A few weeks ago I posted about my dismay for those high elevation masks with more and more studies showing how useless (and hindering) they are. It was at that time, my colleague Matt DeBole asked about my thoughts on Intermittent Hypoxic Training. Honestly, I had not researched much of it, and was not a believer in it. Due to it's growth in popularity, I decided to plunge into the research to attempt to prove myself wrong (spoiler: I did).
What is Intermittent Hypoxic Training?
Intermittent Hypoxic Training (IHT) is a type of training where exercise (often running or cycling) is performed in a room or with a machine that has a decreased percentage of oxygen in the environment.
Is it Similar to The Elevation/High-Altitude Training Masks?
Air isn't 100% oxygen, it is a combination of gases, and "normal" air has about 21% oxygen in it.
With that said...No, IHT and elevation masks are distinctly different. IHT involves training in a room or using a mask that has decreased oxygen in the air, but your actual breathing (respiratory rate) is the same. The training mask (photo far left) makes it harder to inhale and exhale (breathing rate increases), but you are still breathing in air that is 21% oxygen. In short...
Training mask: Same oxygen percent as "normal" breathing air (FiO2 = 21%), but increased respiratory rate.
IHT: Decreased oxygen percent than "normal" breathing air (FiO2 < 21%), but same respiratory rate.
Read this post to see why the training masks are ineffective: link
Before we deep dive into the topic, here's some words you may want to know:
- Hypoxic: an environment with less than 21% oxygen in the breathing air
- Normoxic: an environment with 21% oxygen in the breathing air
- VO2 Max: The maximum amount of oxygen the body can use in a given amount of time during exercise. The higher it is, the better "cardio" a person has
- Running Economy: The amount of energy a person uses while running. To measure this, a person's weight, breathing rate, and volume of oxygen consumed during a sub-maximal bout of exercise is calculated. "Good" running economy means a person does not use much energy to run a fast as others who may be out of shape.
- Mitochondria: The terrible word from high school biology class that means tiny things in your cells that produce energy. The more mitochondria you have in certain muscles, the better they can be used for long periods of time. "slow twitch" muscle fibers of distance runners have more mitochondria than "fast twitch" muscle fibers of sprinters.
What Do IHT Companies Claim Their Products Do?
If you were to read a website or brochure, it would really just say "increases performance". What they actually mean is, it may decrease your running/cycling times (make you faster).
Does it Work?
Most studies looked at sprinting and moderate intensity exercises (~70% max HR):
- One study showed at the end of a 6-week program, a hypoxic training group (runners) had an increase of 5% peak power, 5% increase in VO2 max, 35% increase in time to exhaustion. No changes occurred in any of those categories in the normoxic training group doing the exact same sprint program.
- A study showed that running economy improved in the hypoxic group compared to the normoxic group after 6 weeks of training (testing at 6 weeks was performed in a normoxic environment for both groups). Four weeks after both groups did the training, both groups were tested to see if the benefits were maintained. The hypoxic group maintained the benefits over the normoxic group. A third group went through hypoxic training, and was also exposed to hypoxic air during post-training rest; there was no additional benefit in this group.
- One study was a bit contradictory to the studies above and showed that VO2 max and running speed was higher in the normoxic group. It also showed any improvements made in the hypoxic group were not maintained over time.
- Here's a picture of some comparisons of a ton of studies:
It looks as though the biggest findings is that IHT MAY increase VO2 max better than normoxic training.
How Does it Work?
So there's some promising results of these studies, but obviously some conflicting findings. The interesting part is that in the above studies, blood markers were also taken to see why improvements may have happened. Living in high elevation changes the blood markers in a "good" way for cardio. In these IHT studies, they found that there was no significant changes in the blood markers. This makes sense right? Studies found that for significant changes to occur in blood from high elevation living, adaption usually occurs after at least 3 weeks of exposure to high altitudes for 20 hours a day. Whereas IHT is often only performed 1-2 hours 2-5 times a week.
This led to a theory of what may be occurring in the body. They suspect adaptations in muscle are occurring because of a protein called HIF-1α. This protein is unable to be measured in normal blood testing methods used in the studies, however influences how much mitochondria and capillaries are laid down in muscles. They suspect something is happening to that protein causing it to lay down more mitochondria in muscles. More mitochondria means higher VO2 max.
How about for sprints? Sprinting and long-distance running require different energy systems, so the above would not explain sprinting improvement (read more about energy systems here: link). Several studies showed sprinters were able to run longer in a hypoxic environment than their normoxic counterparts. Researchers theorize that training in that low oxygen environment forces arteries in limbs to become larger quicker to get oxygen to those large fast twitch muscle fibers. It's similar to what nitric oxide in pre-workout does...opens up your blood vessels to be larger for increased blood flow. In short, your body senses low oxygen, opens up your capillaries faster to give your muscles more oxygen, which in turn allows your fast twitch muscle fibers to perform better. I don't quite buy this idea, keep reading to see why.
To sum it up:
- Aerobic benefits theory: An increase in mitochondria in muscles
- Anaerobic benefits theory: Increased blood flow -- vasodilation and perfusion
"Wait, hypoxic sprinters outperformed normoxic sprinters? What happened to "live high, train low"?"
To answer this, let's look at 2 studies. Of the studies I read, only 2 compared normoxic vs hypoxic sprint performance within a session:
Study 1: Hypoxic peformed better
Group 1: Sprint as hard as possible on a treadmill in a hypoxic room for 10-seconds 9 times, then sprint as many times as you can for 10 seconds until you can not complete a 10-second sprint anymore.
Group 2: Do the same thing, but in a normoxic room.
Results: Group 1 was able to sprint an average of 13 sprints after the initial 9 sprints, and Group 2 was only able to sprint 9 times after their first 9 sprints.
Study 2: Normoxic performed better
Group 1: Perform an incremental step test (run at increasingly harder speeds each minute until failure)
Group 2: Do the same thing as group 1, but the hypoxic settings were turned on.
Note: Both groups ran in the exact same room, but they did not know whether the room had the hypoxic settings on or off. This is called "blinding" the participants.
Results: Normoxic group had higher VO2 max and higher running speeds.
