How to Exercise with Chronic Fatigue Syndrome

Chronic fatigue syndrome (CFS) results in persistent medically unexplained fatigue.  For the diagnosis to be made symptoms are present for at least 6 months.  Sufferers experience significant disability and distress that is made worse by a lack of understanding from others, including medical professionals.

No specific cause for CFS has been identified. There is some evidence that viral infection and stress are triggers. There is also evidence of changes in the immune, nervous and hormonal systems. It is likely that different factors apply to different people with the condition.

If you suffer from CFS, you are probably fearful to implement an exercise program.  You may fear an exacerbation of fatigue after attempting to exercise.  This is certainly understandable.  People with CFS respond differently to the stresses of physical exercise.  Therefore, a non-traditional exercise approach is needed.  Thankfully, there is new research proving the benefits of physical therapist-guided exercise in people with CFS.  This article teaches you how to exercise with chronic fatigue.

Symptoms of Chronic Fatigue Syndrome

Common symptoms of chronic fatigue syndrome include physical and mental fatigue.  Exertion makes fatigue worse.  You may experience difficulty with memory and concentration.  Others experience muscle and joint pain, poor sleep, headaches, tender lymph glands, and sore throats. You may also suffer from other health problems, such as irritable bowel syndrome, depression, and anxiety. There are often day-to-day fluctuations in your symptoms.  You may have to give up work or studying, greatly reduce your social life or restrict your activities at home.  In some rare cases, people become bed-bound by their condition.

Chronic fatigue syndrome

Exercise for Chronic Fatigue Syndrome

Researchers from the U.K. have uncovered an altered perception of effort in people with chronic fatigue syndrome (CFS).  This involves an inability to interpret the messages your body gives you during physical activity.  This leads to a feeling of fatigue with very little actual physical exertion. These changes in perception of effort are reversible.

By gradually increasing physical activity, your body gains fitness and strength as well as making changes in your ability to perceive effort.  Exercises involve a gradual progression of physical activity to prevent cycles of increased fatigue. This involves coaching from your physical therapist. The gradual and planned increase in exercise leads to an increase in your ability to undertake exercise and physical activity during your day.

Aerobic Exercise 

Many people with CFS find that when they exercise more than their body is comfortable with, they respond poorly with muscle soreness, fatigue, and stiffness.  Remember, your body is having trouble accurately perceiving effort.  This inevitably leads to a reduction in function, and an inability to sustain exercise.

This boom/bust pattern of exercise is unhelpful to long-term success.  Consistent regular aerobic exercise is essential for your body to adapt. It is far better to perform regular daily walks of 5-10 minutes that are achievable without exacerbating symptoms, rather than 30 minutes twice a week which leads to feeling unwell the next day.

knee arthritis

The specific form of aerobic exercise is up to you.  Choose what you will enjoy and stick with.  Walk outdoors or on a treadmill.  Try cycling or an elliptical trainer.  The key is to start small so it is sustainable and so you are able to slowly progress over time.  As a general guideline, start with 5-10 minutes each day for 3 days per week.  Increase the duration of exercise before trying to make it more intense.  Your physical therapist will help you develop a plan that best meets your needs.

Muscle Stretching 

Alongside your aerobic exercise, start gentle stretches. When you have been less active for some time your muscles tighten.  This results in further discomfort. Stretching will reduce discomfort by increasing the flexibility of your muscles allowing you to move more smoothly and freely.  Stretching also reduces muscle tension and cramping.  It helps you to relax more. Your physical therapist will help you choose the stretches that are best for you.

It is important for you to stretch regularly to see improvements. Start by doing stretches once a day on as many days as you can during the week.  The goal is to do them every day at a time that suits you best. Some people find that it is good to stretch before or after physical activity such as walking or gardening. Other people like first thing in the morning or just before going to bed.  Choose what works best for you.

Relaxation Techniques for Chronic Fatigue Syndrome

Relaxation techniques help your body recover between exercise sessions.  This type of training helps restore your body’s ability to accurately perceive effort.  It is important to be consistent with these exercises.  Also, when you are faced with setbacks (and you will get them), these relaxation techniques will help you get back on track.   There are many relaxation techniques that can help you manage stress and fatigue, such as deep breathing, meditation, and massage.

Guided imagery is one relaxation technique proven to be effective for chronic fatigue syndrome.  This can be guided by a professional or performed independently.  Essentially, you visualize images or symbols in your mind that are related to what you want to occur in your body.  This might involve a mental image of seeing yourself walk at a brisk pace.  Then move deeper into your body and visualize a well-functioning immune system and healthy lungs as you carry out the activity.  See yourself and the desired outcome being carried out.  If you are unsure about how to get started you may find this video helpful.

Strengthening Exercise 

Once you have built up the amount of time you exercise aerobically to 30 minutes per day, 5 days per week, you can start looking to add in some strength training.  It is important that you have developed a good foundation with your aerobic exercise.  Once you feel your symptoms are stabilized (no large fluctuations from day to day) you should integrate 2 to 3 days per week of strength training.  Perform these exercises at home, at a local gym, or within group classes.  You can choose based on what you enjoy.  Your physical therapist will help you choose the right program that is best for you.

