Populations who should not train?

Hi Rip & SSCs,

I was talking to my sister yesterday who is a newly minted emergency medicine doctor. I told her that I got our mom The Barbell Prescription for Christmas and gave her a brief synopsis of the book. She immediately freaked out, explaining that because our mother has both osteoarthritis and rheumatoid arthritis and has undergone Chemo she should never get under a barbell as it would be too "dangerous". I had a slight chuckle at this, but it got me thinking. In your experience are there any actual populations of people who just shouldn't ever train (barring extreme things like paralysis)?

Patients with Abdominal Aortic Aneurysm should not train. People with the flu should stay home. Likewise, people with ebola. Patients with osteoarthritis and RA must train, if they want some of their lives back.

We have trained clients with arthritis, loss of joint cartilage, multiple post chemo patients, auto immune conditions, PTSD, etc. All of them derived strength, health and psychological benefits from training. There are few conditions (aside from acute illness or injury) that completely rule out barbell training. And those may have more to do with the coach's willingness to take on the liability than anything else.

Everyone who is physically capable of moving should perform strength training in some fashion. The method of training may vary depending on n=1 deficiencies and physical defects.

Anyone who tells you otherwise has no idea what they're on about.

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Originally Posted by Diddyin94

I was talking to my sister yesterday who is a newly minted emergency medicine doctor. I told her that I got our mom The Barbell Prescription for Christmas and gave her a brief synopsis of the book. She immediately freaked out, explaining that because our mother has both osteoarthritis and rheumatoid arthritis and has undergone Chemo she should never get under a barbell as it would be too "dangerous".

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Docsplaining.

People with neurological injuries/disorders like stroke, multiple sclerosis, neuropathy, or parkinson disease can and would benefit from training with attention to safety (poor balance). In these cases training is a prescription for paralysis.

I advise patients with inflammatory muscle disorders (dermatomyositis, myositis) and other forms of myopathy to refrain from vigorous exercise of any type. They will get rhabdomyolysis. These are very rare conditions, however. Some of these patients may achieve good enough control of the condition to train, at least to some degree.

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Originally Posted by Mark Rippetoe

Docsplaining.

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Wonder if she made the OP strip down, put on a hospital gown, and sit and wait in a little room on a bench covered with paper, before delivering her docsplanation .

Sully wrote up a solid list of pathologies prohibiting training a few years back.

Doctors are trained with a "risk minimization" mindset, and emergency physicians in particular will always fear the worst case scenario (as they should). However, as discussed at length on these boards in the past, we receive no education in physical training of any sort. This makes it impossible for physicians to perform accurate risk / benefit estimations in these sorts of situations, and they default to focusing on the "risk" side since "heavy barbell training" sounds scary.

Although I obviously cannot give specific advice pertaining to your mother, there is nothing inherently "dangerous" about training with osteoarthritis or rheumatoid arthritis. There is even data to support this for those who insist on seeing published literature for everything.

There is a weight at which the exercises can be performed safely and correctly.

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Originally Posted by dfclark68

I advise patients with inflammatory muscle disorders (dermatomyositis, myositis) and other forms of myopathy to refrain from vigorous exercise of any type. They will get rhabdomyolysis. These are very rare conditions, however. Some of these patients may achieve good enough control of the condition to train, at least to some degree.

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I haven't had any luck with people with any form of muscular dystrophy.

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Originally Posted by Mark Rippetoe

Patients with Abdominal Aortic Aneurysm should not train. People with the flu should stay home. Likewise, people with ebola. Patients with osteoarthritis and RA must train, if they want some of their lives back.

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This.

