After 12 years of marriage I finally succumbed to my wife’s repeated requests to join a family calendar (literally yesterday) as our schedule is just getting to be too busy and I’m worried about forgetting a kid somewhere.

As you can imagine the most important commodity in my life right now is time.  I need more of it and there’s just never enough.

Because of this I sympathize with every North American adult that collectively roll their eyes when they read the WHO or the US Department of Health Services recommendation of required exercise just to maintain optimal health which includes the following:

• 5-3 hours per week of moderate intensity aerobic physical activity (MPA)
• 25-2.5 hours per week of vigorous intensity aerobic physical activity (VPA) or an equivalent combination of these two
• 2 times per week of muscle strengthening exercises (MSE).

I would absolutely LOVE to exercise the minimum 7-10 hours weekly as recommended just to maintain my health, but I already wake up at 5AM six days weekly!

At this point my weekly goal is to exercise 4 times weekly for one hour each exposure.  I usually average 1-2 times weekly for some semblance of cardiovascular exercise and 2-3 times per week doing strength training.  Some weeks I get 3 sessions total in, others I get 5.  I am way past feeling guilty about what I am accomplishing compared to the WHO recommendations because it is just works for me at my stage of life right now.

Being curious, I’ve always wondered just where the recommendations came from and if they are factually associated with a reduction in mortality.  I think it’s safe to assume that everybody understands that exercise has innumerable benefits on one’s entire health profile that can be summed up with this equation I just made up:

More exercise = better health

(Trademark pending).

BUT, what I have never seen studied is exactly HOW MUCH exercise lowers my risk of dying.

I know this is a more binary definition of the benefits of exercise, but to me it’s always been a massive void in my knowledge base.  Essentially I’ve always wondered the following:

“I understand that the more exercise I do the better off I am.  BUT, what is the minimal effective dose of exercise I need to perform to dramatically lower my risk of dying.”

So you can imagine my absolute glee when an article that is the first of its kind confidently answered this question for me.  Not only did it answer HOW MUCH exercise I need to do, but it answered how much light cardio, hard cardio, and how much strength I need to do.  It even looked at combining those three forms of exercise!  It also answered how much benefit I get with incremental additions of cardio and strength exercising beyond this minimal effective dose.

Let’s dive in.

This was an absolutely enormous prospective cohort study of over 416,000 American adults that completed a giant survey that began in 1957 called the National Health Interview Survey (NHIS).  This massive data set is adjusted to produce a representative sample of all US civilians.

In 1997 this survey started collecting data on aerobic exercise, namely Moderate Physical Activity (MPA), and Vigorous Physical Activity (VPA) as well as Muscle Strengthening Exercises (MSE).  This allowed researchers to look back at data from this point, and then compare it with the National Death Index data all the way to 2015 to see how many of these folks ended up passing away.  This means it was a prospective cohort as they were able to follow these folks longitudinally to see an outcome, in this case death.

In total, of the 416,420 participants, there were 45,344 deaths.

Before I get into the results, check out these 2 items that were in the demographic data in the research paper that nerds like me notice:

I was somewhat shocked by this!  The most common BMI category is Overweight for American adults, and over one quarter of the population is either obese or morbidly obese.  Also 21% were listed as ‘current smokers’?  I get that this was from 1997 to 2015 but I feel like I barely know anyone that smokes anymore.  Maybe that’s a positive trend?

Back to the article.

HUGE FINDING #1:

There is an inverse relationship between moderate or vigorous aerobic exercise and mortality risk at just ONE HOUR PER WEEK.  The lowered mortality risk largely plateaus at 3 hours per week. 

To sum this up, look at the chart below.  It is showing that there is a HUGE REDUCTION in your risk of death (hazard ratio) if you complete just one hour of cardiovascular activity and it doesn’t matter if it is moderate physical activity (MPA) or vigorous (VPA).  There is significant added benefit until about 3 hours weekly, and then the benefit plateaus and additional cardio show only slight benefit.

HUGE FINDING #2:

There is a significant inverse relationship between strength training and mortality risk at just ONE TIME PER WEEK but LITTLE ADDED BENEFIT beyond this frequency if the person is also doing cardiovascular activity.

Now the below chart is a bit more confusing.  The x axis on the graph indicates increments of one hour for aerobic activity.  The black dots show people that ONLY do cardio.  The light grey ones show people that do cardio but ALSO do at least one session of strength training weekly.  You can see that the grey dots are incrementally lower than the black dots at each plot along the graph, indicating that including at least one strength session further lowers your risk of death (hazard ratio).  They did find that more strength didn’t really impact the graph, meaning just a single strength session is needed on top of the cardio to get the added benefit!