So, does it contradict "live high, train low"...maybe! Let's get into the issues:
Placebo! Most of the studies admit that their groups were not blinded. In the 2 examples above, the first study did not blind hypoxic group, they knew they were the group getting hypoxic training. They could have been trying extra hard thinking that this super cool technology would enhance their performance. You'd be surprised what the human mind can do. Whereas the second study that supports the "live high, train low" method, had blinded both groups.
For all studies in general, it's hard to compare who had it right and who had it wrong. The variables were all so different:
- some replicated 6,500 feet while others replicated 9,800 feet
- some had people train 2 times a week, others had people train up to 5 times a week
- Some had people train for 1 hour others had them train for 2 hours
- Some had untrained runners and some had elite runners
For those reasons, I think the findings of people performing better in a hypoxic setting may have been a fluke or a problem with the study design. I do believer the gains in VO2 max is legit.
"So...DOES. IT. WORK?! I'm still confused."
Based on current research it seems to be successful in increasing VO2 max more than training in normal air which will allow a person to perform better with long distance running. As for sprints, there is limited evidence to show that it may allow a person to run harder and longer.
"Sweet, what do I actually do with this info now..."
Well first of all understand that this isn't for everyone. This is for those who are elite level athletes looking to shed off a second or 5 on their running times. It's for the elite runners who have to time to fit this in alongside their standard training program. It's also for those elite runners that have sponsorship money to fund the training; it's expensive.
If you did want to do IHT, below are the guidelines that are recommended based on current evidence:
- 70% or higher VO2 max performance
- FiO2 of 16-18%
- 1 to 2 hours a session
- Short rest intervals (1:4 work rest ratio at most)
- 2-5 times a week
So, what are your thoughts? Sound off in the comments. Also, if you are looking for great running training and rehab tips, drop by Matt's website at http://runbetteracademy.com/. He is a highly trained PT that specializes and participates in endurance running.
- Faiss, R. Olivier, G., and Millet, G.P. (2013). Advancing hypoxic training in team sports: from intermittent hypoxic training to repeated sprint training in hypoxia. British Journal of Sports Medicine. 47: 145-150.
- Holliss B.A., Burden, R.J. Jones, A.M., and Pedlar, C.R. (2014). Eight weeks of intermittent hypoxic training improves submaximal physiological variables in highly trained runners. Journal of Strength and Conditioning Research. 28 (8)
- Holliss, B.A., Fulford, J., Vanhatalo, A., Pedlar, C.R., Jones, A.M. (2013). Influence of intermittent hypoxic training on muscle energetics and exercise tolerance. Journal of Applied Physiology. 611-619
- Kilding, A.E., Dobson, B.P., Ikeda, E. (2015). Effects of acutely intermittent hypoxic exposure on running economy and physical performances in basketball players. Journal of Strength and Conditioning Research. 30(7)
- Scott, B.R., Slattery, K.M., and Dascombe, B.J. (2015). Intermittent hypoxic resistance training: Is metabolic stress the key moderator? Medical hypothesis. 84: 145-149
What is Whole Body Vibration (WBV)?
Whole Body Vibration is the method of exercise, or act of doing a task, on a vibrating platform which causes the entire body to vibrate. These machine are considered high frequency as they function within, and above, 3 to 30Hz. Frequency means the amount the plate moves within a given time. In addition, the amount of vibration is also affected by not only the speed at which the platform moves, but also how much. This is called amplitude, and it is often measured in vertical distance change. Most of the machines can move between 1-4 mm in vertical displacement. The higher end machines also allow users to customize these settings.
In the early days, local body vibration (LBV) was used in commercial gyms when "spot training" was still thought to be possible. People would wrap a strap around their stomachs and butt, and then turn machines on that would vibrate those areas only. The fad quickly died for numerous reasons, mainly being that this is not how weight loss or muscle building works.
Whole Body Vibration came on the scene in the 1980's in European countries with gurus claiming it increased strength and performance when exercises were performed on them. The United States then began following, with many companies claiming those same benefits. Research was mixed, however they did find some effective uses for the technology. There is evidence that it prevents severe decline of bone density in sedentary patients in hospital beds. If there is no stimulus to the bones, the body will stop laying down more bone for growth. For the science folks, the mechanism is the principle of Wolff's Law. That research was then, and is still conducted today, in regards for space travel. With no gravity in space, astronauts often face muscle atrophy and bone density decline which can lead to overall decline in health and functional activities. Vibrations as a stimulus to bones may be the answer to the problem.
Today, WBV platforms are in numerous gyms, clinics, and sports perfmance centers. I researched this topic in 2011, and only found literature for bone density, but now that there is a lot more research out there, let's talk about why they're in facilities, if they work, and if so, how they work (or not).
What's the Mechanism
So this can get a bit sciencey, but that's important in understanding all the junk that's out there. Hopefully by the end of this, you can get why these machines are good at something, and then apply that knowledge to anything related to vibrations and fitness. After years of research, the highly agreed upon theory is that the vibrations cause change due to muscle spindles (below).
Muscle spindles are in muscle fibers and act reflexively to contract your muscle if it feels stretch in the muscle. For example, it can be a protective device when you swing your arm so hard that your elbow may hyperextend. The muscle spindle of the biceps activate to contract the bicep to avoid the hyperextension.
The vibrations from WBV are said to activate these muscle spindles since the amplitudes of the platform change the length of muscles quickly, resulting in micro-contractions. So it seems the mechanism is due to a nueral mechanism rather than size increase of muscle. Keep this in mind as we move on to the next section, and it should be a lot easier to think logically about the research.
What the Evidence Says it Does
- Increases muscle activation of the quadricep muscles and plantarflexors (calves). EMG studies showed higher muscle activation after WBV training in a static positon was performed. Even standing on it in a static position recruited more activation of the muscles of the lower extremity than on a stable surface. Activation from standing on it ranged between 12-87% of MVIC (their maximum isometric contraction strength).
- Increases early rate of torque development for functional activities such as gait and running post ACL reconstruction (ACLR). Rate of torque development is important in activating proper timing and strength in leg muscles during gait. Particularly, if the quads do not extend the knee or eccentrically load at the right time, individuals will have impaired walking. Normally, peak RTD occurs at 300 milliseconds, but for walking, the peak needs to occur much faster. After ACL reconstruction, peak RTD is even further delayed. Studies showed doing isometric squats (with hand assistance) at 90 degrees on the platform increased RTD at 100 milliseconds after WBV. This means it can assist clinicians who have a hard time having patients activate their quads for gait and closed-chain exercises after ACLR. This point may not be useful for the healthy general public, as it pertains to those who have a hard time activating their quads.