Unfortunately, the general response is, "I already tried that." To which I usually reply...

http://i.imgur.com/133SGq9.gif


The fact is that if you truly are a person who can't train, you are good and truly fucked. (I think we talked about this on the special snowflake thread). No one gets a pass. Death is probably not that great of an experience for anyone (I don't know for sure, I've never tried it personally, but I have watched a lot of people die). It probably hurts a bit. But if you are not reasonably fit when your time comes, you are almost guaranteed to suffer more and for much longer than people who train. I mean, you could have a heart attack and die in your sleep like everyone seems to wish for. But if you're going to have a heart attack, sudden death only happens about half the time. The other half, you end up crippled and infirm for the next 10-20 years of your life while your sole remaining pleasure is when the home health nurse finally works her way up to your hospital bed to wipe up the feces you've been sitting in for half an hour. Everyone must train.

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Originally Posted by dfclark68

People with neurological injuries/disorders like stroke, multiple sclerosis, neuropathy, or parkinson disease can and would benefit from training with attention to safety (poor balance). In these cases training is a prescription for paralysis.

I advise patients with inflammatory muscle disorders (dermatomyositis, myositis) and other forms of myopathy to refrain from vigorous exercise of any type. They will get rhabdomyolysis. These are very rare conditions, however. Some of these patients may achieve good enough control of the condition to train, at least to some degree.

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I think you could add ALS / Upper Motor Neuron Disease to the prohibited list. Vigorous exercise for these patients may speed up the disease process. But, then again, what else are you going to do if you are facing a diagnosis like ALS?

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Originally Posted by Diddyin94

Hi Rip & SSCs,

I was talking to my sister yesterday who is a newly minted emergency medicine doctor. I told her that I got our mom The Barbell Prescription for Christmas and gave her a brief synopsis of the book. She immediately freaked out, explaining that because our mother has both osteoarthritis and rheumatoid arthritis and has undergone Chemo she should never get under a barbell as it would be too "dangerous". I had a slight chuckle at this, but it got me thinking. In your experience are there any actual populations of people who just shouldn't ever train (barring extreme things like paralysis)?

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This is a great illustration of theory versus practice. In theory, people with a whole slew of conditions should never get under a barbell because it will surely kill them.

In practice, we find that nearly all people, at nearly all stages of physical infirmity, derive some benefit from training. This forum is filled with actively training osteopenics, heart attack, stroke, and cancer survivors, and even cancer patients training while going through chemo. Remarkably, training hasn't killed them--in fact, I think all or nearly all would say their lives have improved immensely as a result of training.

Your sister's heart is in the right place, but she's out of her league on this one.

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Originally Posted by Pluripotent

The fact is that if you truly are a person who can't train, you are good and truly fucked. (I think we talked about this on the special snowflake thread). No one gets a pass. Death is probably not that great of an experience for anyone (I don't know for sure, I've never tried it personally, but I have watched a lot of people die). It probably hurts a bit. But if you are not reasonably fit when your time comes, you are almost guaranteed to suffer more and for much longer than people who train. I mean, you could have a heart attack and die in your sleep like everyone seems to wish for. But if you're going to have a heart attack, sudden death only happens about half the time. The other half, you end up crippled and infirm for the next 10-20 years of your life while your sole remaining pleasure is when the home health nurse finally works her way up to your hospital bed to wipe up the feces you've been sitting in for half an hour. Everyone must train.

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Just wanted to say I appreciate you posting this perspective. Posts like these (and most recently The Barbell Prescription) strongly remind me why this shit matters, and they increase my desire to educate myself so that I'm ready to help anyone who asks.

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Originally Posted by Pluripotent

... if you're going to have a heart attack, sudden death only happens about half the time. The other half, you end up crippled and infirm for the next 10-20 years of your life while your sole remaining pleasure is when the home health nurse finally works her way up to your hospital bed to wipe up the feces you've been sitting in for half an hour. Everyone must train.

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I don't think that possible outcome from not being as resilient and strong a creature can be echoed enough. And truly, if I have a "fatal condition" (for example's sake) stage 4 colon cancer, what's the worst that training can do to me? I'm already on rented time.

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Originally Posted by Mark Rippetoe

I haven't had any luck with people with any form of muscular dystrophy.

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I have a trainee with Type II who is doing quite well.