Start Your Road to Recovery Today

Battling chronic fatigue may seem like a constant uphill challenge. You feel a little better one day, only to feel twice as worse the next day.  Sometimes this happens for no reason at all.  Remember, your body is having difficulty evaluating your level of effort.   It does not know how to respond to exertion.  But you can fix this.  CFS is a complex problem that requires a dedicated and disciplined treatment approach.  Most people cannot manage by themselves.

Get some help.  The physical therapists at BSR want to help you.  Try the strategies outlined above in this article. If you are not seeing a little bit of progress after a few weeks, give us a call.

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Direct Access and Medical Screening in Physical Therapy

Many people visit a physical therapist after seeing a physician and being given a prescription to start physical therapy.  However, this is not the only scenario a patient can be seen by a physical therapist. In New Jersey, as well as all the other states in the country, there is “direct access.” This allows a patient to be treated by a physical therapist without a physician referral.

What is direct access and how does it work?

The American Physical Therapy Association defines direct access as, “the legal right to seek and receive the examination, evaluation, and intervention of a physical therapist without the referral from another health care provider.” This means you don’t have to wait a couple of weeks to get an appointment with a physician. This can be a big help when someone is in pain or just unsure of what to do when they are having difficulty doing activities in their everyday life. The next question becomes: how do physical therapists know what to do without a physician referral?

The profession of physical therapy has gone through many changes in the past 20 years, which is as long as I have been practicing. In the past, it was at a bachelors’ level, and then a master’s level, which I got in 2000. Since then the profession has evolved into a doctoring profession.  Older more experienced therapists were given the opportunity to go back to school and get their doctorate in physical therapy, which I did in 2011.  All this advancement in the education levels of our profession has made physical therapists more than capable to see patients without a physician referral.

What’s different about an evaluation using direct access?

Virginia Mason

When a physical therapist sees someone via direct access the first question that we look to answer is if a patient is appropriate to be at physical therapy.  Your physical therapist will direct your care in the right direction.  He or she will also provide you with whatever type of education you need. This is helpful because waiting to see a physician will only create a longer period of time before relief can occur.

How do physical therapists determine if physical therapy is appropriate?

Physical therapists have many movement-based tests and questionnaires we use to aid in the decision-making process.  This allows us to determine your appropriateness for physical therapy.  Some of the screening tests look at how you move on your feet and isolate different body parts. Others use research-based questionnaires to screen for certain problems or rule out various diagnoses. Physical therapists also do a standard examination looking at your range of motion, strength, and joint motion.  This allows us to isolate the areas that are problematic. We take all this information and determine what is best to help you achieve your goals.


In summary, physical therapists are able to see patients without a physician referral. This is something that doctors of physical therapy have been trained in.  At BSR, most of our therapists have gone on to become board-certified specialists in either orthopedic or sports physical therapy.  These advanced certifications make us even more capable and confident in providing the best possible care.  Direct access can be a very useful tool to allow patients to get care quickly and safely.  When physical therapy is not appropriate, you will be referred to the proper health care provider. Give us a call and see if direct access is right for you.


Overcome 5 Common Barriers to Starting Your Exercise Program

Another new year is upon us and with it comes the resolution to get in shape, lose weight, or commit to a healthy lifestyle.  Nearly 50% of New Year’s resolutions are related to losing weight or starting an exercise program.   We all have good intentions but the fact is most fail miserably at following through.   About 6 of every 10 Americans make New Year’s resolutions but research suggests less than 10% are actually successful by the end of the year.  In fact, 60% to 80% fail by February.  Thankfully, there are steps you can take to ensure success with your new exercise program.

Your Thoughts, Actions, and Results

Successful goal achievement starts with our mindset.  Our thoughts control our actions and our actions determine our results.  Be clear on your desired result.  Is it to lose weight?  Or increase strength?  Or increase energy levels?  Next, work backward and focus your mind on how you will achieve it.  Think positive thoughts only.  Envision yourself achieving your goal.  What will you look or feel like?  Then decide on the necessary steps or actions you need to take in order to achieve your goal.  Write them down.  Track your progress and stay focused.

Remember, your thoughts determine your actions and your actions determine your results.  If you think about getting home to watch television that is exactly what you will do.  However, if you think about how good you will feel and look from exercising regularly then you will make it a priority to eat healthily, get to bed early, and make time in your day to exercise.   If exercise is not really all that important to you there is no need to continue reading this article.

5 Barriers to Exercise That Stand in Your Way

Setting a clear goal and thinking positive thoughts is imperative for success.  You will also have to acknowledge and be prepared to overcome obstacles along the way.  The 5 most common barriers to follow-through with a regular exercise program include the following:

  1. Lack of self-efficacy
  2. Perceived lack of time
  3. Poor social support
  4. Lack of exercise facilities and cost
  5. Pain, injury, or poor health

Lack of Self-Efficacy

Self-efficacy refers to your belief in your own abilities to deal with certain situations.  You choose your path.  You are not a victim of circumstances.  Go ahead and list as many reasons as you can about why you cannot exercise. If you accept these as out of your control you are destined for failure in more ways than one.  If you truly desire to start an exercise program in the New Year there is nothing that can stop you except yourself.  Remove negative thoughts from your mind and take ownership of your health.