- Decreases bone density reduction in sedentary acute care patients. This was already mentioned above, but has little to do with the neural aspect of muscles, but rather the bone. The bone gets a stimulus from the vibration and therefore feels the need to stay strong. Bone density will still decrease in sedentary individuals, but at a slower rate. Weightbearing and resistance training is important in maintaining and improving bone density.
- Increases balance (measured by Berg Balance Test). There could be the neural mechanism explained earlier accounting for this, however it is most likely due to an individual standing on an unstable surface, which is a form of balance training. In more specific research, it did not improve balance for stroke patients since some stroke patients may not yet have enough strength to even stand on two feet with equal weight distributuion.
- Increases functional mobility in non-cardiopulmonary patients (measured by 6-minute walk test). After 8 to 12 weeks of WBV training, individuals who went through this training were able to walk further in 6 minutes than those who did not perform exercises on it. For stroke patients, the effectiveness is inconclusive with some benefiting, and some not. It does not work for cardiopulmonary patients because the limiting factor is not the musculoskeletal system, but rather the cardiopulmonary system.
- Prevents muscle and blood vessel loss when paired with resistive training. Decreases in cross-sectional muscle area and capillaries in sedentary individuals occurs from disuse. WBV prevented a greater decline in both when compared to those who did not receive WBV. This was must likely due to the resistive training than the WBV. Additionally, the stimulus increased blood volume within capillaries which increased peripheral blood pressure. This pressure tells the body it needs that tissue, and therefore the decline in your small blood vessels is reduced. This is good because it allows for more potential for oxygen exchange.
- Increases repair and growth of small blood vessels. Angiogensis is the repair and growth of new blood vessels. This was by far my most exciting finding from the research. As mentioned in the above point, it increases the amount of blood in a local area's small blood vessels. This creates pressure and shearing forces on the blood vessels. It signals the body to strengthen these vessels, and also to create more. Additionally, looking at blood serum, it showed pro-angiogenetic growth factors in the blood after WBV, which suggests WBV also has a hormonal effect. This is important since muscle growth occurs faster than angiogenesis. This may be used to help vessels and other tissues adapt closer to the rate of muscles to ensure tensile strength is sufficient rather than muscles only growing through metabolic processes (study combining it with blood flow restricted training anyone?).
- Increases flexibility when combined with static stretching. The evidence for this goes both ways, but there is evidence suggesting WBV causes a rise in muscle temperature which allows the muscle to be better stretched. Those who did not receive WBV did not improve as much.
- Decreases excessive muscle tone, particularly in those with cerebral palsy and multiple sclerosis. Individuals immediately saw a reduction in muscle tone (measured by H and M wave electromyography). Tone immediately began normalizing, with the largest decrease at 3 minutes. There is a lot of evidence for those with CP and MS, however I did not encounter any studies on healthy individuals or athletes in regard to muscle tone decrease.
What the Evidence Says it Doesn't Do
- Increase muscle deoxygenation for replication of muscle fatigue to stimulate muscle growth. People thought because more blood was found in local regions, that is was because muscles were unloading oxygen more. This was not true when they measured it. If it was true, the hopes would be they could trick the body into adapting metabolically rather than loading a muscle.
- Decrease self-reported pain for individuals with osteoarthritis. Pain was not reported to have decreased when WBV was used for 6 weeks. This was particularly in the knee.
- Decrease self-reported stiffness for individuals with osteoarthritis. Stiffness was not reported to decrease with WBV for 6 weeks. This was particularly in the knee.
- Increases airway clearance and functional mobility in individuals with chronic obstructuve pulmonary disease (COPD). Chest wall vibrations are an affective way to assist in airway clearance for individuals with COPD, however WBV showed now improvements in ability to to clear airways. Also, as mentioned above, functional mobility is not increased because the musculoskeletal system is not the limiting factor for COPD patients.
- Increase muscle strength. Activation was increased according to EMG, however when squats and vertical jump were performed 5-10 minutes after WBV, there was no significant difference in strength or jump height. Just because a muscle is activated does not garuantee its maximum strength can improve.
- Increase muscle size. WBV affects the body and tissues more neurologically, and therefore does not increase muscle size. Even when paired with resistive exercises, there was no difference in those who used WBV, and those who did not. It would just decrease the amount of muscle lost, mainly due to the resistance exercise.
Guidelines on Use
- Do NOT use it for patients with upper body disorders involving wrist extensors, wrist flexors, grip, and carpal tunnel. High frequency vibrations aggravate symptoms in these disorders and syndromes.
- Amplitudes should be within 2-4mm. Others may work however most studies were within these limits.
- Frequency should be within 20-30Hz. Others may work however most studies were within these limits. For tone reduction in patients with MS and CP, a progression from 20Hz to 40Hz over 8 weeks was used.
- No contraindications have been released besides wrist conditions. Just to be safe, it is best to assume it is contraindicated for individuals with cancer, pregnancy, rheumatoid arthritis, and those with poor balance and weak grip (risk of falls if they can not hold on to handle bars).
- For angiogenesis, dynamic and loaded exercises are preferred (squats, lunges, etc.).
- For muscle activation, static exercises is preferred (isometrics). Calf activation was best at a 0-60 degree isometric squat, and quad activation was best at a 90 degree isometric squat. Ankle dorsiflexion or plantarflexion had no significant difference on activation of the quadriceps.
- For muscle activation and balance improvements, 3 sets of 60 seconds, with 60 seconds rest between sets, is appropriate.
- For tone reduction, 3 minutes has the peak reduction in tone, however experimenters did 10 minutes without any negative effects.
So, What Does This All Mean? What Do I Do?
- For the practitioner: There seems to be a lot of benefits such as decreased muscle tone, increased balance, increased angiogenesis, increased flexibility potential, and assistance in activation in quad dysfunction after ACLR. A lot of the research was done on the lower extremity, but if you take the concepts to the upper extremity, you may get similar results. The machines however, are very expensive ($3000+); there may be better ways to achieve each of the benefits via manual therapy and exercise selection. Ultimately it would come down to the cost of whether you want to purchase one or not. Today the most popular machines seen in performance facilities are pictured above.
