Chronic Pain Chronicles with Dr Karmy
Join Dr. Grigory Karmy M.D., a distinguished chronic pain management physician with over 20 years of experience, on a captivating journey through the world of pain relief in his podcast series. Delving into the latest regenerative medical treatments like PRP, stem cell injections, and prolozone therapy, alongside educational discussions on pain transmission and the latest medical innovations, Dr. Karmy shares invaluable insights and real-life stories, empowering listeners to find relief and regain control over their chronic pain.
Chronic Pain Chronicles with Dr Karmy
Episode 27: Weightlifting in Health and Disease Featuring Dr. Maria Fiatarone Singh
Should patients with chronic pain do weightlifting? This question comes up a lot because patients are worried about injury.
Join me for an interview with Dr. Maria Fiatarone Singh, who started her career by trying to get the most fragile and injury-prone segment of our society to do weight lifting-nursing home residents in their 80s and 90s. In the interview, we discuss her weightlifting protocol and the impact it has, not just on pain, but also on a number of other chronic diseases.
Center For Strong Medicine: https://www.strongmedicine.org.au/mariafiataronesingh/
Stronger Book: https://www.michaeljosephgross.com/stronger
Watch the Video Interview here: https://www.youtube.com/watch?v=crtq7xB5zbo&feature=youtu.be
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We did what captain Dior invented back in 1945, which was high intensity weightlifting exercise as a way to treat knee injuries in soldiers. And he figured out that people would rehabilitate much faster if they actually lifted heavy weights. So we used exactly the same principles that he used, which was measuring how strong somebody was and the heaviest weight that they could lift with that muscle group, we would train them at about 80% of that. Hello. This is Dr. Karmy for Chronic Pain Chronicles. And today with us we have Dr. Fiatarone Singh. She is a physician, a researcher, and a pioneer in, studies on weightlifting for not just chronic pain, but a number of other medical conditions. Prior to her studies there was certainly a lot of publicity given to aerobic exercises, and there were a lot of guidelines that promoted activity, and by activity aerobic activity or light activity, flexibility. But what's changed is that there really wasn't a lot of emphasis on weightlifting. And the reason that this is shifting now is because of Dr. Fiatarone Singh and a number of other researchers. Can you tell me how you got interested in exercise and I guess the seniors, because I guess you started out as a geriatrician. Yeah. I am a geriatrician. So yeah, when I've always kind of been an exerciser myself and when I was young actually, I used to watch Jack the lane on TV with my grandmother doing the sort of home calisthenics, weight training type of exercises. And actually the reason I became a physician in the first place was my grandmother when I was in high school fell off a ladder and broke her hip and, ended up with every possible complication of hip fracture that you can imagine, and ended up with malnutrition and decubitus ulcers and delirium and tied down in a nursing home, and Hal all on and on. And that was when I decided that there needed to be geriatric medicine'cause it wasn't working out so well. So that's actually why I went to medical school and there wasn't geriatric medicine at the time, but I I decided that was the field I wanted to go into. That's how it started. And then luckily enough when I, finished my residency and fellowship in geriatric medicine. My first job was at Harvard and Tufts and the person who was the head of the lab, there was Erwin Rosenberg who had coined the term sarcopenia in 19 86. And I was there in 1988 and in a lab that was devoted to the study of sarcopenia. So they were doing all sorts of work on relatively young, healthy, older adults. And I was working in the nursing home at the time as part of my, my job. And we decided that, these people probably needed it a bit more than healthy 60 year olds. So that's when we did the very first study of high intensity weightlifting in frail elders. And then after that we really expanded it to pretty much every chronic condition that you can think of. But at the core of it is this idea that you need to address the loss of muscle mass with aging because it's, body composition changes are really at the core of a lot of different diseases that we work with. For the audience, sarcopenia simply means muscle atrophy or loss of muscle mass. It is common in the elderly and if it becomes severe enough, it affects the ability to, do day-to-day things, including walking. I used to be director of a nursing home back in 1996 or so, and my sense was that, uh, seniors were not very active. I think there was a lot of concern even about people walking. What if they, fall down and break a hip and then the nursing home is responsible. And so the activities that they were, were focused more on reducing chances of