Lack of Time

We all have 24 hours in a day.  We are 100% responsible for choosing what we do with each of those hours.  Not your boss or your spouse, or your parents.  You are responsible.   It comes down to setting and following through on what is important to you.  If your resolution to exercise is a priority, you will think about success and the actions needed to achieve success.  However, if your resolution to exercise is a wish or something you believe would be nice to do, it is not a priority and you are doomed.  When you are committed to your resolution you will make time during your day.  You will get up earlier, leave the television off, and spend less time on social media.  We all have something we can remove from our day in order to insert something more meaningful.  Small sacrifices often result in huge rewards.

Lack of Social Support

You don’t have to go into it alone.  Enlist your spouse or friends to join you.  Social support assists adherence by fostering discussion of exercise, invitations to exercise, and celebrating the enjoyment of exercise.  Seek out environments to exercise that promotes a social support system.  Consider joining a group environment such as Trident Fitness, Hot or Not Yoga, Blacksheep, or others in our area.   There are great benefits to getting around strong fitness cultures that promote community and healthy competition.

Lack of Facilities & Cost

You always have options when it comes to where you choose to exercise.  Anyone can develop an exercise program to perform within the comforts of their own home.  You can join a gym with a plethora of equipment options (Retro Fitness or Planet Fitness).  The cost varies from nothing (in your own home) to $100 or more per month.  The fact is, the cost may be an obstacle to exercising in your ideal environment.  However, the cost can never limit you from exercising at home or starting a walking program.   If the cost is preventing you from getting started, refer to our discussion on self-efficacy.  The only thing that can truly prevent you from exercising is you.

Pain, Injury, or Poor Health

Some people believe they are not fit for exercise because they are experiencing pain.  Some also reference their metabolism or some medical problem which prevents them from losing weight.  Maybe this is the case and nothing can be done to reverse these problems.  Even so, there a number of things you can still do for yourself to lose weight, get fit and become healthy.  Pain, injuries, or poor health may limit your options but there are always options.  Meet with your doctor or a physical therapist if you need to develop a plan to work around some of these obstacles.

Your Physical Therapist Can Help

A doctor of physical therapy can help get you started and assist you along your journey.  If you are unsure about getting started, meet with a physical therapist for a free screen.  There is no obligation tied to this 30-minute session.  Based on the physical therapist’s examination, you will be guided in the right direction.  Guidance may include tips for developing a sense of self-efficacy.  Your physical therapist can also help you find time to carve out during your busy day so you can devote this time to your new exercise program.   After discussing your goals and preferences, your physical therapist can recommend the right environment or facility for you.  And most importantly, based on your health and injury history, your physical therapist will help you design the right type of exercise program for you.

Free Consultation Physical Therapist

Get Started with Your Exercise Program Today

It’s time to take action.  You have decided on what is important to you and you have acknowledged there will be obstacles.  You are willing to do what it takes to get the results you truly desire.  Now, the first step is the most difficult to take.  We want to help you be successful and feel your best.  Give us a call and schedule your free screen with a physical therapist.


Preparing for Our Move to Barnegat 67

We are excited about our upcoming move to the Barnegat 67 Plaza.  We expect to be open for business before the end of January.  Our space is in between Dollar Tree and Planet Fitness.  Framing is complete and the dry wall is going up this week.  We can’t wait to have the larger space for more equipment and greater patient privacy.  Stay tuned for news about our open house!  In the meantime check out these pictures from last week.


BSR Physical Therapy BSR Physical Therapy BSR Physical Therapy

Blood Flow Restriction Therapy Improves Strength without Stressing Joints

Blood flow restriction (BFR) therapy uses external pressure over a body part during exercise. The applied pressure allows the flow of blood through the arteries.  However, it decreases blood flow in the veins past the restricted site. This makes the working muscles tire more easily.  Therefore, the patient is able to make greater strength gains while lifting lighter loads.  This reduces the overall stress placed on the injured joints or tendons.  The result is a stronger muscle without pain.

How Blood Flow Restriction Therapy Improves Strength

Normal strength and muscle size gains happen from lifting weights close to 70-80% of a person’s one-repetition maximal effort (1RM).  Lifting with so much weight is not a good idea for people recovering from an injury or surgery.

BFR therapy allows strength gains with only 20-30% 1RM.  Most importantly, it does so without stressing the injured areas. This is great for patients following an injury or surgery.  Also, a recent study looked at BFR exercise in a patient with Parkinson’s disease and found they were able to improve their walking ability.

Is Blood Flow Restriction Safe?

Medical-grade tourniquets maintain a safe level of pressure for a long time while a patient undergoes surgery.  Similar tourniquets are used with BFR therapy.  A 2016 large systematic review looked at BFR exercise and found little to no research showing a higher risk than typical exercise at higher resistance loads.

However, one should not take a simple rubber band or strap and wrap it around their leg or arm to stop blood flow.  This will increase the risk of bodily harm and serious injury.  Also, people with chronic medical conditions, a compromised cardiovascular system, or other medical problems are not suited for BFR therapy.  Only a trained medical professional can help you decide if BFR is right for you.

How to Get Started with BFR Therapy

Blood flow restriction therapy is a treatment physical therapists utilize to help patients increase strength without loading joints and muscles.  BFR therapy is proven to help people with arthritis, neurological disorders, tendon problems, and those recovering from surgery.

BSR Physical Therapy prescribes BFR exercises as part of a comprehensive treatment plan for patients at our Barnegat clinicCall our office to schedule an appointment.


