What is the Minimal Effective Dose of Exercise? A guest blog by Marcus Blumensaat

So it’s been a while since I’ve blogged and even longer since I’ve had a guest blogger on The Sports Physio. However, I am really pleased to introduce you all to Marcus Blumensaat who has done an awesome post on that tricky and elusive question of… how much exercise is enough?

Why do we even care to know?

Many people do not like to exercise. At all. They do not want to perform exercises even if they have been told by a health care professional that it will help them to recover, heal or rehabilitate an ‘injury’.  In my opinion, getting people to perform their prescribed exercises is one of, if not the most, challenging things we face as musculoskeletal (MSK) health care practitioners. 

Many people don’t even meet public health exercise recommendations that have been shown to decrease all-cause mortality by 40%.1 40%!!! I suppose they are on the ‘we are here for a good time, not a long time’ train. Fair enough, I have been on and off that train many times. I usually buy a ticket when a freshly baked chocolate chip cookie is in front of me.

Back to the clinical setting… if a person is seeking our help and we have employed our critical thinking in a biopsychosocial (BPS) framework and have determined that the performance of exercise would be beneficial to the case at hand, the answer to this question, ‘what is the minimal effective dose?’, is very important indeed.

If we knew the minimum effective dosage of exercise, one would assume that we would increase the odds of the people we are working with actually performing the prescribed exercise(s). With the end result being better clinical outcomes, i.e., happier, healthier people!

Thus, it would be to everyone’s advantage if we could figure out what the minimal effective dose of exercise is for different pathologies and pain. Simple.


Like most questions in the MSK world regarding pathologies, pain, and rehabilitation, this one of ‘what is the minimal effective dose of exercise?’ is shrouded in uncertainty.  

If one exercises (pun intended) their critical thinking skills when contemplating this question, it should become obvious that there are a few details that need to be clarified before trying to come up with an answer.

Most importantly, what is the desired ‘outcome’ or ‘effect’ that you are trying to stimulate in the person by having them perform the prescribed exercise? In other words, what are you hoping to accomplish by having the person perform the exercise? 

Are you hoping to change their ‘capacity’ in some way to better handle the loads* that they face in life? Perhaps the goal is an increase in strength or range of motion.

* Load is the burden (single or multiple mechanical, psychological, or social stressors) that is applied to a human biological system (including subcellular elements, a single cell, tissues, one or more multiple organ systems, or the individual).2

Are you trying to decrease someone’s fear of movement (kinesiophobia) or increase someone’s confidence in using their body?

Are you trying to help them improve their mental health? Perhaps attempting to help decrease their stress levels or symptoms of anxiety or depression?

Are you trying to alter their pain experience? Help to decrease their self-reported level of pain?

Or are you trying to stimulate mechanotransduction in tissues thought to be in need of morphological or structural change?

Reflecting on and having a clear understanding of what you are trying to accomplish by having someone perform a certain exercise, will drastically affect not only your choice of exercise but also the variables (frequency, intensity, volume, rest) of your exercise prescription.

The ‘minimal effective dose’ will look very different for each of the above-mentioned ‘goals’ or desired ’outcomes’.

When it comes to strength and other physiological ‘capacities’, I would like to say that there is some certainty around the prescription variables to stimulate adaptations; but, even in this realm, there is new research coming to light that questions our old beliefs.

Strength & Conditioning

There are many components of physical fitness we could talk about, strength, power, aerobic capacity, aerobic power, anaerobic power, range of motion, etc. I would like to keep this blog focused more on pathology and pain so we will only briefly discuss the strength and conditioning (S&C) realm.

Many of these components of physical ‘capacity’ have generally accepted ‘minimal effective doses’ to stimulate desired adaptations at a population level. However, even some of these long-held beliefs are being challenged by studies and systematic reviews that have recently been published.

For instance, there was a great review3 that looked at the traditional ‘repetition continuum’ (Figure 1) which postulates that heavy load training optimizes/increases maximal strength, moderate load training optimizes/increases muscle hypertrophy, and low-load training optimizes/increases local muscular endurance.

Figure 1. Old repetition continuum. (Schoenfeld et al. 2021)

Based on emerging evidence, the authors proposed a new paradigm whereby muscular adaptations can be obtained, and in some cases optimized, across a wide spectrum of loading zones (Figure 2). So, in some instances, it is not necessary to expose someone to as heavy loads as once thought to stimulate change.

This is especially true for stimulating muscle hypertrophy where the literature indicates that similar whole muscle growth (i.e., muscle thickness, cross-sectional area) can be achieved across a wide spectrum of loading ranges ~30% 1 Repetition Maximum (RM).

Figure 2. Emerging evidence that contradicts the old ‘repetition continuum’. (Schoenfeld et al., 2021)

More recently, a randomized controlled trial was performed that compared moderate load (70% 1RM) with low load (30% 1RM) and measured lean body mass (LBM), 1RM strength and Fat Mass Loss after twelve weeks. Their study showed that twelve weeks of high-intensity functional training with either low or moderate loads resulted in an equal increase in LBM and 1-RM strength (Figure 3).4

Figure 3. Low loads resulted in equal increases in measure outcomes versus high loads. (Kapsis et al., 2022)

So it seems the minimal effective dose may be lower than what we thought in the past.

These new findings have major implications for clinical practice as it is much easier to implement lower load exercises with people than heavier loads. Oftentimes people don’t have access to the equipment necessary to perform the heavier loads. Some people are scared that they are going to hurt themselves with the heavier loads.  Some clinicians are scared that they are going to hurt people with such heavy loads.

From a practicality standpoint, anytime I see a randomized controlled trial (RCT) or systematic review (SR) that shows we can be effective with lower ‘loads’ than previously thought, I am stoked, do some fist pumps, and eat another chocolate chip cookie.

Ingesting cookies is one way to get a mental lift, exercise is another.


Exercise has long been shown to have positive effects on mental health.5 In an MSK clinical setting, decreasing someone’s anxiety or depression will not usually be one of your primary goals; however, decreasing someone’s fear around movement and their associated fear-avoidant behaviours is a common goal you may prioritize.

Graded exposure to feared movements is a fantastic approach to decrease fear around them. The exercise prescription for graded exposure to reduce fear will look vastly different than for S&C purposes as you are trying to create psychological changes versus physical changes.

One thing that you would want to be mindful of is not creating a pain flare as this could further exacerbate the fear-avoidant behaviour and unhelpful beliefs around movement that the person already possesses. In these cases, it would be incredibly important to start at a very minimal dose that is easily tolerated. Let the person experience that they can perform a version of the feared movement with no repercussions. This helps reduce their negative expectations and can start to create new, positive expectations around the feared movements.

“Reassurance is a bloody good pain killer”

Louis Gifford

I believe that experienced physical reassurance is more powerful than verbal reassurance. In other words, a person is far more likely to have less fear and more confidence around feared movements if they experience they are safe when performing them versus being told that they are safe to perform them.

Simply begin at a tolerable dose for the individual and gradually progress. This initial, tolerable dose will usually be much less than the dose required to stimulate the physical changes that you would be looking for in an S&C setting or even in a clinical setting when trying to stimulate mechanotransduction of some sort.  


When it comes to pathologies we see in the clinic, there are some accepted minimal effective doses for exercise prescription, but they too continue to evolve and change. Let us look at a couple of the most common conditions that we see in a clinical setting – tendinopathy and OA. 

It is widely accepted that progressive tendon loading programs are the most effective conservative approach in the treatment of tendinopathy.6 Traditionally it was thought that to effect change in tendons you had to use heavy loads (70% 1RM). A recent study showed that in fact, you may not have to.

In a recent RCT it was found that there was no superior effect of exercising with a high load (90% 1RM) magnitude compared with a moderate load (55% 1RM) magnitude for the clinical outcome, tendon structure, or tendon function in the treatment of patellar tendinopathy.7

Regarding OA, a recent study looked at high-intensity strength training versus low-intensity strength training versus an attention control group (received 60 min educational workshops biweekly for 6 months and monthly thereafter). There was not a significant difference in self-reported pain between the three groups of subjects. In other words, low-intensity training was just as effective at decreasing self-reported pain in individuals with knee OA as high-intensity training.8

What is fascinating from this study is the group who did not perform strength training and only participated in regular educational workshops did equally as well as the two exercise groups!

Perhaps we are seeing the power of high-quality patient ‘education’ at play here?! In my opinion, we can often have a more powerful effect on clinical outcomes with the ‘education’ that we deliver versus any exercise prescription or passive therapy that we perform.

Often, ruling out red flags, reassuring the person (when indicated), encouraging the resumption of meaningful/valued activities at a tolerable level, and letting natural history do its thing is all we need to do to see successful clinical outcomes!

Just so that my movement optimism bias isn’t getting worried, I think it is worth clarifying that there is a copious amount of research showing that exercise of all types, including strength training, benefits those with OA and is a primary recommendation in clinical practice guidelines.9-13

It should be noted that there is not a significant difference in effect between the different types of land-based exercise interventions.14 The most beneficial exercise is probably just the one that the person is actually going to perform!


First off, let’s get on the same page regarding pain. I will assume that those of you reading this blog understand that pain is multifactorial (Figure 4) and rarely mediated by only one ‘thing’.