people injuring themselves than perhaps building up muscle. It seemed like they were incredibly light flexibility, aerobics exercises sometimes done while sitting. Were you the one of the first ones to introduce weight weightlifting for the seniors? Yeah, no, I was there were a few people who had done it with healthy elderly before that. Like people in their sixties who really had no chronic diseases, but no one had actually tried to apply it to very frail. So the first study we did was people in their nineties, they were in a nursing home, so they were quite frail. We just basically looked at the evidence and realized that the kinds of activities they were doing, such as the ones you suggested were not evidence-based. In fact, that kind of activity was the control group for our randomized control trial and has been ever since that sort of gentle exercise stretching group. We use that as a control activity because we know it doesn't work. It doesn't really benefit anything from depression to to anything else. So we basically didn't do anything unique in terms of the physiology of exercise. We did what captain Dior invented back in 1945, which was high intensity weightlifting exercise as a way to treat knee injuries in soldiers. And he figured out that people would rehabilitate much faster if they actually lifted heavy weights. So we used exactly the same principles that he used, which was measuring how strong somebody was and the heaviest weight that they could lift with that muscle group, we would train them at about 80% of that. Which feels hard. So if you think of the heaviest weight you could lift with, your arm or your leg, and then take 80% of that, it would still feel hard, but not impossible. And that's the intensity that we use for all of our clinical trials. And so it was what, eight reps? Three three times per set? Yeah. Yep. And then as the person gets stronger, the weight goes up so that it always feels hard to lift, basically. So you reevaluate that maximum weight once a month? Exactly. In the first study, we actually did it every two weeks, but usually now we do it once a month. And I don't know, maybe I misread the book that I was reading, but there was a bit of emphasis on eccentric contractions. Can you, I guess, elaborate on the mechanism you felt it was important? Yeah, so when you lift a weight, your muscle is shortening or push away your muscle shortening, and that's a concentric contraction. When you lower the weight slowly against gravity. Don't let gravity take it down, but actually slow it down on the reverse movement that's called an eccentric contraction. So the muscle is producing force while it's lengthening, essentially, rather than shortening. So that lengthening contraction, which is called eccentric exercise, causes little micro tears in the muscle. And those little tiny tears actually stimulate satellite cells and growth factors to actually build up new muscle. If you don't include the eccentric phase of the contraction, you don't get as much muscle hypertrophy. So we always include that. You see a lot of people in the gyms, lifting weight and they're just letting it flop back down. They're not really controlling it on the way down, so there's no activity there. Basically, gravity's doing all the work, so that's not useful. So we always make sure that people lower the weight slowly and lifting it, depending on how you're trained, you can lift it fast, you can lift it slow. If you lift it fast, you get muscle power more. If you lift it slow, you get strength not as much power, but either way works. But lowering phase always has to be slow. There's a number of problems seniors have. Not all purely muscle related. So one of the problems that I find a lot of seniors have is with their balance. It's not purely because of muscle. They could have spinal stenosis and maybe they don't feel their feet. But they often have difficulty with balance. They often have difficulty with falls. So do you just need to build up muscle bulk to prevent falls or is power or how quickly you can contract the muscles? More importantly. Right. For balance for fall prevention, the evidence-based suggests that the most effective exercise for that is the combination of strength training and balance training. And the balance training has to be challenging. If you can easily stand on one leg, that's not challenging, you have to then close your eyes or do something else to make it harder. So it has to feel hard to do. Same thing with strength training, and there's a little bit of evidence that muscle power is more related to balance than just muscle strength. They're both related, but maybe a little bit more. So if you think about it, if somebody pushes you over from the side, you have to strike out with your other leg, your hip abductor very quickly or you'll fall over. So that muscle power the ability to generate force rapidly and, and intensively that's what muscle power is. So if we're worrying about falls, then we do use the combination of strength or power training and balance training to prevent