How Power Training Benefits Older Adults

Typically training for power is thought of as something more for younger athletes. However, today older adults are staying more active with activities like tennis, golf, hiking, and dancing.  All of these activities require some component of power.  If you are an older adult looking to keep active, you should be doing some form of power training.  This article will help you start.

What is Power and How to Train with It?

Power is simply adding speed to a movement.   Power is a combination of strength and speed.   When exercising, we typically encourage slow and controlled movement.  But when you are able to control movement during an exercise, what’s next? We can add resistance to the movement, or sometimes we can add speed.

Why would we add speed? Say you are playing tennis and you have to move across the court for a drop shot, how do you move to get the ball? Is it slow and controlled or quick? Does it make sense to only strengthen with slow and controlled motions? Or should we think about adding some speed to the movement you are training for?

Muscles change with age and they also change with the demands you put on them. As you get older and stop doing fast movements your body will accommodate to this.  Is it fair to expect your body to continue to move quickly to react to a drop shot, field a ground ball, or even jump to catch a ball when playing with your grandchildren?  If you want to do these types of things, you need to train for it.

Adding Power Training to an Exercise Program

Adding power to an exercise routine is simple, and fun! You simply do a movement or exercise that you already do properly but add some speed to it. Another idea is to bounce a medicine ball or any ball that can bounce onto the ground or into a wall. Mini jump hops are also another way to add speed to a dynamic movement.

Your Physical Therapist Will Help Develop a Personalized Program

Older Adults are staying active in sports for longer and longer.  Similar to any athlete, you need to train to play the sport you want to do.  A lot of the sports and activities older adults do on a daily basis are not slow and controlled. Power is something to think about with a regular workout routine no matter what age you are.

Call our office to meet with your physical therapist and develop a plan together.  The doctors of physical therapy at BSR have been helping people in Southern Ocean County move without pain since 2007.  We are here to help you.


Bulgarian Split Squat Variations

The rear-foot-elevated or Bulgarian, split squat is an excellent exercise to train the lower body for sport or everyday life.  It is unclear where how this exercise received it’s name but this is of little importance.  The split or asymmetrical stance of the lower body introduces unique deands on the muscles and nervous system.  Acceleration, deceleration, change of direction, sprinting and jumping all require stability of the lower body in similar positions.   Elevating the rear foot increases the difficulty by allowing a deeper squat.  The Bulgarian split squat trains the hip to support the upper body while also controlling the knee position in an athletic stance.

A traditional squat is performed with the feet placed symmetrically side by side.  This creates challenges in primarily one plane.  The Bulgarian split squat is performed with a narrow split stance creating challenges in multiple planes.  Raising the rear leg on an elevated surface shifts the load to the front leg.  The front leg assumes approximately 85% of the total load.

There are many variations to the Bulgarian split squat.  Progressions and regressions can be tailored for the beginner or advanced lifter.  The purpose of this article is to describe several of these modifications.  The Bulgarian split squat can be modified so those new to strength training can incorporate the exercise.  The advanced progressions are best suited for athletes or those with several years of training experience.  The exercise can be modified to challenge balance and stability using lighter loads.  It can also be performed with heavy loads.  Under these conditions, maximal strength development is emphasized similar to training with common multi-joint exercises such as the back squat.

Muscles Involved with the Bulgarian Split Squat

The main lower body muscles involved in the Bulgarian split squat is the quadriceps, hamstrings, and gluteus maximus.  The quadriceps is the first muscle to fatigue, especially when heavier loads are used.  This then requires the gluteus maximus to compensate.  The gluteus medius and minimus are involved to maintain proper positioning of the pelvis and balance. The hip rotators are recruited in order to control the inward or outward movement of the thigh and knee.  The ankle muscles are highly active in order to maintain balance in the narrow stance. The abdominals and low back muscles help maintain a neutral spine position and balance.

Set-Up and Positioning

Taking time to position yourself before the movement will allow for proper performance of the exercise.  Assume a split squat stance with the trail leg just in front of a support box/bench on the floor. While shifting the weight toward the lead foot, place the top of the trail foot on the support box/bench.  The distance from the lead foot to the trail foot support is approximately the length of one leg.  Adjust the support box/ bench distance so the lead knee is directly above the toes. The trail leg support can range from approximately 6 inches to knee height.  This may require some experimentation.  Start with a lower height and adjust as needed.  For stability and balance, the top of the trail foot should remain in contact with the support box/bench throughout the exercise.  The width between the front and trail leg is approximately hip width.

TRX-Assisted Bulgarian Split Squat

Once proper set-up has been achieved grasp the suspension trainer in both hands.  Bend the elbows and hold the straps close to the chest.  This will assist with maintaining proper balance and a vertical position of the trunk.  Maintain this vertical trunk throughout the exercise.  A forward lean is difficult to control with the split stance and rear foot elevated.  Keep the weight of the lead foot distributed in the middle of the foot or near the heel.  Perform the movement by “sitting back” so the trunk remains vertical and the lead knee does not track excessively past the toes. It is acceptable to have the knee pass slightly ahead of the toes.  Lower the trail knee only to a position 1-2 inches above the floor.  Complete the desired number of repetitions on one leg before switching legs.