- For the public: Most athletes use them during their soft tissue routine, and as a way to prime their nervous system since there is evidence that it activates muscles by neural pathways. Athletes also do variations of core exercises on them since they act as a unstable surface, and there is a lot of evidence supporting more core activation on unstable surfaces. If they are in a commercial gym, they may be worth using in the beginning or at the end of sessions for the above purposes. As far as strengthening and increasing muscle size goes, resistance training without them is fine. There are also other ways to prime your motor system and decrease muscle tone, but research has not compared these methods with WBV. It is not worth the cost to buy a machine for home use, unless you have CP or MS. Time-wise, it would most likely take the same amount if you substituted your soft tissue work rather than added to your routine. Also consider if you even need soft tissue work every session.
1) Beijer, A., Degens, H., Weber, T., Rosenberger, A., Gehlert, S., Herrera, F., Kohl-Bareis, M., Zange, J., Bloch, W., and Rittweger, J. (2105). Microcirculation of skeletal muscle adapts differently to a resistive exercise intervention with and without superimposed whole-body vibrations. 35: 425 – 435
2) Cheng, H.K., Yu, Y., Wong, A.M., Tsai, Y., and Ju, Y. (2015) Effects of an eight-week whole body vibration on lower extremity muscle tone and function in children with cerebral palsy. Research in Developmental Disabilities. 38: 258 - 261
3) Kacoglu, C. and Gurol, B. 2016. Effect of body position during whole body vibration on acute jumping performance. Baltic Journal of sport and health sciences. 3(102): 8-12
4) Pamukoff, D.N., Piestrimone, B., Ryan, E.D., Lee, D.R., Brown, L.E., and Blackburn, J.T. 2016. Whole body vibration improves early rate of torque development in individuals with ACL reconstruction. Journal of Strength and Conditioning Research.
5) Wang, P., Yang, X., Yang, Y., Yang, L., Zhou, Y., Liu, C., Reinhardt, J.D., He, C. 2015. Effects of whole body vibration on pain, stiffness and physical functions in patients with knee osteoarthritis: a systematic review and meta-analysis. Clinical Rehabilitation. 29 (10): 939-951.
6) Yang, X., Zhou, Y., Wang, P., He, C., He, H. (2016). Effects of whole body vibration on pulmonary function, functional exercise capacity, and quality of life in people with chronic obstructive pulmonary disease: a systematic review. Clinical Rehabilitation. 30(5): 419 – 431
Here we go, another article of a growing health topic: cupping! Before we begin, I HIGHLY recommend you watch this video that explain pain.
In 2012, Olympic volleyball players popularized KinesoTape, which may have some beneficial effects. However, they got got sued in 2015 for making false claims about other benefits (click here). This year's Olympic is bound to increase the interest in cupping since it is seen on Michael Phelps and other athletes.
What is it?
Cupping is when glass or plastic "cups" are used to cause a vacuum effect on the skin by either using a pump or heat to generate negative pressure. It can cause edema (swelling), errythremia (redness of skin), and ecchymosis (bruising) which is thought to increase healing.
Who SHOULDN'T Use It?
Because it causes bruising and swelling, below populations and/or regions should not have cupping applied. These are contraindications:
- Pregnant women
- Women menstruating
- Cancer (metastatic)
- Bone fracture
- Deep Vein Thrombosis
- On arteries where pulses are felt
- On sunburn, abrasions, rash, contusion, and bruises
- High altitude (Yes, a review stated a guy wound up in the hospital when it was applied on his private jet and atmospheric pressure aggressively increased and ruptured his capillaries).
Why Do People Want It?
Some people claim or are told that it can:
- Increase flexibility (range of motion aka ROM)
- Decrease pain
- Decrease healing time
Does It Actually Help?
Did you watch the video above on pain? If not, it is highly recommended before you proceed.
Multiple studies show that it decreases chronic pain in the neck and shoulder, lower back pain, and even acute severe neck pain. Additionally, it was shown to increase flexibility for movements similar to touching your toes when applied to a few of the back muscles (erector spinae). There were no studies that compared healing times to a control group or other methods of treatment, therefore it can not be accurately claimed to decrease healing time.
Here are other highlights from the literature:
- Cups can vary from 38mm - 120mm, with larger cups generating more suction (Not necessarily a good thing; no studies to identify optimal pressure for claimed effects).
- One study claimed muscle layers are deformed, however more recent studies showed only the epidermis and dermis is deformed. This means capillaries can be deformed in regards to depth, but not muscle or fascia.
- There was no significant difference between "standard medical care" (aka medication) and cupping. This means for those in severe pain who want to get off meds could benefit from this to tolerate other effective treatments for impairments. It is also interesting to note that the group that received cupping was also given exercise. Because of this, it is hard to say that cupping independently decreased pain.
- One study looked at perineal pain (region of your organs) of postpartum women, and reported decreased pain. However as explained before, perception of pain is complex and multifactoral. Pain can also come from emotions, such as loneliness. The study discussed that pain could have decreased because of time spent with the practitioner so they do not feel lonely. In addition, the practitioners' touch on the site of pain can also affect emotion and feeling of being cared for. They stated that the practitioner's presence and touch could have been a variable as well.
Now for the fun part, HOW does it help?
Well...HOW Does it Help (What's the Mechanism)?
All studies proposed theories, but there was really no clear explanation. They all agreed there is no reliable evidence that clarifies the exact mechanism of cupping.
First of all, let's address the aspect of increased range of motion (ROM). We CAN dismiss the theory that it deforms muscle and fascia tissue (stretching the fascia, breaking adhesion, etc.) from this post regarding foam rolling (click here). In fact, the increase in ROM may also be attributed to the same mechanism as foam rolling, which we explained as autonomic inhibition of the muscle not deformation of fascia. With that said, let's go over the proposed theories about PAIN:
- Greek Theory in the Ancient Times: It bring pathogens and "toxins" to the surface of the body so they can release into the environment. This is a bit out there with very little evidence, if any at all. We do know that pathogens and toxins (if there was such a thing as toxins) are filtered through the body and organs to eliminate them. They can not be released into the environment through our skin (maybe sweat, not likely).