falling. And, but it sounds power training just means try trying to contract faster. Yeah. So it means you're lifting or pushing the weight fast and then lowering it slowly, basically. Yeah. Lowering it slow and and broadening it beyond that. One of the things I was maybe not aware of is benefits . Like I was aware that weightlifting builds up or strengthens the bone, which is one of the reasons they often were recommended for women. They're more likely to have osteoporosis. Weightlifting seems to build up the bone well, but I was surprised about some of the other benefits that I wasn't even aware of and also the level of evidence behind some of those other benefits. Can you touch a little bit on that? Sure. So certainly cardiometabolic disease, which is obviously very common, so diabetes as well as coronary artery disease. There's evidence that weightlifting exercise, even without aerobic exercise from epidemiological studies, is a protective factor. It reduces your risk of getting those diseases. And once you have those diseases weightlifting works to improve outcomes. So improves function reduces the risk of recurrent cardiac events, for example, improves glucose control if you have diabetes. There's a little bit of evidence that if you combine weightlifting and aerobic exercise, it's probably a little bit better for diabetes or heart disease. But it's not hugely different than doing just, one or the other. If somebody, can't do two different kinds of exercise. And they're older. I would certainly morph to the weightlifting exercise because there are things that it does that aerobic exercise can't do, which is treating the sarcopenia, improving bone density preventing falls. So those things are things that aerobic exercise doesn't do, whereas everything else in the realm of chronic disease they both have benefit. So if you wanted to be economical about your prescription, then you have to use weightlifting in older adults. And if the person you know has the time and the ability. You can add aerobic exercise. So if you think about somebody who's very frail, like in the nursing home, they're sitting around in, chairs against the wall. Very hard to even, walk right. So aerobic exercise becomes far less possible than weightlifting exercise where you're sitting on a machine and lifting heavy weights. And what we found interestingly was that when we did the weightlifting study, we didn't even do balance training at that point. We just did weightlifting. The people walked around the nursing home about 35% more time using activity monitors on their ankles than the people who are in the control group. So the reason they're not walking is because they don't have the physiological capacity to walk safely. And so if you give them that back, then they will walk more. So it's very different than younger adults where they're wearing their Fitbits and they're recording their steps. And for them it's just about the desire to have more steps, right? It's got nothing to do with their capacity to have more steps. But in frail adults, it's all about capacity, or mostly about capacity. So I think that's why starting with weightlifting makes sense. Adding aerobic later if you can, is great. But you can't leave out the first part. In specifically with diabetes often the recommendation is to lose weight. That's often the initial recommendation with diet. Hopefully healthy diet like Mediterranean diet. And if that doesn't work out, then perhaps start on some medications. I'm talking about type two diabetes. Type one diabetes always gets insulin, but for type two diabetes. Now my question is, sugar control it. Does it have to do mostly with just overall weight or does it have more to do with ratio between muscle and fat in the body? Absolutely. So the body composition, which we measure clinically as well as in all of our studies, that ratio of muscle and fat in the body is hugely important for diabetes because although the, visceral obesity is important in terms of, the way that it re increases insulin resistance if you have a little bit of less muscle than you should. You don't have the ability to actually take up the glucose that's circulating and store it in your muscle as glycogen. You don't have as many glute four receptors on the cell surface to take up the glucose. So improving the muscle, both in terms of size and metabolic activity, which is what weightlifting does, is equally important to reducing the visceral fat. And the problem with diet is that if you lose weight by diet. About 40% of the weight you lose, 30 or 40% will be lean tissue, will be muscle and bone. So you never wanna lose weight by diet if you are already older and sarcopenic. The only thing that stops that is if you lose weight by the combination of weightlifting, exercise and diet. Aerobic exercise and diet doesn't help. You still lose all the muscle. Ozempic. You lose a lot of muscle. There are some studies now with ozempic and weightlifting showing that you can maintain your lean tissue if you combine those things together, but virtually no one does, obviously. And