Bodyweight Bulgarian Split Squat

For many, the weight of the body is enough to provide a training effect.  Progressing away from using the suspension trainer increases balance and stability challenges.  Place the hands on the hips or arms across the chest.  If you are unable to perform the exercise without the arms in these positions you many lack adequate balance.  If this is the case, regress back to the TRX-Assisted exercise or try holding two light dumbbells with the arms at the sides.

Kettlebell (Goblet) Bulgarian Split Squat

There are a few advantages to performing the Bulgarian split squat with a kettlebell held at the chest.  First, this promotes a vertical position of the trunk.  Other variations, such as holding dumbbells at the side of the body or a barbell on the back, require the trunk to slightly dip forward.  Second, the kettlebell helps activate the core musculature and cue proper positioning of the rib cage on the pelvis.  It is important to stack the lower rib cage on top of the pelvis.  The abdominal muscles are primarily responsible for this.

2-Arm Dumbbell Bulgarian Split Squat

Holding two dumbbells to the side of the body lowers the center of mass.  For some, this improves balance and stability compared to the bodyweight exercise.  Start with light loads and progress as strength improves. If you prefer, try holding two kettlebells instead of the dumbbells.

1-Arm Dumbbell Bulgarian Split Squat

Holding a dumbbell in one hand increases balance and stability challenges.  Hold the dumbbell in the hand on the side of the trail leg.  This will increase activity to the hip musculature, especially the gluteus medius of the lead leg.  This exercise is more challenging than it looks.

TRX Bulgarian Split Squat

This variation is performed with the trail foot placed in the suspension trainer loop. Position the suspension loop so the trail lower leg is parallel to the floor.  Maintain the trunk in a vertical position.  Maintain the hands on the hips.  The knee of the lead leg should not track excessively past the toes.  Compared to the bodyweight split squat, this exercise shows greater activation of the hamstrings, adductors, gluteus maximus, and gluteus medius.  The suspended position increases stability and balance challenges.  This is a more demanding exercise for the hip muscles.  It is a progression from the bodyweight Bulgarian split squat.  To further increase the challenge, try holding a dumbbell in the hand on the side of trail leg.

Barbell Bulgarian Split Squat

Performing the exercise with a barbell allows for the progression of the load for strength development.  The barbell also causes the trunk to angle slightly forward to support the load.  Before positioning the bar, pull the shoulder blades back.  Place the bar on the base of the neck resting over the trapezius muscles. Tuck the elbows to your side and maintain the retracted shoulder blade position.  With barbell training, heavier loads and fewer repetitions are optimal.  Start with a weight which allows you to perform 6 to 8 quality repetitions.  As always, focus first on proper technique before progressing load on the bar.

Closing Thoughts

The Bulgarian split squat is an excellent exercise for rehabilitation, injury prevention, and strength development.  This exercise requires stability in multiple planes and challenges the hip muscles to control the position of the lower limb.  Performance in many sports involves lower-body, weight-bearing skills in positions similar to the split squat. Sprinting, change of direction, throwing, and kicking require the transfer of forces from one leg in a similar fashion.  If you are unsure about how to best incorporate the Bulgarian split squat, give your physical therapist or strength coach a call.

Muscle Loss in Older Adults: Prevention and Treatment

Loss of muscle with advancing age is referred to as sarcopenia.  This process begins in the fifth decade of life and proceeds at a rate of almost 1% each year.  Declines in muscle strength usually progress faster than muscle size.  Muscle loss with advancing age is associated with many chronic conditions.  These include diabetes, cancer, reduced mobility, disability, and mortality.   It is estimated that 200 million people worldwide will experience sarcopenia that could affect their health over the next 4 decades.

Muscle loss with aging

Muscle loss is quickly becoming a major public health problem with significant clinical, economic, and social consequences.  Prevention and treatment strategies are challenging due to the growing number of older adults above 65.  Exercise and nutritional strategies are considered the primary treatments for age-related muscle loss.  The rest of this article summarizes findings from research on muscle loss in older adults and offers some practical solutions related to exercise.

Diet, Supplements, and Muscle Loss

Muscle is made of proteins.  Amino acids are the building blocks of proteins.  In younger adults (18-30 years old), eating sufficient protein can stimulate some muscle growth by itself.  This can occur with or without exercise in younger adults.  However, muscle growth does not come so easily in older adults.  Therefore, larger amounts of protein in the diet are needed for older adults to preserve or increase muscle.  Younger adults show increased muscle protein rates with the ingestion of 20 grams of protein during a meal.  Older adults require about twice this amount, or 40 grams, to stimulate muscle growth.

Recent research has investigated the role of protein and amino acid supplements for older adults.  The evidence suggests supplementing with protein or amino acids without engaging in an exercise, does little to preserve muscle mass in older adults.  However, increases in muscle size and strength through exercise can be enhanced by certain foods or supplements.    Diets rich in dairy and fish containing polyunsaturated fats make the muscle more sensitive to exercise.  There is also evidence showing protein supplements and creatine monohydrate is beneficial.  Most importantly, research shows that a specific type of exercise, resistance exercise, has powerful positive effects on muscle in older adults.  Resistance exercise is the key to preserving or increasing muscle size and strength as we age.

Resistance Training

Exercise is a highly effective strategy to offset muscle loss.   Exercising with weights has numerous beneficial effects for older adults.  These include increases in muscle mass, strength, power, mood, energy levels, walking speed, balance, and functional performance.  Other forms of exercise, such as aerobic exercise, do not confer these same benefits.  Aerobic exercise, including regular walking, is not enough to prevent muscle loss in older adults.