Even when we are talking about someone who has had a trauma, such as falling off a ladder, their resultant self-reported pain levels are affected by numerous factors. Things such as previous experiences, beliefs, emotional factors (stress, fear, anxiety, etc.), and quality of sleep, to name but a few.

Figure 4. Multifactorial nature of pain and other outcomes. (Cholewicki et al, 2021)

Though we know that exercise helps reduce self-reported pain16, we do not know how it does this.

Pain is so multifactorial, and the concurrent effects of exercise are so numerous, that the potential combinations of ways that exercise could decrease pain are nearly infinite. I believe that it is a little presumptuous for us to think that we can explain the physiological and psychological mechanisms simultaneously occurring during exercise and exactly how those mechanisms are decreasing pain in an individual.

On any given day, exercise probably decreases pain in different ways in each individual case due to ever-changing contextual factors. Exercise also probably decreases pain in different ways from individual to individual due to the heterogeneity of the biopsychosocial factors in each person’s life. 

In relation to this, there are many unknowns when it comes to the minimal effective dose of exercise to reduce pain.

In my opinion, there is not, and there may never be, an exact ‘recipe’ that exists for the minimal effective dose of exercise.

Although there is a significant amount of evidence in the literature suggesting exercise as an efficacious modality for the treatment of chronic pain, there is virtually no knowledge of the appropriate dose of exercise for a given disease or patient type.16

At the centre of this uncertainty, is the uniqueness of each human being.

N = 1 → Person-Centred Care

The minimal effective dose of exercise depends not only on what you are trying to accomplish but also on who the person in front of you is. Randomized Controlled Trials (RCTs) and Systematic Reviews (SRs) show us population-level data, but we are attempting to use that data to help guide our care of individuals that we see in a clinical setting.

In the clinical setting n=1.

A dose that is effective for one person may not be effective for another person.

What may be enough of a dose to change someone’s fear around a movement, may not be enough to change another person’s fear around the same movement.

A dose that is effective for reducing someone’s knee pain related to OA may not be effective for someone else who is suffering from knee pain related to OA.

For that matter, a dose that is effective for a person on Tuesday may not be effective for the same person on Friday!!!

Simplifying with a Person-Centred, Macro Persepective Approach in a Biopsychosocial Framework

Yes, the irony of the above heading was intended.

I believe we often overcomplicate things by trying to figure out specific recipes of sets, reps, intensity, duration, and frequency when prescribing exercise to simulate a change in physical ‘capacities’ or stimulate mechanotransduction. If we simply revisit the most basic principles of human physiology, it may allow us to simplify our approach.

The Overload Principle states that cells, tissues, organs, and systems adapt to loads that exceed what they are normally required to do. While the Specificity Principle states that overload results in adaptations specific to those cells, tissues, organs, or systems that have been overloaded.

You simply need to prescribe exercise at a level that is more than the person is currently adapted to and you will be stimulating adaptations.

This is an n=1 approach that accounts for individual heterogeneity in the population. The person who is performing the exercise simply needs to feel like it is difficult, challenging and is harder than other things that they are currently doing in their life. 

This last point is very important. Though I have cited a couple of studies that have shown you can often be effective with a smaller dose than was once thought necessary, I feel that we often are under-loading people with our exercise prescription dosages.

By considering all the demands in a person’s life, you may realize that the exercise dosage you have prescribed is not harder than many other tasks that they must perform in life with the same tissues. Thus, you probably are not stimulating the adaptations that you are hoping to.

If you and the people you are working with are not seeing the changes that were hoped for, increasing the dosage would be one of the first things that you should consider doing.

I believe a person-centred approach is even more important when the primary goal of the exercise prescription is to help improve someone’s mental health, or to reduce their pain or kinesiophobia.

There is so much more uncertainty with these outcomes due to the increased involvement of psychological factors relative to cases where a physical change is the main outcome being measured.

Knowing the person in front of you will help you to better tailor your exercise prescription. Are they timid, fearful, anxious, depressed? Are they confident, happy, or resilient?

Do they have past experiences with pain, with pain in this region of their body? Has someone close to them experienced similar pain? Do they persist through pain? Or do they avoid feeling pain?

Do they have support? Do they want to change? Is pain a major part of their identity?

The reason that finding a minimal effective dose of exercise is so difficult is that we are all so different. The answers to the above questions, as well as to numerous other relevant questions, will be vastly different for each person we see in our clinics.

Summing Up

Let’s just have a little fun and say that we figure out the minimal effective dose for the person in front of us. Now the real challenge is having them perform the frickin exercises!!!

To me, this is the biggest challenge in prescribing exercise and/or movement in the health care setting. Earlier this year, I wrote a blog in which I touched on some strategies to help increase adherence to prescribed exercises. You can prescribe the perfect exercise at the perfect dose, but it doesn’t matter if the person does not perform it.  

I digress…this blog may not have provided any concrete answers to ‘what is the minimal effective dose of exercise?’, but I hope that it got your cogs rotating (your upstairs cogs that is) on some of the pertinent topics surrounding exercise dosage in MSK health care.

It also stroked my movement optimism bias, touching on some of the different ways that exercise can stimulate positive changes in people’s lives.

Delving deeper into this topic reinforced to me the importance of n=1 in the clinical setting. In my opinion, it is so vitally important to work in a person-centred manner.

Who is the person in front of you? Where are they? And where do they want to be? The answers to these questions can help the two of you collaborate and determine a starting point of what to do, and how much, how often, and how intensely to do it. From there, it is a process of trial and error, re-evaluating and modifying according to the person’s reaction to the initial prescription.

Though we may not know with certainty what the minimal effective dose is, I hope that we continue to encourage people to move more and challenge themselves physically because there are so many primary and secondary benefits associated with movement. As I like to say, “Every move counts.” And as a wise man once said…

“You can’t go wrong, getting strong.”

Adam Meakins

Marcus Blumensaat


Twitter: @Blumensaat

Instagram: @marcusblumensaat

Facebook: @mb.clinicaleducation


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  8. Messier, S. P., Mihalko, S. L., Beavers, D. P., Nicklas, B. J., DeVita, P., Carr, J. J., Hunter, D. J., Lyles, M., Guermazi, A., Bennell, K. L., & Loeser, R. F. (2021). Effect of High-Intensity Strength Training on Knee Pain and Knee Joint Compressive Forces Among Adults With Knee Osteoarthritis: The START Randomized Clinical Trial. JAMA, 325(7), 646–657. https://doi.org/10.1001/jama.2021.0411
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Big Fat Lies!

a 5-minute read

Have you heard people say that being overweight is a choice? Or that it’s just about calories in versus calories out? Well, misinformed statements like this are often said by those with little understanding or recognition of the complex and multifactorial nature of obesity and are just… big fat lies!

As someone who has struggled with my own weight from a young age and who was bullied for being the ‘fat kid’, I’ve had a personal interest in weight management for as long as I can remember. In fact, I think it’s one of the reasons why I entered healthcare and why I’m such a strong advocate for exercise, having found it to be the best way to control my own weight after trying and failing many other methods.

Me at 16 years old, and nearly 16 stone… and no that cake didn’t stand a chance

Although exercise has, and still does help me manage my own weight I know it’s not the answer for everyone, and I have slowly come to understand that weight management is a complex and complicated topic that goes far beyond just exercise and calories. Unfortunately, many healthcare and fitness professionals have not and many still believe that being overweight is a simple condition brought on by choosing to eat too much and exercise too little.

Calories In / Calories Out

This is bullshit, in fact, if I hear another fitness professional say ‘calories in v’s calories out’ without any context I think I will drop kick them in their fart box, because although in principle this sounds accurate and simple, it’s just not this simple or accurate. The causes of weight gain and obesity are in fact far more complex than just ‘calories in calories out’ involving physiology, psychology, and sociology.

Saying obesity is as simple as calories in versus calories out is no different than saying poverty is as simple as money in versus money out, or depression is simply happiness in versus sadness out! I think we can all agree that no-one chooses to be depressed or poor so why is it any different for obesity?

In the late 1990s, obesity was classed by the World Health Organisation as a global pandemic due to the direct links it has to increases in many other diseases such as diabetes, hypertension, cardiovascular disease, osteoarthritis, some forms of cancer, and mental health issues such as depression (ref).

There is still much debate around if obesity should be considered a ‘disease’. But when you consider a disease is defined as…

  • A condition that impairs function and reduces life expectancy
  • A condition that leaves an individual more susceptible to other diseases
  • A genetic impairment that leads to other functional impairment

Obesity checks all of these, even the last one! Yes obesity is a genetic impairment. There is now some strong evidence that shows obesity is dictated a lot by genetic factors as demonstrated in multiple identical twin studies, done in multiple countries, on various different aged individuals (ref).

It is also known that genetic variations can increase an individuals propensity to obesity such as leptin and POM-C receptor deficiencies (ref, ref). Our genes play an important role in how we all respond differently to the foods we eat, the number of calories we consume, and the environments we consume them in.

For example, have you ever wondered why two people who eating the same types and amounts of food often have completely different weights and body fat percentages? Well an interesting study conducted on 12 pairs of identical twins closely monitored the affects of overfeeding them by 1000 calories a day, everyday, for 100 days, and found weight gains were very similar for each twin, but varied hugely between the pairs of twins from 4kg to 13kg (ref).