- Eastern Medicine Theory: Pathogens block the flow of Qi (energy), and cupping increased the flow to restore natural balance of Qi in the body. This theory is very hard to measure, and many in western medicine dismiss this theory.
- Western Medicine Theory (Counter Irritation Theory): You cause a stimulus, perhaps even discomfort and pain, in another region of the body so that the original site of pain no longer feels as painful. Or you increase pain or pressure substantially in the affected area, so that pain threshold increases. This theory is still supported and studied today, and has some evidence. However, are you really solving the issue? If this is the mechanism or are you merely getting rid of the symptom?
- Neural Mechanism Theory: Small nerve fibers which carry pain are stimulated from the pressure and sends impulses to the spinal cord, midbrain, and pituitary. These are the sites that are well-studied to regulate pain signals. This then releases serotonin, cortisol, and endorphin which are hormones and neurotransmitters that can inhibit pain signals. This is the most comprehensive scientific theory for pain, that many of the healthcare experts propose now. With that said, even if this is the reason that pain subsides, do you want this as a sole treatment? Are you treating the main issue? Pain is very complex and here's the video...again...if you haven't watched it by now:
So What does All This Mean? Should You Use It or Have It Done? (Closing thoughts)
- For the consumer, patient, client, and customer: Cupping has been shown to decrease pain, however we know that the idea pain can be a perception and symptom. Your perception of pain may be decreased, but it will comeback if you do not address your actual impairments. Ways to fix your impairments is by regular exercise and correct exercise, among other aspects. If you use it for increased flexibility, be sure you understand how it works and what to actually do to maintain that new ROM through proper programming or exercises. The point of this article is for you to be cautious of practitioners using this as a means to fix all your problems and giving you false information. You will most likely rely on them for months and years, but independence and a pain-free life should be the true goal. Be sure to really do your research on the practitioner because there have been stories of tissue damage, burns, and infections from unsanitary cups, cups left on too long, and improper heating for heat cupping. Cupping may help manage pain, especially for Olympic athletes who need it daily, however it does not fix the underlying cause. A licensed physical therapist can both educate you in this and treat your impairments in movement and pain.
- For practitioners: Yes, we need to decrease pain in order for some patients to tolerate exercise, but think about your patients and consider their time and money. Is cupping appropriate for the fastest and optimal treatment plan? I think not, but I do not have all the answers nor am I always right. This article is meant for you to critically consider the uses, appropriateness, and mechanisms of cupping. It is also to remind you it is imperative to educate patients on pain, benefits of exercise, and being transparent of how cupping actually works (We really don't know, but we should go toward the neural mechanism theory based on evidence). Educate them to keep them moving.
As always, Thank you for reading. Be sure to comment below on questions, comments, agreements, and disagreements.
- Akbarzade, M., Ghaemmaghami, M., Yazdanpanahi, Z., Zare, N., Mohagheghzadeh, A., and Azizi, A. Comparison of the Effecct of Dry Cupping Therapy and Acupressure at BL23 Point on Intensity of Postparum on intensity of postpartum perineal pain based on the short form of Mcgill Pain Questionaire. Journal of Reproduction and Infertility. 2015. 17(1): 39-46
- Choi, J.Y., Huh, C.W., Choi, C.H., and Lee, J.L. Extracranial vertebral artery rupture likely secondary to "cupping therapy" superimposed on spontaneous dissection. Interventional Neuroradiology. 2016. 1-4
- Chi, L.M., Lin, L.M., Chen, C.L., Wang, S.F., Lai, H.L., Peng, and T.C. The effectiveness of cupping therapy on relieving chronic neck and shoulder pain: a randomized controlled trial. 2016. 1-7
- Dons'koi, B.V., Chernyshov, V.P. Osypchuk, D.V., and Baksheev, S.M. Repeated cupping manipulation temporary decreases natural killer lymphocyte frequency, activity, and cytotoxicity. 2016. 14 (3): 197-203
- Effectiveness of cupping therapy for low back pain: a systematic review. Acupuncture Medicine. 2013. 31: 336-337.
- Lim, K.G., Chuah, S.W., Shan, M.E., Wong, Z.G., Murugesan, A., Azman, S.S. A cross sectional study of chronic pain relief after bekam (traciditional malay "cupping") therapy. 2015. 9(2): 32-36.
- Rozenfeld, E. and Kalichman, L. New is the well-forgotten old: The use of dry cupping in musculoskeletal medicine. Body and Movement Therapies (2016): 20, 173 -178
Foam Rolling is a popular tool being used in the rehabilitation, sports, and fitness world to help with "myofascial release". Fascia surrounds tissues of the body, and also helps with adhering vessels and structures to one another. Because its main function is to hold structures together, it is said that fascia being too tight can cause a adverse effect on muscle function. This post will educate you at when, how, and why to use it.
What They Say It Does, and What The Research Says
- Increases flexibility long term: In all studies including studies reviewed within the ones I reviewed, flexibility (dynamic and static) increased 3.4-4.3% in lower extremities short-term only, not long-term. Measured flexibility was increased right after bouts of foam rolling, however within 1 week and up to 8 weeks, flexibility was not sustained if not combined with resistance training or other methods of stretching (static and PNF).
- Relieves soreness: One study looked at foam rolling effects on Delayed Onset Muscle Soreness (DOMS), and participants reported decreased soreness after high intensity exercises that caused DOMS. DOMS is moderate to severe soreness ~48 hours after a workout.
- Stretches the fascia resulting in increased flexibility: In numerous studies, it reports that the fascia actually stretching does not occur in foam rolling. In one of the studies, it states even for a 1% fascia stretch, the pain and pressure levels are not bearable. So although flexibility may increase short term, this is not the mechanism.
- Increases blood flow: One study proposed that stiffness in arteries at the region being worked decreases, therefore more blood flow enters which may be a mechanism for increased flexibility. With more blood flow, it may be assumed muscle performance is increased, however there have been findings that support the same, decreased, or increased performance.
Below is an explanation of mechanisms, if you prefer to just learn what to do, skip to "How to Foam Roll".
Flexibility and Soreness Relief: What's Really Going on?
It's not the fascia being stretched (why do they call it myofascial release then?), so what causes the acute increased flexibility? First we need to understand active vs. passive range of motion (ROM) of a muscle.