Contrary to popular belief, adults older than 75 years old can grow significant muscle through resistance exercise.  Heavy weights are not required.  Lighter weights with higher repetitions can result in significant improvements in muscle size and strength regardless of age.  In all cases, the success of any exercise program depends on adherence and staying committed for the long run.  Therefore, it is important to make exercise as enjoyable as possible.  Choose resistance exercises you prefer.  Exercise with friends.  Choose environments (gyms, classes, or in the home) you are most comfortable with.   If you are unsure about how to start, work with a personal trainer or physical therapist.

Developing an Exercise Program to Fight Muscle Loss

Many individuals are unsure about how to structure an exercise program.  Those without resistance training experience or those recovering from an injury have questions about what is safe and appropriate.  How often?  Which exercises?  How many sets?  High or low repetitions? How long should I rest between sets?  These are all excellent questions.  Below I have outlined a list of recommendations for older adults engaging in resistance exercise.  These recommendations are based on research evidence conducted on healthy older adults.

Length of the program

1 year to optimize results but small improvements are often evident after 6-8 weeks.  Ideally, a lifetime committment is best.

Frequency per week

2-3 sessions preferably with one day of recovery between sessions (i.e., Monday, Wednesday, Friday).

Duration of each session

Approximately 1 hour including rest periods between sets and exercises.

Exercises per session

6-8 exercises involving the major muscle groups of the upper and lower body.

Sets per exercise

2-3 sets have been shown to result in greater improvements than single set routines.


50-80% of a one-repetition maximum which is the most amount of weight you can perform properly for one repetition.  An easier guide is to use the recommendations for repetitions per set below.

Repetitions per set

7-9 repetitions per set have been shown to be optimal for strength and muscle development.  This means you should only be able to perform 1-3 more repetitions beyond this range before fatigue becomes limiting.  If you can perform more than this amount without requiring a rest break you can increase the weight.

Duration of each repetition

6 seconds or slow controlled movements are recommended.  Muscle power development requires faster tempos of movement.

Rest between sets

1-2 minutes is optimal.  If this seems like a long time, perform some aerobic activity, such as brisk walking between sets.

Choosing Which Resistance Exercises to Perform

Contrary to the opinions of some, there are no good or bad exercises.  The selection of exercises should be based on several considerations.  This is where a personal trainer or physical therapist can help you get started.  As mentioned, the most important consideration is to choose exercises you enjoy performing.  Beyond this idea, I’ll provide some general recommendations and a few examples.

First, incorporate exercises performed in standing positions as opposed to seated or lying down.  For example, the body weight squat is preferred over a seated leg press.  Second, choose free weights over machines whenever possible.  All machines are not bad but using free weights requires greater muscle activation, control, and coordination.  Third, exercises using multiple joints are preferred over single-joint movements.  For example, the cable row is preferred over a biceps curl.   Finally, incorporate at least one exercise for the fundamental movement patterns such as the squat, hip hinge, upper body push (presses), and upper body pull (row).

Closing Thoughts

Aging is accompanied by a decline in physical activity and function.  Loss of muscle contributes to these changes and is also a consequence of them.  This creates a viscous cycle characterized by muscle loss, weakness, declining function, and developmennt of chronic conditions. Other negative consequences ensue such as osteoporosis and increased body fat.  Exercise can slow down these processes and even reverse them.  In fact, resistance exercise is one of the most effective means to combat the effects of aging and many chronic diseases.  Some have referred to resistance exercise as the, “Fountain of Youth.”  Dietary strategies and supplements can enhance the effects of exercise.   However, there is no magic pill.  Success requires goals, a plan, positive habits, and a commitment.  If you are not sure how to get started, call your physical therapist today.




Strength is the Foundation: Getting Stronger Benefits Everyone

Muscular strength is the ability to exert a force on an object or against some type of resistance. You express strength when hitting a baseball or when standing up from a chair.  Pressing a barbell overhead and carrying your groceries requires strength. Optimizing strength across your lifespan will have profound effects on your athletic performance, quality of life, health, and longevity.

How Strength Impacts Sports Performance

Athletes exert large forces against gravity (i.e., sprinting or gymnastics), against an opponent (e.g., football) or when manipulating an object (e.g., throwing a baseball).  Strength is a limiting factor in many of these athletic endeavors. "Power" refers to how fast force is produced.  Stronger athletes produce more force and do so in much less time. Power is associated with several important sports variables like speed, jumping, and throwing velocity. Improving muscular strength through resistance training is a surefire way to improve power and your sports performance.

Your ability to run, jump and change direction is crucial for success in sports. Enhancing strength improves these characteristics that transfer to sport-specific skills. Stronger athletes jump higher and further than weaker athletes. Strength is expressed when an athlete elevates for a rebound in basketball, jumps to spike a ball in volleyball, or dives to catch a ground ball. Athletes, who produce large forces on the ground, are able to jump higher and further than weaker athletes. This results in a true competitive advantage in many sports.

Strength training after ACL surgery

Stronger athletes are also able to accelerate running over short distances. Elite athletes produce greater forces, with short ground contact times, and with greater stride lengths. Evidence strongly suggests a correlation between maximal strength and running speed1.  Athletes who produce greater amounts of force over a shorter period of time are able to change direction at greater velocities. This is important in basketball or football when attempting to elude defenders.