so we're seeing a lot of accelerated sarcopenia in even middle aged people, who are either losing weight by diet or with bariatric surgery or with ozempic and that's not good. That's going to have long-term consequences in terms of the risk for osteoporosis and sarcopenia related conditions. Would it be accurate to say that it's easier to preserve lean muscle mass than trying to build it up when you're in your 80s? It's probably reasonable to try and prevent the sarcopenia. You do gain muscle when you do the weightlifting, but not to the extent that lose it over your lifetime. So you lose about 40 or 50% of your muscle mass with aging from age 40 or 50 to 80. So that's a lot of loss. So you're not gonna get all of that back but the thing is, you can gain a lot of strength even if you don't return the muscle mass to its former state. And the strength you gain quite quickly. Muscle mass takes a bit longer to gain. But the thing that actually impairs your physical function in terms of your ability to walk around is your strength, your muscle mass is probably more important for your metabolic control of things like diabetes. But it's your muscle strength that is protecting you from falling, et cetera. That's a little bit of a distinction. I guess one can train to maximize muscle mass as in bodybuilders and one can train to, uh, maximize strength like power lifters. Right? And the protocols would be a little bit different. Bodybuilders, they train four to six hours a day, right? That's a different sort of thing. Even if they're natural bodybuilders, that's a lot to, to look like that. You can't do that with an hour, three times a week. So we're never really trying to get to that with our clinical programs, but we certainly can see that we can, markedly improve people's muscle strength. Which is what they notice immediately in terms of their physical function. Yeah. So let's move on a little bit closer to the area that I guess I'm more familiar with and that is chronic pain and I think in pain specifically value of exercise has been recognized for a long time. But there's different types of pain. There is pain due to osteoarthritis, so for instance, knee osteoarthritis, where typically they will strengthen the quadricep muscles as one approach. And then there's another type of pain, which, and honestly I find recommendations harder to make, and that's people who have nociplastic pain, things like fibromyalgia. So does the approach differ in, those two groups. I think arthritic pain is a lot easier to treat, I would say. So most of our, in clinic I have a clinical practice where we have five exercise physiologists who work with me, and we pretty much all of my patients do weightlifting exercise after they see me. So in, in that clinical cohort, virtually everybody has arthritis. We're constantly treating arthritis. We do certainly find that you're obviously not, not getting rid of the arthritis, but you're improving the strength and the reducing the pain and the swelling. And the stability of the joints is improving. So that I think, certainly works. And if you look at the the Cochrane reviews on the treatment of arthritis it's pretty clear that strengthening exercise has the largest effect size for arthritis and particularly for knee arthritis, but also for hip. Aerobic exercise works to some degree but not quite as well. For things like fibromyalgia, there is evidence that some of the symptoms of fibromyalgia, including not just pain, but depression and fatigue do improve with either aerobic exercise or weightlifting exercise. I think it's a bit harder to know what benefit you're gonna see in an individual. I think it's pretty variable and it's a difficult, as, disease to diagnose and figure out what's causing it. So we do, we do treat people with that condition with exercise. And I think most of them, I think I would say would tolerate both kinds of exercise weightlifting or aerobic exercise to the same sort of degree. Now I guess maybe a disclaimer, I don't actually supervise the exercise program. We're mostly a procedure based clinic and the way that at least in Canada things work, we rely on physiotherapists or chiropractors to do that part of it. But having said all of that it, if you have somebody with chronic pain, especially fibromyalgia type, chronic pain, and they're always in pain and then they do exercise and then the pain of course gets worse when they exercise. And I think that's probably in general for weightlifting. They're always worried, what if I am injuring myself? Mm-hmm. How can they tell when they're doing exercise and it's good kind of pain because, when normal people could have some muscle pain, especially the morning after exercise, how do they separate that from pain that you know is actually injuring them? Yeah I mean, if you get an acute pain while you're lifting a weight then that's not normal. Or a sign of good training that you know, that means you could have injured yourself doing whatever it is you were doing. If you get muscle pain two days later or a couple of days later that's