal EKG and a normal Bruce protocol, this does not mean that the pain was not angina. Look up Prinzmetal's Angina. I'll bet you had the symptoms at rest, and not why working or training, right? Mine always work me up in the middle of the night. I'll go a little further and bet that you were doing a lot of conditioning at the time. I'll bet you had subsequent symptoms, and that they tapered off over a few weeks.

In the absence of an abby-normal cardiac assessment, I suppose they have to do something. But I have had both vasospastic angina and very bad acid reflux, and the symptoms are absolutely not confusable. No fucking way that a self-aware person himself could possibly not know the difference between esophageal symptoms and angina, having experienced both. But not everybody has experienced both, and most never will. In the absence of the normal presentation for occlusive CVD -- sedentary fat pile of shit in the ER, donut crumbs on the shirt, smoker, you know, 1/2 of the entire population -- the guy has to tell you something, so gastric symptoms get the call. I maxed out a Bruce protocol, absolutely no pathology on the EKG, was in hard condition and very strong, so I did not fit the template. Most importantly, nitroglycerin stopped the angina within a minute. Local cardiologist was incapable of thinking through the problem, so I went to Dallas and was diagnosed with Prinzmetal's, even though the guy was very reluctant to do so and still insisted that I take statins. It went away, which is the normal history of the disorder. I believe that systemic inflammation, especially in the vicinity of the cardiorespiratory structures, was the etiology. NSAIDs should have helped this, and maybe did, but the price was stomach trouble. Some of this may apply to you, and to other people reading this.

My personal supposition is that Prinzmetal's is under-diagnosed, especially since the advent of CrossFit. But see the above disclaimer.

Second is the mistreatment of the symptoms using a strong PPI. Again, I have been there, and it's not a happy place. In fact, there may be a very complex relationship between NSAID abuse (of which I have been guilty), acid reflux, PPI abuse, subsequent calcium absorption, and cardiac vasospasm. After dealing with acid reflux for years, close examination of the long-term situation revealed that I had stopped taking my nightly Vitamin C (the result of some apparently bad advice from a very smart guy) prior to the onset of the acid reflux, which happened to coincide with my greatly elevated levels of conditioning work. I think that what happened was stomach damage due to NSAIDs taken for excessive chronic soreness (confirmed with esophageal endoscopy), subsequent treatment of the stomach symptoms with PPIs, and the development of tolerance to the PPI.

I slapped myself on the head one day after realizing that gastric acid production responds to ingested acid by a response reduction in acid production. This is why a Coke settles an acid stomach. I started taking my 1500mg Vitamin C (ascorbic acid, a mild acid) before bed, and my acid overproduction went away that night. I had previously stopped taking the NSAIDs and radically reduced my conditioning load, and the vasospastic angina had subsided already. About once a month I have to take a ranitidine, so I keep some on me. I still keep nitro in my travel bag.

I think the two were unrelated, although the CA+ absorption out of a dumbed-down stomach remains in the back of my mind as a possible contributing mechanism to the vasospasms. At any rate, the Vitamin C has definitely stopped my stomach problems, and I'd recommend that you try it. Since I assume you are having no further chest pain, maybe this will help you sort some things out.

Jonathon Sullivan

We have tried the vitamin C thing at Casa O'Sullivan, and it does seem to help a lot.

I don't know if Prinzmetal's is under-diagnosed or not, but I will concede that it doesn't leap to the forefront of the medical mind when one is confronted by such presentations as alluded to here.

As to allopathic medicine in general: Yeah. We're dumb. We are completely and utterly missing the point, and have been for a long time. And even a doctor like Yours Truly who's ferociously disenchanted with where we're going in medicine and is willing to say so can have a very hard time thinking outside the box. Rip caught me out off-line in some dumbass doctor shit just the other day. Be patient. We're moving the mountain one stone at a time.

Best of the Forum

Diagnosed with Ankylosing Spondylitis

Over the past year I have been trying and failing to do your basic barbell training program. I haven't been disciplined enough to make each workout and eat like I need to, also I don't have all of the equipment I would like but I have been able to safely improvise. I'm 28, 6'2, 330lbs, I know I need to lose a large amount of weight but how my Dr here in the UK has told me to do it doesn't work without making me feel like shit. Hence me attempting to start your program. This is all background to my question for you.

In January I went to the hospital and was diagnosed with anterior uveitis. After 6 weeks of medication, injections and frequent visits to the hospital I was asked to do some blood tests and chest and back x-rays. The uveitis was dealt within 10 weeks of the original visit. I got the all clear for my blood tests and x-ray. I had to go back again with the same eye problem 2 weeks ago and after a checkup yesterday the DR had some news for me. They did find something on the blood results, a HLA B27 marker, and this coupled with the anterior uveitis means they have diagnosed me with Ankylosing Spondylitis (AS), although I currently suffer no back pain outside of a small ache every now and then but that is only after not getting enough sleep. What I would like to know is if you have any advice on how to proceed and stop the AS from affecting me. At the moment I'm thinking that actually making your program happen will help a great deal into making my back stronger. Is there anything else or any alterations that I should make?

Mark Rippetoe

You should just train, doing the program, which you have not yet done. You may well be fucked, but what are you going to DO about it? Take the fucking, or train?

Evan with AS

I've been living with this shit for 9 years, diagnosed for 1. Like Rip says, do the program. Squats and deadlifts are the best possible thing you can do to help yourself, particularly at this stage. It's always better to have good muscle around bad joints.

I just got some good news I thought I'd share. I got diagnosed about a year ago, left SI joint is partially fused, right SI is significantly eroded, three discs significantly narrowed. Since then I stopped fucking around, stopped skipping deadlifts when things hurt. I've missed a total of four workouts since being diagnosed. On Tuesday I got my one-year MRI checkup.

And the 2013 MRI is almost identical to the 2012 MRI. There has been no additional degradation in the last twelve months. I'm lead to believe that this is a Big Deal, since the medication I'm on isn't supposed to stop the progression of the disease at all.

So. Lift those weights. Do something active every day; if you're not lifting, go for a walk and stretch. Stretch every day; focus on hip and lumbar mobility and hamstring flexibility. Get as much sleep as you can. Never sit when you can stand. Above all, remember, good muscle helps bad joints.

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