Becoming stronger is a no-brainer for any athlete looking to jump higher, run faster, or rapidly change direction during their sport. Lateral lunge variations are excellent to improve strength in the frontal plane where many athletic injuries occur.

How Strength Impacts Your Quality of Life in Children

There has been a steady decline in fitness and strength in children across the world. Research shows greater muscular fitness in school-aged youth (4-19 years) is associated with improved body composition (e.g., decreased body fat), and improved risk factor profiles for heart disease and diabetes2. There is also strong evidence between muscle strength and bone health and self-esteem in children2. Therefore, youth physical activity programs promoting strength have many benefits related to overall health and quality of life in children.

How Strength Affects Quality of Life in Older Adults

Sarcopenia is the age-related loss of muscle size and strength in older adults. Loss of muscle mass begins at approximately age 25 and progresses to a loss of 30% or more by the age of 80. Loss of muscle occurs primarily in type II muscle fibers which are highly responsible for muscle strength and power. Therefore, the rate and magnitude of strength loss usually exceed that of muscle mass by 2-5 times.

physical therapy for balance
Lower body strength training reduces fall risk

Age-related loss of muscle strength and bone mass (osteopenia) is associated with impaired functional mobility, compromised balance, and increased risk of arthritis, joint replacement surgeries, falls, and fractures. All of these factors substantially diminish your quality of life. Nearly 20% of women and 10 % of men over the age of 65 cannot lift a 10-pound weight or kneel down on the floor. The age-related loss of strength is also associated with an inability to live independently and premature death3.

Maintaining muscle strength is a key strategy that leads to healthy aging. Sedentary behavior and physical inactivity are key drivers of sarcopenia and can accelerate your loss of muscle mass and strength. Maintenance of physical activity and engagement in a regular strength training program will diminish or even prevent these age-related changes. Pulling exercises or row variations are great for strengthening your upper body and core musculature.

The Importance of Strength for Optimal Health & Longevity

Aerobic fitness is associated with decreased risk for chronic disease and premature death. The health benefits of exercise programs that target muscular strength are less known to the general public. A 2017 study published in the American Journal of Epidemiology showed resistance training reduced the risk of all-cause and cancer-related death to a greater degree than aerobic exercise4. There is now a growing body of evidence suggesting poor muscular strength is associated with death from all causes in both healthy and diseased populations.

hip and knee arthritis

Another review in the European Journal of Internal Medicine reported a reduced risk for all-cause mortality with increased levels of muscular strength5. This association persists even after controlling for age, body fat, smoking, alcohol intake, medications, other health conditions, physical activity, and levels of cardiorespiratory fitness. Handgrip strength has been associated with survival and long-term outcomes in patients with cancer. Muscular strength has also been shown to be associated with long-term outcomes in patients with heart disease.

The health and mortality benefits of muscular strength are related to multiple physiological mechanisms. This includes improved blood pressure, blood lipids, and body composition. Reduced systemic inflammation and reduction in insulin resistance have also been linked to improved muscular strength and mortality.

Based on the available evidence showing a strong association between muscular strength and mortality, adults should perform muscle-strengthening exercises at least 2 days per week in order to reduce mortality risk. For most, basic lower body exercises such as squats and hip hinges are great places to start with a strengthening program.

What You Must Do to Get Stronger

We continuously perform activities during sports and in our daily routine that require the expression of muscular strength. To a certain extent, muscular strength is inherited. However, your strength will never be optimized and will ultimately decline with age unless you do strength training exercises.

Optimizing or preserving muscular strength is strongly associated with improved sports performance, improved quality of life, improved physical function, reduced risk for chronic disease, and reduced risk for all-cause death. This should be sufficient evidence for all individuals, regardless of age or health status, to engage in some form of resistance training today.

See your physical therapist and learn the best way to get started with strength training.


  1.  Suchomel TJ, Nimphius S, Stone MH. The importance of muscular strength in athletic performance. Sports Med. 2016;46(10):1419-1449. doi:10.1007/s40279-016-0486-0.
  2. Smith JJ, Eather N, Morgan PJ, Plotnikoff RC, Faigenbaum AD, Lubans DR. The health benefits of muscular fitness for children and adolescents: A systematic review and meta-analysis. Sports Med. 2014;44:1209-1223. doi:10.1007/s40279-014-0196-4.
  3. McLeod M, Breen L, Hamilton DL, Philp A. Live strong and prosper: The importance of skeletal muscle strength for healthy aging. Biogerontology. 2016;17(3):497-510. doi:10.1007/s10522-015-9631-7.
  4. Stamatakis E, Lee I, Bennie J, et al. Does strength promoting exercise confer unique health benefits? A pooled analysis of eleven population cohorts with all-cause, cancer, and cardiovascular mortality endpoints. Eur J Intern Med. 2017; Ahead of P:1-37. doi:10.1093/aje/kwx345/4582884.
  5. Volaklis KA, Halle M, Meisinger C. Muscular strength as a strong predictor of mortality: A narrative review. Eur J Intern Med. 2017;26(5):303-310. doi:10.1016/j.ejim.2015.04.013.