more like what we see with delayed onset muscle soreness or doms which is normal, which is actually the sign that the eccentric muscle damage has happened and you're repairing it. So it's the pathway to hypertrophy. And that's what I think the best thing is to, certainly educate people that if they get that kind of pain a couple of days after starting a weightlifting program for the first time generally it will go away, after a week or two. The first episode, it will go away in a couple of days, but then if you exercise again, it might come back. But after a couple of weeks of training. You don't get DOMS anymore. Now if you stop training and you go away and you start again, you'll get it. Or if you don't go back for three weeks and start again, it's like you're starting over. But once people are training regularly, at least a couple of days a week, they don't get DOMS. And so I think just educating them that, it's not an injury, it's a sign of good adaptation to the exercise. But that's very different than if they got like a sudden pain in their shoulder while they were lifting and maybe they, tore a rotator cuff or something. That's very different. The pain that you see that's acute, like that is more, it would be in a joint rather than in a muscle. So it would be different sort of pain. Yeah. I guess fibromyalgia patients are odd in the sense that my experience with them is that they will have more pain while they exercise because obviously they have a pain for muscles. You pull your load that muscle, of course it's gonna hurt more, but then it's not so bad. The worst pain comes the next morning with any activity for them if they overdo it. And sometimes the flare up can last a week, two weeks because there's a lot of peripheral and central sensitization with these people. So I guess , the sweet point you're trying to go for is somebody who may have a little bit of pain the next morning, but doesn't stay there for three or five days because then it'll really mess up their day-to-day schedule, et cetera, et cetera. But often they don't know what's too much while they're doing things Right. And. I guess I haven't. been able to give them a good row of thumb, except that if you flare for the next five, six days, probably it's too much and you're better back off. Yeah., Generally what we do, which seems to prevent most doms, from being very significant at all, is we test somebody's strength, which is basically the, maximum amount that they can lift on a particular machine, and then for the next three or four days that they come in for training. We would have them lift 50% of that, then 60, then 70, and then by day four, which is week two or whatever, that's when they get it to 80%. So we gradually get them up over three or four days. And by that point they've gotten stronger a little bit already. So that 80% usually is very doable and doesn't really cause any symptoms. And then, we basically try and increase it by 3% or so every session as they come in and then retest them after a, a few weeks. So in that way we haven't really seen much in the way of doms at all in, in my clinical patients, and they have lots of chronic pain from their arthritis. And often then they may have, other things going on in terms of peripheral neuropathy or spinal stenosis. And so we do see a lot of pain but we don't really find that the exercise itself is causing more pain. If anything it's, it's lessening it over time. Yeah. Two quick observations that I just observed over the years, I've been doing this for over 20 years. One is in terms of specifically fibromyalgia, whip lash that kind of stuff with sensitization, it doesn't occur as commonly in people , who are very muscular, let's put it to you this way. I don't know if it's coincidence or not, yes, it can happen, but it's much less frequent in patients who are very muscular. They might still get joint pain, but not so much all over the body kind of pain. And the other observation is just like seniors, weirdly enough, patients with fibromyalgia have balanced problems. Normally people in their forties, thirties, fifties don't fall. They have good reflexes maybe if it's very slippery and conditions are very difficult perhaps once. But I have a number of fibromyalgia patients that fall four or five times a year. So there's something odd about their balance system that reminds me, a little bit of seniors just random observation. Yeah. I do think, like you said, I think there is accelerated muscle wasting in those people, for a variety of reasons. But some of it probably due to chronic inflammation of some sort some of it due to low levels of activity. So usually your muscle mass doesn't start to decline until you're 50 or so, and then it starts to go down. But that might happen a bit earlier, I think, in somebody with fibromyalgia. So yeah, I think thinking about preventing sarcopenia at Middle Ages would be really important for those people. Yeah. So let's maybe talk a little bit about just the practicalities you have. I think it's called Center for Strong Medicine. Is that the right