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Originally Posted by I_iz_a_fatass

I don't think that possible outcome from not being as resilient and strong a creature can be echoed enough. And truly, if I have a "fatal condition" (for example's sake) stage 4 colon cancer, what's the worst that training can do to me? I'm already on rented time.

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I have been on a fairly morbid kick lately. The patient population last week seemed to be all end-of-lifers with some form of horrible end-stage process from which we are supposed to save them by "doing everything." I am probably one of the more aggressive docs I can think of in terms of trying to explain to people why that might be a bad idea. It doesn't always work, but sometimes you can save people from a little extra suffering. In residency, a particularly cantankerous neurologist would make fun of all the heroics we end up seeing at end of life, saying, "we have to save them! ...So that they can die of something even more horrible later. Because clearly, what they're going through now is just not horrible enough!"

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Originally Posted by Austin Baraki

There is a weight at which the exercises can be performed safely and correctly.

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This.....AND there are remedial versions of the lifts that almost anyone can use.

If only someone would have the sense to write a book about this?

Oh, well. ;)

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Originally Posted by dfclark68

People with neurological injuries/disorders like stroke, multiple sclerosis, neuropathy, or parkinson disease can and would benefit from training with attention to safety (poor balance). In these cases training is a prescription for paralysis.

I advise patients with inflammatory muscle disorders (dermatomyositis, myositis) and other forms of myopathy to refrain from vigorous exercise of any type. They will get rhabdomyolysis. These are very rare conditions, however. Some of these patients may achieve good enough control of the condition to train, at least to some degree.

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Well, I am not a Doctor, but I can tell you this: my 56 year old wife has been battling dermatomyositis for over 15 years. Low dose Prednisone daily, as well as intermittent Methotrexate. She is a fanatic exerciser. P90X and every derivative you can name, jogging, walking, dumbbell nonsense, and even a little fooling around under a barbell (but no real training). She exercises in one form or another at least two hours a day. Pretty healthy eater, but not enough protein. Her commitment to physical activity has saved her thus far. In my opinion, telling someone with this, or any, autoimmune disease to refrain from vigorous exercise of any type is telling them to sit around and die.

Of course, she won't listen to me about barbell training. I have bought The Barbell Prescription. Currently plowing through it. Hopefully, when I return home from my current deployment, I can convince her to read it and agree to give me 60 days of barbell training to see if it makes a difference. I'm sure she can continue walking and even occasionally jogging, because she is already well adapted to it. What she has done so far has certainly staved off physical decline. She is the hardest working person I have ever known. If I could just focus it in what I think is the right direction, I think it would enhance and extend her quality of life.

Refrain from vigorous exercise? No chance. She will probably die by dropping a 25 pound dumbbell on her head while bouncing on a bosu ball.

I have a son with a chronic neuromuscular disease (mitochondrial encephamyopathy with muscle CoQ10 deficiency diagnosed by muscle biopsy) who I have helped train since he was 14, which is the earliest age my gym will allow some one use free weights.

He cannot do the strict Starting Strength lifts at any weight because he has low coordination and he has language difficulties which make it hard for him to use verbal prompts. He uses a leg press machine instead of squatting. I would love to find a way for him to do some sort of modified dead lift -- any ideas out there?

His favorite exercise has been a pseudo press done on a bench like this:

http://allthingsrecreation.com/wp-co...t-Machines.jpg

He began only being able to lift the handles which he would do with the palms of his hands, because his grip was too weak to actually grasp the handles. Now, after 3 years of doing this 3 days a week his personal record is 150 lbs (75 lbs on each side)! His form is not great, so he does sets of 1 and holds them for a few seconds, and I have to slightly push against his abdomen while he does them since he is still learning to brace himself with his abs,

Over 3 years his leg press has also gone from 30 lbs to a personal record of 310 lbs, Most days, he refuses to do any bench press equivalent, so he has made little progress there.