Warm-Up to Optimize Your Training and Performance

Walk into any gym and you will see people who completely neglect their warm-up. Others spend 45 minutes or more on the foam roller, stretching with bands, or torturing themselves with lacrosse balls. So what is the deal with warming-up before a training session?

The purpose of the warm-up is to prepare your body, mentally and physically, for the upcoming training session, practice or competition. When done properly, your warm-up will improve your performance and lessen your chances of injury.

The Benefits of a Proper Warm-Up

The positive effects of a warm-up occur with an active form.  Passive or static stretching does not get the same results. This is because many of the positive effects happen through temperature-related effects.

Temperature-related effects include increased muscle temperature, core temperature, enhanced nervous system function, and improved connective tissue flexibility. Non–temperature-related effects include increased blood flow to muscles, improved oxygen consumption, and improved muscle contractions.

Other physiological and performance benefits of the warm-up are:

  • Faster muscle contraction and relaxation
  • Improved rate of force development
  • Faster reaction time
  • Improved muscle strength and power
  • Lower stiffness in your muscles and joints
  • Improved oxygen delivery to your working muscles
  • Increased blood flow to your working muscles
  • Increased psychological preparedness

The Basic Phases of an Effective Warm-Up

There are 2 basic phases to a well-designed warm-up. These are the general warm-up and the specific warm-up.

The General Warm-Up

The general warm-up typically consists of 5 minutes of slow aerobic activity like jogging, skipping, or cycling. The aim of this phase is to increase your heart rate, blood flow, muscle temperature, breathing rate, and joint mobility. This is followed by general mobility exercises that replicate the movements required for your upcoming training session.

The Specific Warm-Up

This phase incorporates movements even more similar to the movements of your sport or training session. This includes rehearsal of the skill(s) to be performed. It is recommended the specific warm-up last 10 to 20 minutes with no more than 15 minutes between the end of the warm-up and start of activity (training session or competition).

The warm-up for a game or competition aims to maximize performance in the subsequent event. However, for the training session, in addition to optimizing acute performance during the session, the specific warm-up should contribute to the overall long-term development of the athlete. This is an ideal time to incorporate individualized corrective exercise into an athlete’s program. For the baseball pitcher this may include rotator cuff activation exercises such as diagonal patterns with resistance bands.

Structure Your Warm-Up to Optimize Short and Long-Term Performance

Effective warm-ups should be thought of as an integral part of any training session, not as a separate entity.  Raise, Activate and Mobilize, and Potentiate (RAMP) is an acronym used to describe a more detailed structure for a warm-up2. This builds on the general and specific structure and maximizes both acute and long-term performance.


This phase is similar to the general warm-up and aims to elevate your body temperature, heart rate, respiration rate, blood flow, and joint mobility through low-intensity activities.

General aerobic exercises, like cycling or the elliptical trainer, are inserted here. However, it is more beneficial to simulate the movement patterns of your upcoming activity or develop the movement patterns or skills you will need within your sport.

Instead of treadmill jogging before a squat session, perform walking lunges to prepare physically and psychologically. In this way, your training session, from the start of the warm-up, is targeted at key movement patterns and skills and not just aerobic capacity.

Activating and Mobilizing

Activating and mobilizing refers to the stretching part of a warm-up. Perform key movement patterns required your training session or sport here. This might include corrective exercise for core stabilization or dynamic mobility drills.

Warm-up basics
Skipping and bounding exercises are excellent to incorporate into your warm-up

Incorporate static stretching as corrective exercise if specific deficits exist. Baseball players will insert static stretches for the lats, forearms, or rotator cuff. Any decrement in subsequent strength or power from static stretching is likely very short-lasting.

Performing dynamic warm-up activities following static stretching will override any small transient performance decrements. The focus of mobility exercise is always on actively moving through a range of motion not static stretching. Dynamic stretches are extremely time-efficient. Prior to overhead pressing with the bar, try warming-up with 20 reps of a door slide exercise or band external rotation to press.


Potentiation refers to the specific warm-up and focuses on the intensity of activities. This phase incorporates specific activities that progress in intensity until the athlete is performing at the intensity required for the training session.

Do not skip this phase. It is common to see an athlete proceed from a stretching exercise directly into their first working set of a squat or Olympic lift. This only compromises strength and power output.

There is strong evidence showing high-load dynamic warm-ups enhance subsequent power and strength performance. The more power necessary for the exercise or activity, the more important the potentiation phase of the warm-up becomes. The objective is to include high-intensity dynamic exercises in order to prepare the nervous system.  Exercises which include short bouts of a high-intensity sprints, jumps or throws are ideal.  Try a few sets of 2-3 plyometric jumps performed before getting under the bar for squats.

RAMP Up Your Warm-Ups

Many athletes or fitness enthusiasts are unaware of the optimal structure and performance benefits related to a proper warm-up. The RAMP protocol is a great foundation to structure your warm-up. More importantly, any properly designed warm-up should prepare your body for the subsequent training session.  If you are looking for performance gains for your next training sessions and the long-term, get serious about warming-up.

Your physical therapist will help you develop an individualized warm-up program.  Your physical therapist will fully evaluate your strength, mobility, and movement patterns to determine what the best strategy is.  Call our office to get started.  The doctors of physical therapy at BSR have been helping people in Southern Ocean County move without pain since 2007.  We are here to help you.