name? Yeah. In Australia. I'm not aware, like we certainly have a lot of physiotherapy places, obviously all over. And maybe that's an interesting point. You have physiologists working at the center . so how is your center different from a physiotherapy clinic? Or is it, but you do research. Yeah. Unfortunately, physiotherapists are not really trained how to do resistance training. It's not what they do. They do rehab from, various things and they, when they do weightlifting exercise. It's generally very low intensity and non-progressive. Like I have patients who've been to a physio and they've been doing these same exercises like sit to stand for 20 years, and if you can stand up against gravity, unless you've been in outer space for a while. Gravity is not an uncustomary force, so it has to be an un customary force. And unfortunately that's what physios tend not to do, is really get it to a level that works and they'll have people use at least here, elastic bands or, various body weight things that, that really are not progressive enough to change somebody's strength. So that's why I don't use physios. We sometimes send people to physios for specific neck problems or something. But in terms of delivering our exercise, we use the exercise physiologists who, have been trained how to deliver certain kinds of exercise. And they work with me directly. So they also know a lot of medicine and, they're not really just, delivering exercise. They're really delivering geriatric medicine because this exercise is part. As I see it, of geriatric medicine. They're actually helping to treat their diabetes and their heart disease and their arthritis and their depression and their cognitive impairment as well as their, falls and balance and frailty. So all of those things are really in their purview, but it's very different than what happens with a physio, actually. Yeah. Not sure if you're familiar with what's going on in Canada, but is there an analogous clinic in Ontario? I don't know what I mean. There could be, but I don't know of one. Yeah, there could be. So then I come to, again, practicalities of it. You mentioned resistance bands. I guess the nice thing about them is you can do them from home. You don't need to go to a gym. A lot of patients with chronic pain have very limited resources because perhaps they're not able to work because of their pain. So in perfect world, they would do something that's inexpensive. A lot of them are on disability, et cetera, et cetera. So you're saying the resistance bands are not helpful If you use them properly. But what happens is people often just use the same band for a long time, and as you stretch a band over time it gets le, more and more elastic. So the force is less and less. So it's the opposite of progressive resistance training. It's regressive resistance training. And you can't really measure it because if if you have your hands far apart, that's different than if you have 'em close together. The resistance is different. And so it's hard to measure. So we like to measure stuff. And that's how you can see progress. So that's why we do use them for certain, muscle groups sometimes like for the shoulder. But we try and get to a weight stack sort of thing as soon as we can so that we can measure what we're doing basically. Yeah. So are you saying free weights better, a better option? Free weights or machines. Yes. You can do, and there are some body weight exercises that are always hard, like pushups, right? Those are hard. So you can do those at home. There are things like step-ups with one leg, onto a high step. That would still be a hard exercise which you could do at home. With body weight or, some dumbbells that could take the place of going to a gym. I think for some people it's hard for them to do it on their own without supervision. So we try as, as much as we can to supervise the exercise because we know the outcomes will be better. I mean, there are home-based, resistance training programs that have been published and they work, but the strength changes and things that you see are definitely not as high as they are in the clinic. We try and get people to, to come in as much as we can. Yeah. And supervision can be done in person, which is I assume ideal during COVID, there has been a lot of experimentation with remote supervision. I'm not sure if you have any thoughts on that or perhaps even recommendations. Yeah, we, I mean, we do some of it for people to live far away and can't come into our clinic. We do telehealth sessions with them where we watch them exercise at home, on a zoom call and we, make sure that they're doing it correctly and we give them advice. So we, we do that when we can't get people to come in. I think it, it does work if you do it well. And, again, there are published studies from COVID and afterwards of doing it at home, whether it's aerobic or other kinds of exercise. And it certainly has benefit. So sometimes we, if we can get people in just once a week even, and then. They do other exercise at home, we can do it that way so that works. Yeah. And