This clearly shows how genetics has a role in determining how much weight is gained based on the calories consumed. There have also been a number of studies that looked into the effects of genetics on weight gain in rats to try and see if they could find any more answers.

Fat Rats

In one study 100 rats were all fed the same high-calorie diet for a few months. Again they got a lot of variation in amounts of weight gained by the rats, with a bell shape curve with a few of the rats not putting on any weight at all, a few rats putting on huge amounts of weight, and most of the other rats falling somewhere in between (ref).

Now the interesting part with this study is they then took the rats from this trial who didn’t put on any weight and bred them together, as well as taking the rats who put on the most weight in the trial and bred them together. And after a few rounds of breeding these different weight gaining rats they got two very different types of rat.

In the first group of rats they got offspring who were very diet-resistant, that is rats whose weight did NOT increase when they over-consumed calories. However, in the other group of rats they got obesity-prone offspring who gained weight very quickly and very easily with overconsumption of calories.

What’s also interesting is that if you take these obesity-prone rats and place them on a low-calorie diet they lost weight, but as soon as their calories were returned back to normal baseline amount their weight quickly returned back to their starting obese weight, even though they were not over consuming calories. Meaning you can get an obese prone rat to lose weight, but unless you keep it on low calories forever its inherent nature is to be an obese rat.

The same thing most likely applies to humans. If you were to take a thousand children and weigh them, their weight will also be distributed in a bell-shaped curve. Some skinny kids, some kids in the middle, and some overweight kids. Some of the skinny kids will remain skinny throughout their life, and some of the obese kids will stay obese throughout life, meaning you could argue that their weight, to some degree, is predetermined.

Now, of course, it’s not just this simple as humans have had the same genes for 100’s if not 1000’s of years, and it’s only recently that obesity has become a bigger problem, so how do we explain this? Well, the obvious answer is the sudden increase in the easy access to very calorie-rich food.

It is now extremely easy to eat your entire daily quota of calories in a single meal that doesn’t cost much and doesn’t leave you satisfied for long. High-calorific meals full of calories dense corn starches and sugars, not to mention sugary drinks and alcohol that can contain 100’s if not 1000’s of calories without providing much satiety mean we over-consume really easily.

Although our genes play a big role in our weight, our environment also plays a huge role too. The readily available abundance of calories in many modern lifestyles is a relatively ‘new thing’ in human evolution, and it appears our genes haven’t quite managed to adapt and it’s not certain if they ever will.

In our history, genetic selection has prepared and equipped us much better for famine rather than feast, and for good reason. Food used to be scarce and infrequent, and periods of starvation were common throughout human history. Obviously, this was difficult and unpleasant to deal with, but is the opposite scenario we now face any better?

So if obesity is a disease the question we need to ask, just like we would for any other disease, is how can we prevent, treat, or even cure it? Well just like any complex disease there will not be any one single simple quick fix or solution. However, one interesting area that could hold a lot of potential is how our neurophysiology can affect our behaviour.

Fat Hormones?

A neurotransmitter called GLP-1 has been shown to affect nerve cells that control whether we feel full or not, and so dictate if we eat or not, and GLP-1 has been found in both our brains and our guts literally allowing them to ‘speak’ to each other (ref). Research has shown that if you increase levels of GLP-1 your desire to eat is significantly reduced and even halted, acting a bit like the full signal on your cars fuel tank and although more work is needed there are some promising results here (ref)

Of course, GLP-1 or any one neurotransmitter in isolation is not the whole answer to obesity and there are numerous other avenues of research into physiology, psychology, and behaviour change needed, not to mention a huge shift in governmental and societal approaches and beliefs to food and weight management. However, research like this does give us some insight into the complexity of obesity and some hope that there are solutions for this growing pandemic.

Moving forward we all have to recognise that if anyone wants to loose some weight they often have to change their behaviour but also their environment to do this, which isn’t always easy or possible to do. However, if we want to change a populations weight then its essential that we all change the environment so that it is suitable and conducive to weight lose for everyone, and not just for those in privilege!

Lose some weight, lose some pain

Personally I think a lot more healthcare and fitness professionals need to be much better educated into the complexity of obesity, and far better educated and equipped to help and support those with it. A recent paper has highlighted how obesity is highly prevalent in chronic pain populations, and as a physio, I have found helping some people lose some weight can be a great way to help them lose some pain (ref).

Not only does losing weight decrease some of the physical and mechanical loads on our bodies which may be sensitive or irritated, but it can also, and probably more so, help to lower systematic inflammation levels and improve a host of other metabolic and neuroimmune functions.

More importantly, I think helping someone in chronic pain lose some weight by helping them find some strategies that work for them in their current situation, can help improve their confidence and self-efficacy which can in turn, help them gain control and ownership over many other aspects of their lives which may help mediate their pain.

Again, I am not going to say this is simple or easy to do, but from my own personal experience I know how much better I felt once I gained control over my own weight, and I think many others will do too.

As always, thanks for reading


Same Shit, Different Treatment

A 4 minute read

Do people with the same musculoskeletal diagnosis need the same treatment to get better? Do those with tendinopathy always need to load it? Do those with chronic low back pain always need pain education or spinal manipulation? Well, the simple answer is no, but also yes! Confused? So am I… so let me try to expand a bit more.

The topic of using standardised evidence-based treatments and protocols for specific pathologies and diagnoses in musculoskeletal physiotherapy is something I have always been interested in. But I have been thinking about it more recently due to the growing research that highlights there is very little difference in outcomes with different treatments for individuals with similar problems or pathologies (ref, ref, ref).


This is also true when our physio treatments are occasionally compared to shams or placebos, with research again often finding very little difference in outcomes (ref, ref, ref).  Now, I don’t want to get too nihilistic or despondent here but the awkward and uncomfortable truth for musculoskeletal physiotherapy is that a lot of its treatments just don’t seem to do much over and above placebo, time, and natural history, be that massage or manipulations, needles, tapes, suction cups, scrappy tools or electro machines that go bing.

This is also true for our exercise-based treatments, be that simple strengthening, stretching, or mobilising exercises, even the overly complicated motor control corrective exercise claptrap. They all seem to do very similar things for most people with similar problems and pathologies, and that is they don’t do much more than distract people in pain whilst natural history kicks in (ref).

So this has left me wondering if it really matters that much in the big ol’ grand scheme of things what the hell us physios get our patients doing if it all has similar effects and is all not that much better than doing nothing? Does it really matter if someone with back pain gets spinal manipulations or deadlifts? Does it really matter if someone with patellofemoral knee pain gets k-tape or glute exercises?

Well, again yes it does and no it doesn’t! Still confused… well hold on a bit longer and I will try and clarify soon!


Since physiotherapy began to research and investigate what it does there has been a slow shift towards using evidence-based interventions, and I mean a really slooooow shift… think glacial speeds. Anyway, this slow adoption of evidence-based treatments has thankfully meant a reduction in less effective treatments and outright woo and quackery being used within the profession. But it also means more people with similar diagnoses are now given similar looking treatments and protocols.

A classic scenario here is someone with Achilles tendinopathy. Ten years ago, they would have had a wide range of treatments from tendon friction massages, calf muscle massages, taping, acupuncture, therapeutic ultrasound, as well as a range of stretches and exercises of the lower leg, and other areas to address so-called dysfunctional movements thought to have caused the pathology.

However, since more research has been conducted into Achilles tendinopathy most are now simply given advice, load management, and specific exercises to load the tendon. Often these exercises are slow, heavy, eccentric, types of exercise to reflect those used in the well-known research trials.

Now don’t get me wrong, I think the removal of the wasteful and outdated treatments is great, I mean friction massages were a bugger for my fingers and thumbs. But, where I think this adoption of evidence based practice is not such a good thing is when treatments are limited to only what the research trials did.


Limiting our clinical treatments to exactly replicate what was conducted in research trials fails to recognise an individual’s response to an evidence-based treatment. Only using one particular type, style, or dose of treatment based on a research trial protocol is a failure of evidence-based practice and sound clinical reasoning.

It’s important to remember that a lot of research trials report their findings as an ‘average effect size’. This is often presented with ‘confidence intervals’ to show the spread of that effect over 95% of the subjects in that trial, meaning in very simplistic and not totally accurate terms, the smaller or bigger the spread of the confidence intervals, the smaller or bigger the variation in that treatment’s effects.

Often what happens in research trials is a few individuals get an amazing response from the treatment, some get a good result, others average, some only have minimal effects, and a few get negative and adverse responses. The reasons for this variation are complex and uncertain but often it’s due to differences in subjects’ characteristics such as their health, culture, concerns, beliefs, past experiences, occupational and/or social status.

It can also be due to variations in the clinicians or researchers characteristics who are conducting the trial, such as their training, experience, beliefs, and biases as well. And finally, it can also be due to differences in the application or administering of the treatment such as variations in setting, location, instructions, level of compliance, and timing of the outcome measurement.

All these differences in patient, clinician, and intervention characteristics are termed ‘clinical heterogeneity’ and they all have the potential to significantly confound research results which can lead to inaccurate conclusions being drawn about what does and doesn’t work, and why, and for who. Currently, a lot of healthcare research does a poor job at recognising and/or controlling for clinical heterogeneity and as a consequence, this can and does affect the results and conclusions often made (ref).