He hated doing thiese lifts at first, but after about six weeks when he started to see his numbers go up, he really got into it and has enthusiastically stuck with it ever since. Now he is the one who wants to set a personal record. Not me.

An added benefit to his training is that while most of his teen age classmates with disabilities are now on meds to control their mood swings (most of which cause huge weight gains) we have so far been able to keep him off of psychoactive drugs,. Thank God.

My advice to those with loved ones with disabilities is find some way, any way, to have them lift with a goal toward lifting serious weight. It greatly improves their quality of life and by extension, yours.

I wrote an appendix of contraindications to barbell training for BBRx, which ultimately could not be included in the book but will probably be an article. While it was in process I was discussing it with a client of mine, a PA with incredible clinical skills who should have been a doctor. He reminded me that I often say, "anybody who can lift weights should lift weights."

Except, he pointed out, anybody who has a longstanding relationship with a vascular surgeon.

Yeah, that's about right.

Right now I've got a wonderful client, 65, a very coachable and affable man, but with profound sarcopenia, deconditioned and weak as hell, who is making slow, careful, steady progress. I really love working with him. I built my coaching practice for people just like him.

But now the interwebZ and sundry orthopods have convinced him that deads and squats will surely cause his artificial hip to disintegrate, and I can't point to any definitive data that says it won't (he's a physician....I'm getting more of them). So in spite of the fact that he can barely squat 110 yet, and really needs this training, I'm probably going to lose him.

We still have so much work to do.

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Originally Posted by Mark Rippetoe

Patients with Abdominal Aortic Aneurysm should not train. People with the flu should stay home. Likewise, people with ebola. Patients with osteoarthritis and RA must train, if they want some of their lives back.

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I have a variant of RA. Barbell training has made my daily life appreciably easier/better.

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Originally Posted by dcollage

She will probably die by dropping a 25 pound dumbbell on her head while bouncing on a bosu ball.

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An unclean death. Hurry home.

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Originally Posted by Jonathon Sullivan

But now the interwebZ and sundry orthopods have convinced him that deads and squats will surely cause his artificial hip to disintegrate, and I can't point to any definitive data that says it won't (he's a physician....I'm getting more of them). So in spite of the fact that he can barely squat 110 yet, and really needs this training, I'm probably going to lose him.

We still have so much work to do.

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This has to be so frustrating to you as a coach. I'm frustrated just reading it.

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Originally Posted by Jonathon Sullivan

Right now I've got a wonderful client, 65, a very coachable and affable man, but with profound sarcopenia, deconditioned and weak as hell, who is making slow, careful, steady progress. I really love working with him. I built my coaching practice for people just like him.

But now the interwebZ and sundry orthopods have convinced him that deads and squats will surely cause his artificial hip to disintegrate, and I can't point to any definitive data that says it won't (he's a physician....I'm getting more of them). So in spite of the fact that he can barely squat 110 yet, and really needs this training, I'm probably going to lose him.

We still have so much work to do.

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That is pretty bizarre. Is there a proposed mechanism by which the implanted artificial hip will be destroyed, and which you can walk through in a logical way and debunk?

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Originally Posted by crabcakelover

I have a son with a chronic neuromuscular disease (mitochondrial encephamyopathy with muscle CoQ10 deficiency diagnosed by muscle biopsy) who I have helped train since he was 14, which is the earliest age my gym will allow some one use free weights.

He cannot do the strict Starting Strength lifts at any weight because he has low coordination and he has language difficulties which make it hard for him to use verbal prompts. He uses a leg press machine instead of squatting. I would love to find a way for him to do some sort of modified dead lift -- any ideas out there?

His favorite exercise has been a pseudo press done on a bench like this:

http://allthingsrecreation.com/wp-co...t-Machines.jpg

He began only being able to lift the handles which he would do with the palms of his hands, because his grip was too weak to actually grasp the handles. Now, after 3 years of doing this 3 days a week his personal record is 150 lbs (75 lbs on each side)! His form is not great, so he does sets of 1 and holds them for a few seconds, and I have to slightly push against his abdomen while he does them since he is still learning to brace himself with his abs,

Over 3 years his leg press has also gone from 30 lbs to a personal record of 310 lbs, Most days, he refuses to do any bench press equivalent, so he has made little progress there.