are there any websites, apps, online resources that would have trainer, personal coach, whatever that you think is well done? There's a million people putting weightlifting, videos online. I mean, most of them are actually pretty good when you look through 'em, they're doing the right kind of exercise. I don't know of any specific names that I would recommend over others, but we do have a lot of materials that we, send to people about exactly how to do it both at home and in a clinic. We have videos and fact sheets that show exactly how to do each exercise. I'd be happy to send those to you. They're, and you can distribute them as you will. So we've outlined exactly a good range of exercises, both for balance and strength training for the home setting and the clinic setting. And the videos show you, exactly how to do it. In good form. And then the fact sheets tell you, what the steps are. And they're developed from a research study that we did where we had 6,000 people in an online program for brain health and part of the treatment was exercise. So we developed all of these web-based resources to use with this population that we weren't seeing face-to-face actually. So they're quite good and useful and easy to follow. I'm happy to send you those. Yeah, that would be awesome. Now I guess looking forward into the future, and I don't know if you're the right person to ask, but are there going to be some biologics that will stimulate muscle growth? I think some of the original steroids, perhaps that muscle builders use, where there was some hope that they would help with people who are weak, I think, but I'm not totally sure. So I guess what about medications in the future to grow muscles. The drug companies have been searching for this for 40 years now, and most of the original studies were some kind of a growth hormone analog of some sort. But it gave everybody diabetes and carpal tunnel syndrome, so that didn't work out too well. Steroids themselves are not really possible because of the well andronizing effects in women, but also liver problems. Oxandrolone is used in burn units to help with muscle recovery, which is a synthetic testosterone. And we actually used it in a study of women. In Boston and, we used it with and without weightlifting exercise, and we found that it didn't change, it didn't improve their muscle strength gains. So weightlifting did that, but it did improve their muscle size a little bit. So it was complimentary in that way. And that's generally what with testosterone as well. By itself it doesn't really improve muscle size and strength. It does in combination with weightlifting exercise, but those drugs are not really gonna be the future. People have looked at other drugs like a myostatin inhibitor that , will hopefully increase muscle size. But the thing is, like all of the drugs that are being tested and trialed now are basically, using weightlifting exercise as the, gold standard of what you're looking for. So to me it's why do you want a drug to replace what weight lifting can do? We know how to fix this problem. It's, we know what works. So why do we want a drug to replace it? That's, likely to have, other side effects probably in the field that we don't want. And just increasing muscle size is not gonna make you stronger very much. So that's still not gonna be an answer. You have to have that neural drive to, to increase the muscle contractions force in addition to whatever it is that you're using to build up the size of the muscle. And they've been trying for decades and so far, it hasn't really come to fruition. I think there are things that can be done like making sure the person isn't protein malnourished, which a lot of older people are. So making sure the diet is is good. If there are sources of inflammation and those are met, like depression for example is inflammatory, so is anxiety. And all of those conditions will lead to loss of muscle tissue ultimately. Treating the inflammatory conditions that people have, I think is again, in sort of underutilized way to help prevent muscle loss. But yeah I feel like we have the solution to it. We have the solution to sarcopenia we just need to pay for it. And make it medicine because it is medicine, it's not just muscle. It treats depression better than a drug. It improves cognition improves heart failure, improves renal failure, works for COPD. So , it has so many benefits, in addition to its benefits for muscle that, we definitely should be paying for it in medicine, as a treatment and we're not, unfortunately. So even with diabetes, you think about metformin, which is used to both prevent and treat diabetes. And if you look at the diabetes prevention program, the DPP that was done a few years ago, they had a group that had exercise and diet versus metformin versus control. And the metformin worked about half as well as the diet and exercise group, which included weightlifting. It was done at YMCAs in America. The medical system will pay for metformin for life, but they certainly won't pay for diet and exercise coaching, for