Now before some of you rush down to the comments section to tell me “Science is broken” or “I don’t need research to tell me what treatments work” just stop because I am not saying research can’t tell us what treatments do or do not help people. I am just highlighting that often there is a lot of uncertainty in the how much, the why, and the who they can or cannot help.

I am also not saying that we should suddenly ignore research or abandon the scientific method of investigating our treatments, going back to our clinical observations which have consistently been shown to be unreliable and full of biases (ref). What I am saying is that we should recognise the variations in responses to our evidence-based treatments and be more flexible and less specific and constrained in our prescriptions and application of them.

This however is not a green light to go wild and totally off-piste from research-based guidelines, rather to consider tinkering and tailoring with evidence-based treatment parameters and prescriptions more to fit the individual in front of you or based on their response.

Just because one particular type, method, or dose of exercise or even manual therapy has been shown to help individuals with a particular problem or pathology in a randomised controlled trial, this doesn’t mean it helps everyone equally. This means you don’t have to use the same treatments for all people with the same diagnosis, and you can fiddle and adjust the settings, parameters, dosages, and application of a treatment when in the clinic to suit your patients response or situation.


  • Friction massages suck ass… stop doing them!
  • Research isn’t perfect but it’s the best method we have to work out what may or may not help our patients, so embrace it!
  • Look at the effect size of a treatment to get an idea of how much it may help your patients… but don’t get too excited!
  • Look at the confidence intervals to get an idea of how much variation there may be in that effect!
  • Look at the subjects in the trial and consider if they reflect your patients.
  • Be more flexible in your prescription and application of evidence-based treatments
  • Remember there’s always an individual response buried within a mean effect.

As always thanks for reading


Keeping Your Mojo Strong!

There is no denying that trying to keep focused and motivated on something that is hard, effortful, and tough to do can be really challenging and difficult over extended periods of time. That’s especially true with exercise and especially true during the holiday and festive seasons with lots more distractions, diversions, and interruptions to our normal daily lives and schedules.

Having struggled to engage in regular exercise throughout my life I know how easy it can be to get distracted and sidelined from it at any time but even more so during the holiday periods. So I thought I would share some of my tips and tactics I have found helped keep me going when it felt like everything around me was trying to get me to stop.

Tip No 1: Don’t Hit The ‘Fuck It Button’

It’s important to recognise that life is full of ups and downs, easy patches and tough times and so there will be many times when we have to prioritise what we do and when we do it. Now, no matter how much drive, enthusiasm, passion and commitment you have to exercise, no matter how focused, determined or bloody-minded you are to exercise, there will be times when other things will get in the way of exercising regularly.

When this happens it’s important NOT to hit what I call the ‘fuck it button’ in our minds. This ‘fuck it button’ is our innate tendency to cancel and write off all our plans and goals when we encounter a temporary setback or small change in our best-made plans.

This happens a lot with exercise and training schedules when we miss a workout or run. Instead of just accepting it and moving on to tomorrow, we hit the ‘fuck it button’ and decide to write the whole week of training off, which then because we’ve missed a whole weeks training we decide to cancel the rest of the month, and very easily one missed run or workout can soon turn into… “well I might as well not bother at all now.”

When something does happen and you miss a workout for whatever reason it’s important to not blame off yourself, which is easier said than done. I know that when I haven’t been able to exercise due to my workload or other personal commitments I often feel guilty and ashamed, thinking I should have done it if I really wanted to. However, I have recognised that at times other things have greater priority and importance to me than exercise and so now I am better at accepting missing a few sessions now and then.

As important as regular exercise is, it’s simply should not be the only thing that has importance in our lives. Missing a few workouts or runs now and then has very little effect on our health, strength, endurance in the grand scheme of things, and as long as we don’t hit the ‘fuck it button’ when we do miss a workout or run now and then and get back to it when we can then missing exercise now and then is ok.

Tip No 2: Focus On The Journey

Having goals with all types of exercise is great, but often they are not the best way to keep you exercising for life. For example, let’s say you want to exercises to lose 10-20lbs in weight, or add another 10-20kg to your squat, or even run 5K in under 20 minutes. You work hard for 3-6 months and achieve this goal… great stuff… job well done… but now what… sub 18 minute 5K, another 20kg or 20lbs?

Well yes possibly adding more goals after you achieve your original one can be useful, but I have learnt over many years of exercising and making many goals that when you achieve them it’s very easy to get lost and distracted unless you have learnt to appreciate and understand the processes of how you achieved those goals.

For me losing 20lbs in weight is not as important as developing the skills, knowledge, and discipline of knowing, tracking, and monitoring your weekly calories and macros. For me adding another 20kg to your back squat is not as impressive as learning how to progress and regress the volume and intensity of a training schedule to achieve it over a couple of months.

Without understanding, appreciating, and focusing on the skills and knowledge needed to achieve goals with exercise you will soon find yourself lost when you do achieve them.

Tip No 3: Surround Yourself With Like Minded People

Personally, I think humans are way too tribal and all too often sit in their segregated groups nodding and agreeing with each other and hating on any others who act, think, and even look differently to themselves. This group mentally is an unfortunate but normal part of our human nature and we all do this, myself included, but I think it’s getting worse and causing more and more issues and more and more problems in the world, increasing ignorance, prejudice and hate as a consequence.

However, when it comes to exercise I do think it’s vital for you to go and find your tribe, your clan, your inner circle and immerse yourself as deep as you can inside it. If you want to stay motivated, encouraged and committed to regular exercise surrounding yourself with like-minded people and having a strong support group helps immensely.

Whether that’s a running club, a CrossFit box, a gym, a Facebook group or a forum it doesn’t matter, just go and find those who share your interest, curiosity, passion, and drive for what you want to do and let them help and shield you from all the negativity, criticism, and bullshit that often surrounds all types of exercise. There is nothing worse than seeing people trying to exercise regularly being put off by some hateful trolls on the internet, or some bellend telling them they are doing it all wrong or that it’s not the best type.

Despite many claims made there is NO one type of exercise that will suit EVERYONE nor should it. Exercise just like humans comes in all shapes and sizes and so there is a type of exercise out there to suit everyone, you just need to find it and stick with it. And as much as I have my own biases and preferences when it comes to exercise I know that ALL exercise is great and no type is more superior to another… except maybe for squats and deadlifts!

I’m only joking… kinda!

Tip No 4: Keep It Fun

A favourite saying of mine is ‘when shit is fun, shit gets done’. There is no doubt that fun things get done more often than boring things and this definitely applies to exercise. Dragging yourself through something you loathe and hate just won’t last long, doing something you enjoy and value will.

Now don’t get me wrong I don’t think exercise has to make you skip around like a butterfly in a daisy field with your heart singing, in fact, I would argue exercise shouldn’t feel fun most of the time when doing it. For exercise to be beneficial it simply has to be challenging, difficult, intense and hard work and this just doesn’t feel pleasant, nice, or fun, in fact, it can feel downright horrible and nasty.

Many confuse and conflate exercise with physical activity when in fact they are two very distinct and different things, and both have benefits, and both should be done regularly. Physical activity, which is just simply unstructured physical movement such as walking, gardening, doing housework and other chores etc doesn’t have to be effortful, intense, or hard work, exercise does!

However, if you can learn to love the effort and learn to embrace the suck during tough, difficult, and intense exercise it does make doing it regularly easier. One way to do this is to find meaning in what you’re doing, not just when you’re doing it.

For example, I always question my reasons for running when I’m actually running and my lungs are burning and legs are throbbing. But when I stop and feel a sense of achievement of having run a few miles as well as now being able to have that extra portion of pie without feeling guilty and still able to maintain my bodyweight that’s when I really value running.

Tip No 5: Keep It Varied

Another favourite saying of mine is ‘don’t keep doing the same thing and expect to get different results’. This applies to so many things in life but especially to exercise. Now there is no doubt that focusing on one type of exercise can and does make you better at it, and if that’s what you want to do then I suggest you do that.

But unless you have dreams, aspirations and plans to become a world champion in a specific type of exercise there is no need to ONLY do that exercise. And I would still argue even if you are planning to be a world champion in something there is still room for doing some other stuff.

Doing various different types of exercise can keep you mentally engaged, interested and motivated but also can help you physically as well. Our bodies are very good at adapting to the stimuli we apply to them, but if that stimulus becomes consistent and regular it can lose its effect.

Giving our bodies and minds different stimuli from time to time can be a bit of a shock and feel uncomfortable but it can also help keep us adapting and progressing in many other ways. So if you are a runner, do some weights or go for a swim now and then. If you are a weight lifter, do some yoga or tai-chi now and then, and if you are a professional kickboxer… well you sir can just do whatever the hell you like!

My point here however is very simple… exercise variety is the spice of life… and the source of happy healthy bodies


So there you go a few tips on how you can keep your mojo strong when trying to exercise for life. I will say however that sometimes all the tips in the world just won’t help you and at times we just have to suck it up and grind it out. Life can be difficult, tough, unfair and hard bloody work and sometimes you just have to get your head down, move forwards, or sideways, or upwards or whichever way you have to go and smash it… just remember that tough times don’t last, tough people do!