Active ROM is when you use your own muscle contraction to move your body or limb as far as you can. Muscles tighten up due to, in short, the neurological components of your muscle. The neurological components tell your muscles to tighten up if they feel the muscle is lengthening too far.
Passive ROM is when someone else stretches you without you giving any effort. Muscles begin tightening up due to more of the structural components of the muscle rather than neurological.
Foam rolling acts on the nuerological components of flexibility. It stimulates neurological components such as 2 out of 4 mechanoreceptors and the golgi tendon organs. By stimulating these, less spasm and tightening of the muscle occurs and flexibility is increased short-term.
As far as soreness goes, pain threshold increases. Although the soreness is there, increased pain threshold means a person may not perceive the soreness as high. This is also why people begin to use foam rollers that are more dense. It's not because their muscle structure is changing, it's because their mechano- and pain receptors need a increased stimulus.
How to Foam Roll
There are a lot of different recommendations. One study suggested the ideal way is do each region of the body for a minute, while another suggested 30-40 seconds (or 10 times each area) for 3 sets. As far as exactly which positions should be done, there are many, so it is best to look at other resources. In regards to flexibility, it is beneficial to do both single and multiple regions of the body (fascial trains). Most studies recommended 3 times a week.
In regards to flexibility, I am a firm believer that traditional stretching is the way to go. Most people go to foam rolling because it takes less time, and it's painful ("no pain no gain, I must be getting better, right?"). Of course you can do both, but if you had to choose one, I would go with traditional stretching over foam rolling. As far as soreness, if you are consistently so sore that you need to foam roll everyday, it may be due to programming. I good program should leave you sore a few times, not all the time. Although no studies have been done to confirm this, I feel if you are foam rolling with high-density rollers 5-7 days a week, it is causing bad trauma on your muscles, it's best to give it a rest when it comes to recovery. Just because you are not sore, it does not mean you are not getting better. Lastly, few studies are out studying the affects of foam rolling on the spine (a bony structure opposed to muscular), so I have no say on that. Disagree or have something to add? Comment below.
Bushell, J.E., Dawson, S.M., and Webster, M.M. (2015). Clinical relevance of foam rolling n hip extension angle in a functional lunge position. Journal of Strength and Conditioning. 29(9): 2397-2403
Junker, D.H., and Stoggl, T.L. (2015). Foam rolling improves hamstring flexibility. Journal of Strength and Conditioning. 29(12): 3481 - 3485
Pearcey, G., Bradbury-Squires, D.J., Kawamoto, J., Drinkwater, and E.J., Behm, D.G., Button, D.C. (2015). Foam Rolling for delayed-onset muscle soreness and recovery of dynamic performance measures. Journal of Athletic Training. 50(1): 5-13
A few months ago I sent out a survey to understand how I can improve my current profession to help others market better, and also how to fix a profession that has a lot of false information that can potentially harm the public. 150 participants (49% female, 51% males; 51% ages 18-24, 36% ages -25-34) around the United States took a survey regarding exercise habits and their thoughts on personal trainers. Here are some interesting statistics:
- 75% of participants can not differentiate trainers' certifications (ex: CSCS vs. CPT vs. fake certification)
- 70% of participants learn through online blogs and forums
- 77% rate trainers highly based on their ability to explain the science behind their decisions
- 74% look for trainers through referral from friends and family
- Certifications are poorly regulated, and consumers can't tell the difference. This means although it's easy to make up great things about one self, it is equally hard to show them why your certification is better than another's. Certifications DO help with hiring because people within the profession can differentiate them.
- The public loves to read blogs, and some can contain poor information. The biggest point of this question is that it was an overwhelming preference of free resources compared to paid resources like workshops and seminars. People will go for options that free, and accessible to them on their own convenience. Regulating false information is difficult, and money is always a barrier.
- Because most people can't tell certifications apart, they look at how well a personal trainer can explain the sciences. Can personal trainers still mislead or over complicate information? Yes, but the main point is that customer service and interaction seems to dominate having letters behind your name in the eyes of your potential patients and clients.
- Social media is a crucial part in marketing, but services such as Yelp seem to be losing interest. Word of mouth, is still king in the marketing of this profession, but in order to even get clients, you NEED a digital footprint. Then, give your best effort to your clients every day. Besides the fact that they are paying you and expect the best, they are putting in their time and effort to better themselves; they deserve your best.
Now that you understand WHY, click this link here for HOW Updoc Media has helped multiple companies brand themselves.
Many people and companies claim to have specific workouts that will increase foot quickness, but if you understand the mechanism, you can develop a program just as good on your own. This week we go over the concept of agility, foot quickness, or what it really should be called, motor control.
What is Motor Control?
Motor control is how fast you can stop and start contracting your muscle. Yes, you can strengthen muscles for a little agility, but if you have no motor control, it's like driving a car with no steering wheel or brake pads. When people have a ton of agility, it can be observed by fast foot movement; they are moving their foot fast because they can take short quick steps by starting and stopping quickly. See the video below:
Role of Genetics
Of course with most things in the human body, genetics can be a huge factor in quickness. Genetic factors include length of limb and muscle fiber type. Although this is true, they are not enormous factors, and there are other ways to train. Below are ways to develop a good agility program.
Direction of Movement
Sports are multi-directional so it is important to develop a drill in different directions (linear, lateral, diagonal, etc.). Muscles need to be able to start and stop quickly in different directions by activating certain muscle fibers for each direction.
Magnitude of Range of Motion (ROM)
Sports can be unpredictable so one may have to raise the legs high, or low to ovoid an obstructions, or initiate of movement. For this reason, drills should include sets where you raise your knees higher, or intentionally keep them low.
Precision of Movement
This is perhaps might be the most important part of motor control as it is a direct focus on control of movement. When developing an agility program, one must focus on control during a drill. For example, if one is jumping back and forth laterally over a line, are they just jumping to random spots, or are they staying very close to the line or aiming to go very wide away from the line. With novices, random jumps everywhere are performed. Good program has athletes focus on a certain foot location to develop control.
Equipment for Agility
Below are two common types of equipment used for agility exercises, and how they work.
Resistance Bands - Resistance bands cause the legs to move faster when moving the legs closer to the body. This can help with quickness because the body needs to adapt to this change, and learn how to start and stop the muscle with the new external force.