life. It's just a misunderstanding of where the evidence is in the literature. I think. So this is building on what I mentioned about the future. What about current supplements? Everything from creatinine to whatever it is that people are using. What are your thoughts on supplements for? Yeah. Yeah, I don't use them. We do give people protein supplements, like a little drink after their weightlifting session if they are sarcopenic. So like within an hour of training creatine, is useful for. It actually increases the amount of water in your muscle. If you take, it for a few, couple of weeks, your muscle will look bigger, but it's just, it's mostly water. It's not increased muscle fiber size. So it, it is used by bodybuilders to look bulked up. But we don't use it for as part of our weightlifting. There are some studies now looking at it for cognition. Creatine is something that you have naturally in your body. The supplements are a lot higher dose than that. I haven't actually read all of the studies on creatine and cognition. I think it, there's probably a bit of hype there in the media about it now, but it's, it looks like, it's everywhere when you look now in the public media, I tend not to use any of those supplements. We just basically rely on good food, mediterraneanish diet, more protein if they need it. And high intensity weightlifting. We don't use any other supplements. So I guess going back to just in general weight lifting and exercise as a medicine I always assumed it was partly political because, it's not really positioned as a drug. There isn't really anybody that's who's going to financially benefit from promoting exercise because nobody has a patent and exercise. And also it is very time intensive if in terms of if you give somebody metformin. You don't have to supervise how they take metformin every day. Where as with exercise, if you wanna do it properly, that means probably somebody akin to personal trainer, uh, and a facility that has all the equipment necessary. And if you are going to do it on population basis, because exercise is good just for about everybody and every medical condition. That's probably a lot of money. So again, that's just my guess. But I don't know. Do you have thoughts why there's been difficulty with coverage? Well, I mean, I think it's really not understanding the literature. Like for, cardiac rehab for example, is covered, for it used to be 12 weeks, now it's about six weeks here. That's covered because there are so many studies showing that cardiac rehab reduced, mortality and recurrent heart attacks by 35% or so. And so that was considered, cost saving to actually put people through cardiac rehab. So that is paid for at least a short term of it. But other than that, there aren't very many and there's really no idea that exercise should be a long-term solution for these chronic conditions. I think, whether it is more expensive than, taking five or six drugs for all of these conditions you've mentioned? I'm not sure. But it's certainly, I think part of the problem is that physicians are not trained in exercise. If you think about it, if we had a drug that reduced your risk of, death, cardiovascular death by 50%. You'd probably learn about that drug in medical school. We have that drug. It's exercise. We, there's a million studies. We know it. And yet not a single hour of my medical school career was devoted to learning about exercise and it's still that way. There still is no training and exercise for physicians, so they're not prescribing it as medicine because they haven't been told it's medicine. And that's a huge problem. I'm not sure why that is, but there's so many, other things that are, come into the training now in terms of, genetics and, all the the other things that they're meant to learn that there seems to be very little place for exercise and nutrition in medical school. Yeah. I think most honestly, most physicians are aware that exercise is good for patients, but I don't think they go too far beyond that. Yeah. And they dunno how to prescribe it, they're basically, yeah, say go take a walk or something like that. But that's about as much as they can say. Anyway, thank you very much for taking the time to speak to me. It was very informative. As I said, I, after reading the book, stronger by Michael Gross I. I was always a aware of exercise being good, but really I guess weight lifting was a little bit of a poor cousin of aerobic exercises where that was my assumption in terms of health benefits and this really changed my outlook. Thank you very much for talking to me. My pleasure. Have a good night. The information shared in this podcast is for educational and informational purposes only, and should not be considered medical advice or a substitute for professional medical care. Always consult your own physician or qualified healthcare provider for personalized guidance regarding your. Any exercises or therapeutic activities discussed should be performed only under the supervision of an appropriate healthcare professional or trained expert to ensure safety.