As always thanks for reading…


Failed Physiotherapy

The term ‘failed physiotherapy’ is a common one used by many doctors, surgeons, and physiotherapists. It is often used to justify further treatments and interventions but also to shift blame from physios to patients for not getting results that were expected?

To me, the term failed physiotherapy screams out poor communication, low motivation, shitty relationship building skills and general therapist apathy. I actually don’t think patients fail physiotherapy at all, I think more often physiotherapists fail patients, but also that the physiotherapy profession fails both physiotherapists and patients alike.

Over the years I’ve seen and heard many physios blame their patients for not making the progress they wanted or expected, and I still continue to see and hear it today. I will admit, much to my shame that I have done this myself in the past, often because it’s easier to blame others for a poor result rather than admit your own faults and failings.

No one likes to admit their own faults and failings and physios often find themselves in demanding and difficult situations that set them up to fail a lot of the time. This, in my opinion, is the crux of failed physiotherapy, either it’s due to inadequate teaching and training at universities and many postgraduate courses, but it’s also due to overloaded, underfunded, poorly managed working environments, with little to no support, guidance, or respect from other healthcare professionals!

In my experience, those physios who ‘fail’ patients at physiotherapy the most are those who are in the worst working environments, with the least support, and have the poorest training and understanding of how to develop a good working relationship with a frustrated, stressed out, worried and concerned person in pain!

Trust, Respect, Reassurance

It’s known that the therapeutic relationship a patient has with their physio and vice-versa can hugely dictate their outcome (ref, ref). And although not conclusive there is evidence that those therapeutic relationships that have the highest levels of trust, respect, and reassurance often tend to get the highest outcomes regardless of the severity or chronicity of the issues (ref, ref, ref,).

However, there is no doubt that developing good therapeutic relationships can be challenging and difficult to achieve at times. Why we don’t develop good relationships sometimes can be due to many things such as prejudices, prior experiences, personal choices and a multitude of other factors. All human relationships including professional ones are complex, nuanced and multifactorial and one of the many joys and frustrations of being human.

That being said one of the biggest factors for failed relationships between physios and patients I think is simply a lack of time, empathy, and understanding on both sides. Physios often don’t understand, appreciate, or recognise patients concerns, frustrations, or situations as much as they should, and patients I don’t think understand, appreciate or recognise physiotherapists pressures, demands, and limitations as much as they could.

I am in no way blaming patients here or justifying the poor, lazy, uncaring, apathetic physiotherapy that is rife within the profession. I am just trying to point out that it happens a lot due to a lack of support, guidance, leadership, respect, and recognition that many physiotherapists get.

If more physios were given better working environments with better caseloads that gave them time to breathe between patients, or better reimbursements for doing the simple things really well like education and exercise, or better recognition for the effort, time, and training they do, or were better respected for their place within healthcare, I’m sure many would try harder, go further, and listen more to patients in an effort to get them better results.


However, regardless of the current healthcare systems and its shitty limitations, more physios need to realise that if a patient isn’t making progress or they aren’t following their advice or recommendations it’s not automatically the patient’s fault, and before they label them as non-compliant or failing physiotherapy they should reflect on and try to find out why the patient isn’t progressing.

A lack of patient progress can be due to many factors, such as simply insufficient time to let things settle or take effect. It could also be due to a misdiagnosis of something else masquerading as something else. But the most common reason for lack of progress I think is that the patient just hasn’t started or changed anything significantly since starting physio.

The classic scenario here is a patient not doing their home exercise program given to them by a physio to help a specific issue or to just get them moving more, and it’s a situation I’ve encountered many, many times. I used to think these patients were lazy or lacking discipline, or that I hadn’t found the right exercise for them to do that they found fun or engaging.

I now know it’s often non of those things and more because the patient simply doesn’t understand why they need to do these exercises, and that I haven’t helped them connect the process of doing them to an outcome that’s meaningful. A common misconception in physio rehab is that patients will only do exercises if they like and enjoy them. That’s just not true. People put effort into things that are important to them, regardless if they like or dislike them.

Take me and running as a perfect example here, I do it 3 times a week and have done so for most of my life, but I don’t ‘enjoy’ it, in fact, I find running tedious and mind-numbing. I run because I understand that cardiovascular training is good for my health, gives my body a different stimulus from the weights I usually do. But it more importantly means I can eat more, and I love to eat more. Running also has very few barriers or obstacles for me being quick, cheap and very easy to do.

This is what physios need to do with patients more, help them understand the why better and help them connect the process of what you’re asking them to do to something that has an important and personal meaning for them. Physios also need to check more for barriers or obstacles that may get in the way, prevent, or deter patients from doing what they have been asked to do such as lack of equipment, poor environment, or time constraints.

Granddaughter Rucksacks

A recent example of mine was an elderly female patient I saw with low back pain who had never done any resistance exercise in her life and had no interest in doing any now. She was a busy working grandmother with little spare time but her main issue was she couldn’t pick up her youngest granddaughter anymore without her back hurting.

This key piece of information was simply found out by asking the question ‘what is the main thing your back pain is stopping you from doing currently’ and this clearly this was her most meaningful goal. Now all I had to do was help her understand the how and why to get there. I did this by asking her to judge how much her granddaughter weighed, which she estimated was around 4 stone (25kg). I then asked her to start lifting half that weight using a rucksack filled with books and bottles off the floor and to pretend it was her granddaughter when she was smaller.

I then got her to focus on lifting her ‘small granddaughter’ 3 x week doing a few sets each session until she felt her back tiring or aching. I asked her to add 2-5kg into the rucksack each week depending on how she felt until she reached the goal of her granddaughter’s weight.

The beauty of this was that she soon realised if she wanted to continue on picking up her constantly growing granddaughter she should keep trying to lift heavier and heavier weights. In the last session I saw her for a few months ago she was regularly lifting 35-40kg, had little in the way of back pain, but more importantly, had a desire to keep doing these granddaughter rucksacks lifts a few times a week for the foreseeable future.

Now don’t get me wrong it’s not always like this, with it often being much harder to find a meaningful personal goal for some patients that you can attach a treatment process to. This may be because some patients just haven’t thought that much about it and just need longer to think about it, other times it’s because their pain although annoying and frustrating actually isn’t actually stopping them from doing the things they value.

It’s in these cases that I think ‘formal’ physiotherapy treatment is often not be needed. These patients I think simply need to recognise how they are still continuing on despite the pain, being reassured that this is great and ok to continue to do, and perhaps that they just need to give it a bit more time or make a few simple activity or lifestyle modifications to help.

I think many patients are told they fail physiotherapy simply because their pain hasn’t suddenly or miraculously improved or disappeared, when in fact they don’t need the pain to improve or disappear because they are managing it very well. Some patients just need advice and reassurance that it’s ok to do this and to keep going and give things more time.

Some patients are also just not ready for physiotherapy at that time due to other factors going on in their lives meaning they can’t or don’t want to change anything currently. Again this isn’t them failing physiotherapy, this is just them being not ready for physiotherapy yet.


So that’s my quick look into the horrible term ‘failed physiotherapy’. In summary, patients don’t fail physiotherapy, rather physiotherapists often fail patients due to their apathy, lack of empathy, poor training and understanding.

But it should also be recognised that the physiotherapy profession fails both physiotherapists and patients with its culture of quick fixes and silly treatments, not to mention its woeful underfunding, poor working environments, inadequate leadership, outdated training and general lack of respect or recognition for what they do. And until these issues are addressed, I fear many more will continue to fail physiotherapy!

As always thanks for reading



SExSI Strength

A recent trial on ‘strengthening’ exercises for shoulder pain called the SExSI trial has just been published this week with some interesting results and even more interesting reactions and comments being thrown around on social media. In fact, its been really disappointing to see some individuals twist and contort what this trial shows just to try and have a cheap shot at strength exercise and a favourite saying of mine… ‘you can’t go wrong getting strong

In fact, I think it’s totally pathetic to see some well-known, influential physios gleefully misrepresenting my position on strengthening exercise for those in pain. But what I have found more astounding is those who are trying to claim that strengthening exercises don’t help those with pain, and some who think those who strongly advocate strengthening exercises for patients are the modern-day equivalents of those who advocate correct posture.

So in this blog, I’m going to discuss what this SExSI trial does and doesn’t tell us about strengthening exercises and shoulder pain, as well as defend the use and promotion of strengthening exercises in physiotherapy, and finally respond to some of the asinine comments about getting strong and those who advocate it.

SExSI Stuff

However, before I begin I want to first congratulate the authors of the SExSI trial as I know it’s bloody hard to do research, but also for coming up with such a great acronym for the study. So the ‘SExSI trial’ which stands for Strengthening Exercise for Shoulder Impingement, randomised 200 people, aged between 18-65 who had long-lasting shoulder pain for an average of 10 months, to have either ‘usual physiotherapy’ or usual physiotherapy plus ‘three additional’ strengthening exercises over a 16 week period.

These three additional exercises were added one every 5 weeks and were 1) supported ER at 45º of scaption 2) scaption raises between 0-45º, and 3) unsupported ER again at 45º of scaption. They used rubber bands to add resistance and monitored the total time under tension using a sensor attached to the band.