Additionally, in physics, we know that if resistance is applied farther from the axis of rotation of a lever, it is harder to move the lever. In this case, the axis of rotation is the hip joint, and the lever is the entire leg. This means that the further the resistance band is down the leg/foot, the more difficult it will be to move.
Strength Shoes/Jumpsoles - Jumpsoles or strength shoes are weighted equipment put on the shoe are replace the shoe entirely. These can increase vertical jump and quickness because it keeps you on your toes which can aid in training the Stretch-Shortening Cycle (SSC), but we will go more into that in another post. The main reason it increases quickness is because of what we mentioned above. It adds more resistance to the furthest point of the lever, your leg. This forces you to train your muscles to figure out how fast and how hard it needs to contract to stop your feet to step in a particular spot.
Just like any other training, it is important to properly progress through exercise (simple to advanced) and difficulty (no equipment to equipment). Now that you understand the mechanism, not only can you cut out the mindless marketing of companies, but develop a program for yourself.
You should arch your back. You shouldn't arch your back. Which one is right? As with most things, you have to consider goals and purpose. This week we explain the risk and benefits of the arch.
Flat Back Bench Press
Above is a picture of safe form for the bench press. Although it is referred to as "flat", the spine is actually slightly arched to create a neutral position. you want a slight arch that you can fit a hand under. Below are cues to get the right form:
- Keep the shoulder blades tight and pinched together
- Slight arch in the back
- Hips on the bench
- Arms 45 degrees at the bottom phase to take stress off the shoulder joint (if the bar hits your nipple line, you will be at 45 degrees)
This is safe and the direction of force from the humerus and torso is perpendicular to the torso's alignment.
Arched Back Bench Press
Above is what we mean by arch in the back. Notice the foot position and hip position. This is a good position for powerlifting since the goal is to push as much weight as possible within the proper guidelines on form and rules.
Why can some people lift more like this? The arch turns the traditional flat bench into somewhat of a decline press; the direction of force is LESS than perpendicular from the humerus to the torso. For that reason, there is less distance the bar needs to move if the bar touches the xiphoid process or below. Another aspect that makes lifting with an arch easier is due to the angle of pull. Below is a bell curve explaining that with most free weights, a lift starts easy, gets hard (often when the moving joint is parallel to floor), and then finishes easy as the movement is done. The shorter range of motion means it is easier, but some may still have a "sticking point" elsewhere in the movement due to one's own weakness.
So if the goal is about the maximal amount of weight you can lift while performing a bench press, an arch may be the best way to go, given you practice benching with an arch. This is due to the reasons below:
- Shorter ROM meaning less distance
- Due to shorter ROM, the humerus joint angle is less likely to encounter common sticking point
- Decline press showed the highest EMG (graph showing amount of muscle activation) of the pectoralis major compared to other chest exercises and variations (Bompa & Carrera, 2005). More neuromuscular signal means more strength.
As for the actual cues for the bench press, I myself do not practice this form too much as I do not work with many powerlifters. I often refer them to my good friend Zach Trahan (@zach_trahan or #coachedbytrahan on instagram) for all things powerlifting/strongman. Contacting him or asking me for his contact info would be the better option in my honest opinion.
Of course there can be risks as well. One risk is that it can cause impingement along the backside of the spine due to hyperextension. Anytime you extend your spine, you risk going too far back and actually hurting it; hence we say neutral spine, not extended spine, all the time. The core should be properly trained and angle of arch should be optimal, not as far as can be. A second risk is that some competitions allow hips off the bench (not powerlifting competitions), some let require they stay on (powerlifting competitions). Practice what you are training for; don't get disqualified or lift less weight just because of unfamiliarity of form. Nothing is wrong with the traditional way either.
Each form is okay to do, but should be chosen based on goal and ability to perform each form correctly. The argument whether arch should be used for all athletes is commonly debated, and trainers can always have their own opinion. For non-powerlifting athletes, I opt for the traditional form, but that's just me. To each his own, however everyone should understand the mechanisms behind form and function.
ACSM Resources for the personal trainer 4th edition. (2014).Walters Kluwer.
Baechle, T. R. & Earle, R.W. (2008). Essentials of strength training and conditioning 3rd Edition. Champaign, IL: Human Kinetics.
Bompa, T.O., & Carrera, M.C. (2005). Periodization training for sports 2nd Edition.
Champaign, IL: Human Kinetics.
Resistance training can be very broad. It can mean elastic bands, machines, small dumbells, springs-loaded machines, etc. Those are all great, but at some point, they will build muscle endurance rather than actual strength. Those types definitely won't build definition or the "toned" look most are looking for. Even with all this known, a large amount of the female population choose to stick with that form rather than heavier weights. Here's why more women should lift heavy weights.
What are the benefits?
You've all heard it before; benefits include: higher bone density, muscle mass retention, muscle mass development, more strength, more stability in joints, and more coordination due to neuromuscular activation. So instead, let's focus more on the top 2 concerns with lifting heavy (heavy for this context is considered above 75% of 1-RM).
"I don't want to look bulky"
This is probably the number 1 reason my female clients present, so let's clear it up. Muscle mass development is primarily affected by hormones, one of them being testosterone. In studies where blood was drawn to measure these levels in men and women. Women showed significantly lower levels of testosterone than in men before, during, and after exercise (even during hypertrophy programming). Males actually showed an increase in testosterone during the workouts, whereas women had little to no change. Due to hormones, women will actually have quite a hard time putting on mass. Yes, genetics are different for everyone, so you may still see some females putting on mass easier.
Another reason is their programming. Although the previous studies showed little testosterone and muscle mass change in women during hypertrophy phase, it can still occur. If you do nothing but hypertrophy training for months, then of course you will get bulky. For example, people who are veterans in CrossFit, tend to appear a little more built compared to others because CrossFit follows a hypertrophy model (moderate to high weight, little rest time, high volume). A co-worker and legit Strength and Conditioning Coach suggested never having females on more than 2 weeks of hypertophy; not because it will get them big, but because it can be useless due to low testosterone levels.
So don't be afraid. Lift on with an occasional hypertrophy program, but for the most part strength programming to get optimal benefits through other adaptation methods.