He hated doing thiese lifts at first, but after about six weeks when he started to see his numbers go up, he really got into it and has enthusiastically stuck with it ever since. Now he is the one who wants to set a personal record. Not me.

An added benefit to his training is that while most of his teen age classmates with disabilities are now on meds to control their mood swings (most of which cause huge weight gains) we have so far been able to keep him off of psychoactive drugs,. Thank God.

My advice to those with loved ones with disabilities is find some way, any way, to have them lift with a goal toward lifting serious weight. It greatly improves their quality of life and by extension, yours.

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That's a DAD right there. Gave me Throat Lump.

So, to be clear (better safe than sorry): can somebody who had kidney failure (both, 10 years ago) train?
I ask this because I am to put my girlfriend's mother on the novice program and show her the exercises.

She's on dialysis?

She isn't anymore but she still has a fistula in her left arm that can cause her pain during some movements. So, apparently, deadlifts will be an issue.

Is there a weight she can deadlift without pain?

I don't know. We have not started yet. I was asked to "train" her just yesterday. She is 50 or so and she badly needs to be stronger.

My girlfriend told me that doing a bicep curl makes her forearm hurt so I guess that it might be an issue for deadlifts when it gets heavy. We will see.

I will keep you posted in another thread so not to hijack this thread too much.

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Originally Posted by Austin Baraki

Sully wrote up a solid list of pathologies prohibiting training a few years back.

Doctors are trained with a "risk minimization" mindset, and emergency physicians in particular will always fear the worst case scenario (as they should). However, as discussed at length on these boards in the past, we receive no education in physical training of any sort. This makes it impossible for physicians to perform accurate risk / benefit estimations in these sorts of situations, and they default to focusing on the "risk" side since "heavy barbell training" sounds scary.

Although I obviously cannot give specific advice pertaining to your mother, there is nothing inherently "dangerous" about training with osteoarthritis or rheumatoid arthritis. There is even data to support this for those who insist on seeing published literature for everything.

There is a weight at which the exercises can be performed safely and correctly.

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I absolutely understand that Doctors are paid to accurately asses risk/reward of certain situations, what would be the downside in her/any doctor saying "I don't know what the risk is"? In your experience, are there situations in which you need to tell a patient "I don't know" is this an acceptable answer to them?

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Originally Posted by Diddyin94

I absolutely understand that Doctors are paid to accurately asses risk/reward of certain situations, what would be the downside in her/any doctor saying "I don't know what the risk is"? In your experience, are there situations in which you need to tell a patient "I don't know" is this an acceptable answer to them?

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I don't know is an acceptable answer and there are plenty of situations where it is the correct answer. Sometime it's not an acceptable answer to the patient, who thinks you should know everything, since you're the doctor.

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Originally Posted by Pluripotent

I don't know is an acceptable answer and there are plenty of situations where it is the correct answer. Sometime it's not an acceptable answer to the patient, who thinks you should know everything, since you're the doctor.

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To be fair, in my experience, it is much more often unacceptable to the doctor than it is to the patient.

Given the General Population's normal tendencies, this is obviously quite true.

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Originally Posted by BMueller

To be fair, in my experience, it is much more often unacceptable to the doctor than it is to the patient.

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I suppose the IDK needs to be defined. If you don't know something that you should know, that's a problem. You need to be knowledgeable about your scope of practice. But people have a tendency to not fit neatly into the defined population groups in RCTs, so to some extent we are virtually always extrapolating trial data to our unique patient, which may or may not be accurate, but until that start doing trials on the types of patients we generally see, it's necessary. So to some extent, no one knows.

And sometimes I just say IDK because it's more polite than saying, "that is totally irrelevant to what is going on now."