They gave instructions to increase the resistance if subjects felt they could do more than the recommended reps and have no pain flare-up, or decrease it if they could not do the recommended reps or had a pain flare. They asked them to do 3 sets of the first exercise with 1-minute rest every day for the first 5 weeks, but as the 2nd and 3rd exercises were added they asked them to do just 2 sets per exercise every other day. The total time under tension for these exercises over the 16 week period was calculated to be an additional 12 hours which they suggested was optimal for muscle protein synthesis and strength gains (ref).

They used the SPADI as their primary outcome measure as well as measured the subject’s shoulder abduction and external rotation ‘strength’ using dynamometry. After 16 weeks 156 of the original 200 patients completed the trial and they found NO significant difference between SPADI scores or shoulder strength measurements between the two groups.

Their conclusions were “adding a large dose of shoulder strengthening exercise to current nonoperative care for long-standing subacromial shoulder impingement did not result in a superior outcome for shoulder-specific disability after 4 months.”

From this conclusion, it seems that some soft-skinned therapists and pasty professors who couldn’t deadlift their way out of a wet paper bag, or show you one end of a dumbbell from another are suggesting that strengthening exercises don’t help, or are not needed for those with shoulder pain.

Utter Nonsense

First things first, this trial doesn’t actually show strengthening exercises don’t improve shoulder pain. In fact, this trial DOESN’T show ANY changes in strength OR pain levels at all. Call me old fashioned but I think for a strengthening exercise to be classed as a strengthening exercise it has to at least increase… strength.

If a resistance exercise doesn’t increase strength then it’s best called a… resistance exercise, and this may come as a shock to some physios and professors out there but not all resistance exercises increase strength. In fact, many do not.

Anyone who has tried to get stronger knows it takes more than just a few minutes of pulling a poxy physio band for a few weeks and also knows it’s not easy to do. In fact, trying to get stronger is hard as hell, requiring a lot of effort, intensity, volume, and most of all consistency.

Yes, there are some initial easier gained early increases in strength in the first few weeks of training, especially in those inexperienced to resistance-based exercises mostly due to neural adaptions (ref, ref). But to achieve significant tissue structural changes such as muscle hypertrophy (not hyperplasia as some professors who should know better are claiming as this only accounts for about 5% of muscle adaption in humans (ref, ref) requires regular intense resistance-based exercise, with sufficient dietary protein, rest, and recovery done over a long duration.

What the SExSi trial actually showed is that these particular exercises, at this dosage, in this population, does NOT increase shoulder strength or reduce shoulder pain, and that’s not surprising when we look a little closer at them.

The exercises in the SExSI trial did not strengthen the subjects because of the very low volume and I suspect insufficient intensity, but more likely just due to the fact they have pain because individuals in pain do not respond to stimuli such as touch, temperature and stress/strain the same as individuals without pain (ref). I also guess there may be an element of subject boredom, disinterest, and lack of motivation that may also have had an effect on why they didn’t improve in strength and pain levels.

2.4 Minutes!

The authors note that the subjects did not achieve anywhere near the total time under tension they wanted during the 16 weeks to achieve muscle protein synthesis. The aim was to get subjects to perform an additional 12 hours of time under tension, however, they only achieved on average just 2.9 hours, with 1.6 hours done in the first 5 weeks, 0.8 hours in the next 5 weeks, and just 0.6 hours for the last weeks. This equates to just 36 mins over the whole of the last 5 weeks, that’s just 7.2 mins a week, or 2.4 mins a session.

Again this is not surprising, because no one wants to do anything for a long time when in pain. However, I would NOT expect anyone with or without pain except for the most severely de-conditioned individual to get stronger by pulling a rubber band for just 2.4 mins 3 times a week. If it was this simple and easy to get stronger all our patients and everyone else would be walking around like Thor and looking like Arnold.

The ‘additional’ exercise group in the SExSI trial actually spent on average 16 mins a week LESS time exercising than the usual care group. This shows the subjects were not happy or engaged with their exercises for whatever reasons, maybe it was boredom, maybe it was pain, maybe it was lack of support from the physios etc who knows, either way, these exercises were just not done. To be fair the authors do attempt to adjust for this difference in their post hoc analysis, but I still suggest that these exercises were not done at any sufficient volume or intensity to make any meaningful tissue adaptions.

These exercises were also chosen to strengthen the rotator cuff muscles but only in a limited range of movement of just 45º of elevation to avoid aggravating pain. The assumption here is that the cuff muscles were the source of the subjects long-lasting shoulder pain and that restricting their range of movement and avoiding pain is the best way to help them.

In my experience, this is not the case at all. Maybe, these exercises are an option to start with for those with severe shoulder pain for the first few weeks, but not for 4 months solid. To ask subjects with long-lasting shoulder pain to only do 3 exercises, below 45º of elevation and avoid pain for 16 weeks is in my opinion not evidence-based progressive rehab. In fact, encouraging some pain during rehab has been seen to have beneficial effects in many chronic musculoskeletal painful conditions, including shoulder pain (ref, ref).

Also, remember this trial made no changes in subjects pain, and so it’s not surprising that there were no changes in their strength. It’s well known and well researched that pain inhibits muscle function (ref, ref, ref). Basically, it’s really hard to produce force/torque/power/work when it hurts (ref).

So what the SExSI trial found was three, limited range of movement, shoulder exercises, done at low volume over 4 months, avoiding pain does not improve shoulder strength or reduce pain. What this trial does NOT show is strengthening exercises don’t help people with shoulder pain.

Pathetic and Pedantic

I really just can’t understand some of the comments I’ve seen around this trial or the growing criticism of resistance-based exercises by some so-called evidence-based clinicians. I do understand that a few are genuinely trying to be fair and equal in their critique of all interventions, but many others are just trying to be edgy contrarians with their pathetic, petty, and pedantic comments and constant misrepresentations of those, like myself, who advocate and promote strengthening and resistance-based exercises a lot.

To claim those of us who promote and advocate getting stronger as PART of a patient-centred management approach are the modern-day equivalents of those who tell patients they need to improve their posture is a ridiculous comparison and a narrow-minded, reductionist view of the many benefits that resistance-based exercises have.

I find it ironic that those who seem to critique resistance-based exercises the most are often those who look like they use them the least. I also find it highly ironic that those who like to remind us that pain and pathology are multifactorial, and treatments and interventions for pain are multidimensional in their mechanisms of effect, only focus on the effects that resistance-based exercises have on tissue structure and patients pain levels when it suits their agenda.

Resistance-based exercises help pain, pathology, AND people via a multitude of pathways, process and mechanisms, both physiological and psychological. Resistance-based exercises affect people positively.

I am also struggling to contain my frustration with the increasing criticism of resistance-based exercise by some who think it doesn’t get the same level of critique as other interventions because I see the exact opposite. All I see on social media and in clinical practice are lots and lots of promotion and propaganda by clinicians for silly, over-complicated, pseudoscientific, active and passive interventions and very little advocacy for simple robust resistance exercise.

Least Used

I argue that resistance-based exercises are one of the least used interventions within a lot of physiotherapy for many reasons such as lack of training, knowledge, confidence, and equipment. But also because they are seen by many physios to be not sexy, skilled, or sciencey enough to warrant their time or attention.

All too often I see and hear patients who have had months of massage, needling, cupping, pelvic tilting, and transverse abdominus clenching with little to no advice, guidance, or encouragement to do any robust generic resistance-based exercises or activities.

And yes, I am well aware that resistance-based exercises do not outperform any other type of exercise or even some of the pseudoscientific passive claptrap for reducing pain. But what resistance-based exercises DO outperform EVERYTHING else on is their effect on an individuals health, wellness, function and quality of life (ref, ref).

Despite some claims that strength-based exercises are not effective for pain, there are actually numerous studies (admittedly some better than others) that do demonstrate resistance-based exercises help reduce pain (ref, ref, ref). What a lot of these studies don’t prove is that resistance-based exercises actually get people stronger as this is often not measured or assessed.

These trials also don’t tell us HOW or WHY resistance-based exercises reduce pain or improve function. It may be more the act of doing them rather than the results. It could be the surrounding contextual and psychological factors around resistance-based exercises such as reducing feelings of fear and fragility, challenging beliefs and expectations, or improving pain self-efficacy that helps reduce pain, not the physiological effects of tissue adaptions such as muscle hypertrophy (ref).

I also know and accept that being strong or getting stronger is not sufficient to reduce either the intensity or frequency of pain experienced throughout life. I know this only too damn well myself as well as seeing many other strong people in pain, sometimes frequently, and sometimes lasting a long time.

However, what stronger people do have is significantly fewer risks of many diseases, illnesses, age-related disabilities, and other conditions which are often accompanied by pain. Being stronger may not prevent you from having pain in life, but it will equip you better for coping with and overcoming it.

There is also NO evidence that getting people stronger is either harmful or detrimental for many painful conditions, so again I really can’t understand why there is so much criticism, snarkiness, and bitterness towards a simple, cheap, and effective method of helping people in pain or with a disability, or those who advocate for it regularly and passionately. Personally, I think if some of these exercise contrarians used as much energy actually doing some resistance-based exercise as they do on questioning it they may find it more worthwhile.