I would rather look "toned"
I hate the word "toned" as much as I hate the word "functional", but I'm not here to get into that. The other main reason females do not want to lift heavy is just the alternative to being bulky. Here's why weights are good for more muscle definition. You may see another guy or girl in the gym that has the nice slim body, but they can hardly lift a 15 pound weight. This is referred to as "skinny-fat". If you continually do high repetition exercise (running, swimming, bodypump, etc.), you will release cortisol, a hormone which actually breaks down muscle protein. You may lose fat from caloric expenditure, but the definition will not be there if there is no muscle.
Doing a balanced program of weights, cardio, and other activities will get you the defined body you want, in addition to following a sound nutrition program. Although this article is aimed to encourage more females to weight lift, a balanced program can benefit everyone.
The holidays are upon us, and many people are looking to get healthy (or healthier), to offset the indulgence during holiday events. Here's our guide to finding a personal trainer, but first we talk about whether the money is worth it.
Is Personal Training Worth It?
Of course it matters how advanced you are, but if you have a few questions about anything fitness, it is definitely worth it. Yes, we are bias as personal trainers ourselves, but all of our clients have left with a lot of information to get going on their own. Personal training can cost between $60 - $140 per sessions, but understand it is an investment. Yes, you may see changes short-term, but you will leave with information and a gameplan that you can use for years on.
Certifications and Qualifications
There are many certifications out there, so make sure your trainer has a cert that is accredited by the NCCA. Personally, we like the ACSM and NSCA certifications best because they offer monthly journals with scholarly research for their members. Their content puts a little more information in physiology as well, which is absolutely important for any trainer to understand. (Check out the ones I personally chose here; the industries top and most evidence-based)
The number one qualification you should look for is a B.S. degree in Kinesiology. A B.S. degree in Kinesiology trumps all certifications because that individual was required to pass college-level courses in programming, physiology, safety, and research. Although there may be great trainers out there without a degree, make sure they have been in business for numerous years. The degree or years of experience (combined with a certification) guarantees the trainer did not just pass 60% of the minimum needed for a certification, but has put the time in to learn about the body and knows the extra steps to continue building their knowledge. The one argument we would have against this is if they are in a niche such as olympic lifting, powerlifting, or bodybuilding. If you specifically want to be good at those things, you should work with those trainers, but continue reading to help you find a good trainer within that niche.
The majority of personal trainers offer these. Yes, this is meant to be a sales pitch, but a great trainer will let their service speak for itself. Do they take the time to get to know your life and your goals? Does their workout focus on your wants, or did they just put you in a workout that is not tailored specifically to you? Do they ask about medical history and past injuries? Do they do legitimate assessments and take down quantitative data? These are all questions you should think about. Go around to different trainers, and try them out free sessions to see if you want to invest your money and time with them.
Anecdotal vs. Scholarly Research
Before I start, let me say that a great trainer should be in great shape. Find someone who practices what they preach. Saying this, a lot of trainers take advantage of their own looks as their marketing.
Pay attention to the language of the trainer. Do they actually understand why adaptation in the body occurs, or do they only show you what to do? These are the trainers that use the word "I" a lot. They will tell you to do something because that's what they do. Everyone is different. A good trainer understands this, and is able to work with all backgrounds (diabetic, obese, post-surgical, etc.) rather than just put together a workout. Great trainers know that scholarly research is tested, whereas anecdotal evidence can be bias.
Do you look forward to training every day? And when we say every day, we mean month after month? A good trainer has you buy into a philosophy that makes you excited about training every workout day. They ensure you avoid burnout, and help you take the right steps outside the gym.
At the end of the day it comes down to results. Are you seeing change? Exercise will make you feel better, but is your trainer showing you quantitative imporvement in body composition and strength? There's 168 hours in a week and you're probably with a trainer maybe 3 hours of that time, so it is up to you, but a great trainer will look at the numbers with you to see where and why things may not go your way.
Lastly, did the trainer set you up with a program that is sustainable? Do you leave your first 1-2 months with enough knowledge to workout on your own? Do they make you eat brown rice, turkey, and broccoli every meal? Do they tell you to stay on supplements your whole life, or can you hit your goals with good nutrition and exercise? You should be able to leave with confidence and independence to enjoy your life while keep in tip top shape for years to come.
Altitude training has been around for awhile. When done correctly, it can increase red blood cell (RBC) count which means better performance due to more oxygen. In order to save you time of traveling to high elevation, companies have released "altitude training masks". These do not work to increase your RBC count, but rather make you tired. They can actually hinder your performance. Here's the science simplified:
Is There Less Oxygen Up High?
First of all, let's dismiss the myth of there being less oxygen at higher elevations. There is less pressure in higher elevation which just makes it harder for oxygen to move into the blood stream. So in short, in higher altitudes there is the same amount of oxygen, but less pressure to allow the same amount of oxygen to bind to RBCs.
How is Oxygen Important?
Oxygen is needed in order for muscles to function and energy to be maintained during exercise. RBC's have the ability to bind oxygen to themselves, and distributes the oxygen to muscles through capillaries. You breathe more/harder during exercise because your muscles need more oxygen to perform at a higher intensity.
Live High; Train Low
Now that you know what oxygen does, and what happens at higher elevation, let's talk about training. Because oxygen has a more difficult time binding to RBC's, your muscles can not function due to the lack of sufficient oxygen. If you were to go up high, you would become tired faster, and simply won't be able to perform at the level you could in lower elevation. How do you train properly?
We know that the body will adapt to even things out. The best way is to stay a few days or weeks up in higher elevation, then train. By that time, your body will have adapted to create more RBCs so that more oxygen can bind (diagram below). After your body has adapted, you can train at your normal intensity in the higher elevation. Even better, you could return to lower elevation to perform better (explained in the diagram below).
Why Elevation Masks Don't Work
Elevation masks restrict your oxygen. If your muscles do no get enough oxygen, you won't perform well. wearing could possbily mean you're only able to perform at 80%, but if you're tired and training at 80%, how will you get better? Even if you wanted to have the same adaptation as altitude training you would need to wear the mask for days or weeks. All it's good for is some form of torture or to look really intense in the gym (but not really).
That's the mechanism to altitude training, and that's how those altitude masks work (or don;t work). Let us know if you have any questions!
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