So I’m going to continue on promoting the use of resistance and strength-based exercises in all those we see with pain or disability, and I will continue to use my phrase of ‘you can’t go wrong getting strong’ until I am blue in the face. And I really don’t give AF if some don’t like it because it’s a short, catchy, easily remembered, slogan, that fits beautifully on a nice cotton t-shirt, that grabs attention and promotes strength-based exercise to everyone.

Finally to those who critique the role of strength-based exercises in physiotherapy ask yourselves why you do this and carefully consider if what you are doing maybe detering clinicians and patients from engaging with it even more than they currently are?

Now I’m sure some will whine, moan, and even complain to the authorities about this blog as they have done before, but honestly, I don’t give AF again. Because if I have to spend my evenings writing blogs defending how being vocal, passionate, and biased towards strength-based exercise in physiotherapy is not wrong, I don’t want to be right.

As always thanks for reading


If you want to find out more about how to get shoulders SExSI strong make sure you check out my upcoming LIVE+ONLINE Shoulder Complex courses here

Long COVID and Physio!

A few weeks ago I posted a short article from the Guardian about the use of Graded Exercise Therapy or GET as its often referred to and its use for those with Long COVID. To my surprise, this created a lot of response and reaction that I was not expecting, and as I know very little about Long COVID I thought I should do some further reading and share my thoughts on what I’ve found so far.

The first thing to mention about GET is that it seems to be surrounded by a lot of emotion, anger, and accusations that I have no desire to get involved with at all. A lot of this hostility appears to revolve around some researchers and advocates of GET being accused of callous, malicious, and harmful behaviour by some Chronic Fatigue Syndrome and Myalgic Encephalomyelitis groups or CFS/ME for short (ref, ref)

This is because GET has been seen to significantly exacerbate, worsen, and prolong symptoms in many of those with CFS/ME and other post-viral fatigue syndromes to which Long COVID is thought to, in part, belong. There have also been accusations of GET advocates not listening or believing those with CFS/ME calling them lazy, malingerers, and even fakers who are disrupting their scientific studies. This has allegedly led some GET researchers to receive official complaints, hate mail, and even death threats which is just crazy.

Now, as I said I do not want to get involved in any of this toxicity other than to say calling anyone suffering from any symptom a faker or malingerer is abhorrent and horrible, even more so if you are a healthcare professional. But then so is making false allegations and death threats to anyone especially someone trying to help others by conducting research into a mostly unknown condition. Anyway regardless of who may, or may not have said what this nastiness just needs to stop and the time and energy directed elsewhere.

What is Long COVID?

So after a few weeks of reading around Long COVID, CFS/ME and GET I will admit that I still know very little about it, and there are clearly still a lot of uncertainties, unknowns, and speculations going on by some armchair experts and amateur bloggers to which I am now adding to. There are also a lot of attacks and accusations being flung at anyone who does share an opinion, express a view, or write a blog on this topic and so it is with some trepidation that I write this as I am sure there will be some mistakes and misinterpretations within it… so if you’re reading this #BeKind.

Long COVID is still a largely unknown condition with many varied symptoms, no clear diagnostic criteria, and no firm ideas about how best to manage or treat it. Long COVID is thought to be a collection of many different syndromes that can manifest in many different ways (ref). One type of Long COVID that appears to be most uncertain is one that has no signs of any adverse organ deficits or clear objective tests and is thought to possibly be a post-viral syndrome which is also known to occur after many other viral infections such as Ebola, Dengue, Zika, even Herpes and good old traditional influenza (ref).

This type of Long COVID is believed to share a lot of similarities with CFS/ME such as profound generalised post-exertional fatigue, loss of muscle power, pain, and malaise often reported to be delayed in onset and quite unlike the ‘fatigue’ experienced by healthy people (ref). This type of Long COVID is also thought to cause cognitive issues such as difficulty concentrating and ‘brain fog’, as well as symptoms of unprovoked breathlessness, increased heart rate, dizziness, difficulty sleeping, anxiety, and depression (ref).

The causes of many Long COVID symptoms are currently just not well understood but are clearly a mix of physiological, psychological, and social factors. One of the strongest theories of post-viral syndromes is that they may be due, in part, to a process known as mitochondrial hijacking (ref). Mitochondria are our tiny yet extremely powerful ‘engines’ in all of our cells providing energy for all its chemical cellular reactions to occur, and without them, nothing happens. Once inside our cells, a virus like COVID-19 is thought to invade our mitochondria and hijack them to provide energy for their own replication rather than doing their original jobs, slowing down and even stopping our normal cellular processes (ref, ref).

How Long is Long COVID?

The simple answer is no-one really knows how long Long COVID lasts, but some estimates suggest that 1 in 7 people may suffer from Long COVID like symptoms for up to 4 weeks, 1 in 20 up to 8 weeks, and 1 in 45 with symptoms lasting more than 12 weeks (ref). It also seems older age, higher BMI, and female gender are greater risk factors for longer Long COVID (ref).

This clearly means that a lot of people will have Long COVID symptoms when you consider that in the UK alone we had 4.27 million known infections at the time of writing this blog, and these are only the infections we know about. There is also no doubt that many physios and other therapists will start to see more and more people with COVID related issues that affect their function and ability in an effort to help them with their recovery, which leads us back to the topic of what should we be advising and recommending to those with Long COVID symptoms to do in terms of exercise and activity.

Now there is no denying that there simply isn’t enough information yet to say definitively what is or is not the best advice. But using what we do know based on current knowledge and experiences of other post-viral fatigue syndromes, rest, recuperation, and convalescence is without a doubt, an important factor in recovery. However, there is also no denying that as clinicians and human beings are all pretty crap at recommending and engaging with rest, recuperation and convalescence with it often being viewed negatively as lazy, idol, and unproductive.

And there is no doubt that too much time away from activity, work, and other tasks can be detrimental and unhelpful, but so can pushing too hard, too quickly with post-viral syndromes as this just doesn’t help them recover faster or better (ref). So where does this leave us with our recommendations for activity and exercise? Should we tell those with Long COVID to do nothing, a little now and then, or more than that?

Long COVID and Exercise

A lot of the debate and disagreement I have seen around the topic of Long COVD, CFS/ME and exercise seems to revolve around differences in the interpretation of the words exercise, activity, graded and pacing. For example, some strongly suggest that all exercise is to be avoided and only paced activity is to be recommended, in fact, this is now in the UKs national NICE guidelines for CFS/ME here.

However, this is where I have some difficulty I think due to differences in interpretation of what is, and what is not, considered an exercise or an activity. For example, some define exercise as something that is always planned, structured, repetitive, intentional and progressive that either improves or maintains fitness, whereas activity is not. I disagree and think this is a narrow and limited definition of exercise which can often be unplanned, unstructured, unintentional, and not progressive, and conversely, at times activity can be structured, planned, intentional, and progressive and also help improve or maintain fitness.

Others think it is the task itself that differentiates an exercise from an activity, for example walking is an activity, running is an exercise. Again I disagree because what I think defines what is, and what is not an exercise or an activity is based on the individuals perceived level of effort doing the task, not the actual task itself.

For example, walking for some can be perceived as very effortful and so could be classed as exercise, however, for others running can be perceived as not effortful and so would be an activity and only classed as exercise when it reaches an intensity where it feels challenging.

I do agree that exercise and activity are not the same, but my simpler definition of exercise is basically anything an individual feels challenging and effortful. This can therefore mean that for some getting out of bed, lifting a coffee cup, or sitting upright in a chair can be classed as exercise, such as when recovering from an extended period of inactivity say after admission on an ITU, or due to a post-viral syndrome such as Long COVID.

Now it’s important to say that post-viral syndromes are not physiologically the same as deconditioning from extended periods of inactivity, however, although they are completely different in cause and effect I don’t think this means the underlying principles of managing them needs to be completely different. In my opinion, anyone with fatigue or deconditioning regardless of the cause should first steadily work within their tolerance levels, ensuring sufficient rest and recovery, and let the processes of time, homeostasis, and adaption do the rest.

For those with Long COVID or any other post-viral syndrome this means asking them to internally monitor their own feelings of pain/energy/fatigue hour by hour, day by day, week by week, doing what they can, when they can, avoiding boom or bust cycles, and of course, resting and recovering when needed. One way of helping with this is to use wearable heart rate monitors to ensure that during exercise or activity they don’t go above their anaerobic threshold. A simple way to calculate this is to use approximately 55% of your max heart rate which can be done by subtracting your age from 220 and multiplying that number by 0.55, so for myself that would be 220-47 = 173 x 0.55 = 95 bpm, a target zone of 10% either side is then suggested so for me that’s between 85 and 105 bpm (ref).

Now if you decide to call this graded exercise therapy, paced activity treatment, or anything else I don’t think it really matters that much in my humble opinion. This simply is probably best described as individualised person-centred or patient-focused care or any other term you may want to use.

Managing and supporting those with post-viral fatigue syndromes also means carefully and compassionately explaining and reassuring them about the unpredictable and multifactorial nature of their symptoms and how many physical, psychological, environmental, and societal factors can affect them. It also means being empathetic, understanding but most importantly being honest and optimistic about the condition and prognosis which is that symptoms should get better over time, some may take longer than others, but there are things you can do to help.

For more on self-management with Long COVID check out this awesome FREE resource from PainToolKit.org here.

Chronic Fatigue and Chronic Pain

After reading a fair bit on post-viral syndromes these last few weeks I see a lot of similarities between chronic fatigue and chronic pain. Although different in presentations and symptoms they are both multifactorial, multidimensional, highly individual, complex conditions, that have both physiological and psychological components (ref). They both also often have no clear diagnosis or prognosis, with no clear definitive tests, scans, or objective markers, and often no clear reliable signs or symptoms, and of course no clear treatments.

Another similarity between chronic fatigue and chronic pain is that there is a lack of recognition, understanding, and social support around them both, with unfortunately a lot of stigmatism and prejudice also surrounding them both. This often produces a lot of mistrust, anger, frustration, and resentment in those who suffer from either.

One final thing I would like to discuss about both chronic fatigue and chronic pain is how there is also so much easily accessible, poorly controlled information, speculation, conjecture, and hypothesising around them which I think has the very real potential for negative cognitive priming to occur and affect individuals symptoms and prognosis.

Cognitive priming is a well-researched phenomenon in which words, pictures, and conversations have been shown to enhance an individual’s perceived intensity of their symptoms and behaviours (ref, ref). The mechanisms of cognitive priming are complex and highly individual and in no way mean or imply that an individual’s symptoms are not real or genuine, just that they can be affected and altered both positively or negatively by information you receive and assimilate.

I know this only too well with my own feelings of fatigue, anxiety, and depression recently being hugely affected by the information I read and conversations I have to know that cognitive priming affects us all in many ways. Again I want to stress that I am in no way, at all, in any shape or form, denying that symptoms are real, faked, or made up, just that they can be affected by what we see, hear, and read, and at the moment there is so much on Long COVID everywhere.

However, in my opinion, a lot of this information on Long COVID in the scientific journals, news, and of course social media is confusing, contradictory, speculative, and often pessimistic, downbeat, and negative. Even some of the official sites and support groups are full of rumours, speculations, fears, reluctancy and hesitancy, which I can understand given the current situation, but which also, in my opinion, can be negatively priming many with Long COVID symptoms and could be harmful and detrimental to their progress as highlighted in this recent article here.


So that was my brief review of Long COVID, physio and exercise. As I said at the start I have only just scratched the surface and there are still many unknowns and uncertainties. I understand that this can be confusing, upsetting, and frustrating if you are experiencing Long COVID symptoms currently, especially if you have experienced prejudice, disbelief, scepticism and stigmatism by those who don’t understand it, and I apologise for their ignorance and behaviour!

My advice is to please try and ignore these people and try and stay positive, take things slowly and steadily, and focus on one day at a time and progress will follow. Also please try to be patient with yourself and others, particularly some of us healthcare professionals who do genuinely do want to learn more and try and help support you, but who will also make mistakes and errors along the way.

And finally, my last words are to all the healthcare professionals clinicians who may be reading this, please recognise that we actually know very little about Long COVID and post-viral syndromes, so please don’t think that there is a best way to help someone with it. Instead listen to your patients more, respect and trust what they tell you, and you won’t go too far wrong.

As always thanks for reading


Further Resources

For more info on Long COVID and physiotherapy see this site here

For a FREE online introductory tutorial on Long COVID please see Physiopedia.com here

For more info on CFS/ME and physio see this site here

Steps to success!

When it comes to exercise I’m a strong advocate for both resistance and cardiovascular training to be done frequently and consistently, and usually the harder, heavier, and more intense it is the better I think it is. However, over the last few years, I have come to realise that there is also a place and a need for the more easy, more relaxing, less intense exercise in our lives.

Don’t get me wrong I don’t think low-intensity activity should detract or divert attention away from the many, many physical health benefits of hard, higher-intensity exercise which are well-researched, well-known and well-documented (ref, ref). But when it comes to improving our general wellness and mental health I have found a new love for lower-intensity more easy-going exercise.

Lockdown Mojo Loss

So this all came about at the beginning of the first COVID lockdown when I found my motivation and dedication to engage in my regular higher-intensity exercise was slipping. Without knowing it I soon came to realise that I went to the gym to help get my higher-intensity training done. It turns out that I actually love doing this kind of exercise only in the environment of a gym with all its sounds, smells and atmosphere, and trying to do it at home just wasn’t the same, and so I found it harder to get shit done. Basically, I had a lockdown exercise mojo loss.

Now some of you maybe think well you just need to drink a cup of concrete Meakins and get ya head down and get that shit done. And I agree, I did but I also realised that I need some help and support to do this and so I reached out to a personal trainer friend of mine called Louis Calvert to help me with some online coaching and accountability.

Now part of Louis grand plan for me was to start to focus on the number of steps per day I took, something that I have never done before, and thought I didn’t need to being a fit healthy and highly active physiotherapist on the go all the day. To begin with Louis set me a daily target of 8000 steps a day to achieve something I thought was very easy to do and if I’m being honest a little bit insulting to be asked to do.

So at first, I was very reluctant to do it and actually said to Louis that I would rather run 8000 steps per day than walk them. My reasoning for this was I thought walking for the sake of walking was boring, daft and a complete waste of time. My mentality was back then if you have time to go for a walk, go for a run or a workout instead.

However, Louis convinced me to give it a go for a while, particularly when he showed me that my average daily step count for the last week was only around 3000 steps something that took me by surprise. So slightly embarrassed I relented and began to focus on trying to achieve 8000 steps per day on top of my other resistance and cardio training.

Hated it

And as predicted, I hated it, finding it dull and boring and was literally watching my step counter slowly, painfully, creep up to its target each day. I also got annoyed with walking ‘interfering’ with my other usual daily activities making me get up an extra 45 minutes earlier than usual to go and get a few thousand steps in before work, going for a walk during my lunch break, or walking after I’ve done a workout or got back from work.

However, after about 6 weeks something really strange started to happen, I started to find I began to look forward to my walks and I actually increased my daily step target to 10,000, and then 12,000 steps a day.

I found I was enjoying these calm moments in the early morning before everyone else was up. I loved watching the sunrise in the peace and quiet before the chaos of life kicked in for the day, I became fond of the feeling of walking on a cold misty morning. I started to relish my lunchtime walks between clinics to unwind and decompress from the stress of work, and even when it was raining or dark I found the sound of my footsteps in the puddles and mud almost soothing and cathartic.

Without knowing it a few months of walking regularly and I had become a walking addict. I start to find myself going for small short walks whenever and wherever I could.

Slower Mind

I also started to notice some other surprising benefits from all this walking, the main one was my mind slowed down. Now this may not sound like much of a benefit, but for me, with my mind and thoughts often rushing around at 100mph and feeling stressed and jumbled a lot, I felt calmer, more relaxed, and a lot more ‘I don’t really give that much of a shit’ since walking every day

I didn’t think that I was that uptight or stressed but after my mind calmed I realsied that I do have a tendency for speaking before thinking, deliberating too much on stupid stuff, and giving too much of a shit about things and people that don’t really matter.

I found walking more has given me more time to think and organise my thoughts better and I am in a much calmer and stress-free place than I’m used to, which allows me a better perspective on things. My 10 to 12,000 steps a day have been what many others call ‘taking a deep breath and counting to 10’, I’ve just realised that I need to count to 10,000.


But it’s not just psychological and mental health benefits that I’ve noticed since walking daily, there have been some rather surprising physical ones as well. First of all my stamina on my usual long Sunday runs has improved, which may also be due to my increased resistance training. But I do think spending an extra 90-120mins a day every day on my feet has helped reduce the tired fatigued and heavy feeling I used to get in my legs on my long runs.

I have also lost a lot of body fat since walking, which again has surprised me and is no doubt mostly due to my lower-calorie diet, higher levels of resistance training, and a new love for jumping rope. But the daily walking has, I’m sure helped place me in a calorie deficit, burning fat, and stopped me stuffing my face unnecessarily as it now occupies a lot of my spare time.

me 6 months apart


So I am converted when it comes to daily walking and have started to promote it more, to more. Although many talk about reaching the magical 10,000 steps a day target as a holy grail, I don’t actually think it needs to be that much for more many people. The 10,000-step target first became popular in Japan after a pedometer was launched there called Menpo-Kei which when translated literally means the 10,000 steps meter (ref).

However, research has shown that when it comes to walking, some is always better than none, and increasing the number of steps by as little as an extra 1000 steps can have positive benefits for a lot of sedentary people (ref). In fact there have been some recommendations for achieving just 5000 steps a day for most as this can have some pretty big changes in sedentary individuals’ health status (ref).

Also, a recent study has shown that when it comes to steps more does not automatically equal better, with any extra steps taken above 10,000 a day not shown to have much significant impact on health or mortalilty (ref).


So in summary I hope my experiences may have motivated you to consider walking more. If like me you can’t see the point or the benefit please just give it a go for 6 weeks and I bet that you will start to see and feel the change.

My tips are try to make time in your life to walk intentionally every day, fitting it in when and where ever you can, don’t worry too much about step targets, but do get a step tracker to get an idea of how far you’re going. My other tips is to get some comfortable shoes, a warm waterproof coat, and finally relax and enjoy it. Don’t think about rushing to get your walk done, take it at a comfortable pace, stop now and then to look around you and take in the scenery and start to enjoy the time you have walking.

Happy walking


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