MODERATELY HUGE (BUT EXPECTED) FINDING:

The association between aerobic physical activity and mortality risk is stronger in older folks. 

When they stratified the data out by age you can see below that there is continued benefit for individuals over the age of 60 for more and more aerobic activity.  For those under 60, the benefit completely levels off at 3 hours and any additional cardio did not lower your risk of death.

So what have we learned?

Before delving into our conclusions, if you feel guilty about not hitting the WHO recommendations, surveillance data in the states shows that 70% of all US adults FAIL TO MEET this recommendation.  I was not surprised by this.  But, one stat that I was surprised by was that 58% OF ALL AMERCIAN ADULTS currently do zero muscular strength exercise at all!

This number is alarming.  We know the numerous benefits of strength training on your health (increasing bone mineral density and insulin sensitivity etc), but likely the most important benefit of strength training is offsetting age related sarcopenia/muscle loss.  This causes frailty and decreased functional independence which are both major risk factors for death.

This paper was one of the first to look at strength training and mortality and is definitely the first to establish a minimum effective dose to reduce your risk of death.  To sum up our strength training conclusion:

There is a marked inverse association between muscular strength training and mortality risk with as little as once weekly.  There is additional mortality risk reduction when it is combined with any sort of aerobic exercise.  There doesn’t seem to be much added benefit for death reduction past 1-2 times weekly (though there is definitely added health benefits).  Strength training 3 times per week as we age can reverse muscle loss and improve physical functioning making us live longer. 

There was a higher association with aerobic/cardio exercise where lower mortality risk is optimized at about 3 hours per week and this held true independent of your age or sex.  When you dig into the data one cool observation was that it didn’t really matter what type of cardio you do whether moderate or vigorous.  Both have a similar positive effect.  What this means for you is that you should really just identify whatever cardio activity you enjoy and stick with that!

To sum up our aerobic training conclusion:

There is a marked reduction in mortality with as little as one hour of aerobic activity all the way to 3 hours, and then it plateaus with little added benefit for those under 65.  This means the WHO guidelines are supported BUT even if you perform cardio below their guidelines you will materially lower your risk of death.  It doesn’t matter what type of cardio you perform.  Interestingly, the total number of bouts does not seem to matter….it’s the ACCUMULATION that matters.  Even repeated 10 minute bouts confer significant benefit.  It’s the TOTAL AMOUNT of time that seems to matter. 

Regarding the added benefit for more and more cardio with age, the researchers think it is likely because physical activity gives people a more robust immune response and helps in the chronic conditions that occur as we age.  Makes sense to me.

So don’t feel bad if you can’t hit the WHO recommendations for minimum exercise.  Now we know that less exercise still offers significant benefit as it relates to mortality.  Below is the final conclusion of the paper that nicely sums up all of the above:

“Regardless of sex or age, our observations suggested that: (1) Significant mortality risk reduction may result from aerobic physical activity performed 1 hour/week, with minimal additional benefits beyond 3 hours/week and (2) muscular strength training performed in combination with aerobic physical activity may further decrease mortality risk, with strength exercise performed exclusively 1-2 times/week resulting in significant mortality risk reductions.” 

Now if you’ll excuse me….I have to go pick up my kids.

The post Finally an answer to HOW MUCH aerobic and strength training is required to lower your risk of death: first appeared on The Proactive Athelete.

Before you read any further I need to address two things.

• This blog is long so feel free to scroll down just to look at the pictures.

• Most of you will have never seen a picture of my wife Jaclyn before. You are going to be startled at the disparity in essentially every quality between us.  I am extremely aware that I ‘married up’ so there is no need to email me to remind me or mention it the next time we see each other.

This whole escapade began back in February when I was mentioning to a few people that I wanted to do something special for my wife’s 40^th birthday.  Since we had our third kid we have never been away alone.

One issue……my wife is what can be described as ‘frugal’.  It’s more that she hates spending any money on herself.   Fine, she’s cheap (which I love).  I knew the only way this would happen was if I just booked something and then told her.

I consulted some very well traveled folks I know and a couple of them suggested California, and specifically Yosemite Valley.

One particular recommendation caught my eye called the Half Dome Cable hike. My thought was simple: Jaclyn likes to be outside, she’s in incredible shape, and I think our marriage would likely survive my incessant complaining on the way up the mountain..…..a hike would be perfect!

I went online back in February and it turned out that this particular route is so popular that they limit it to a pre-season lottery and only allow 225 permits per day (plus 75 for people camping on the mountain).  Some days, up to 18,000 people apply.  The lottery application window was open and I noticed if you are willing to go towards the end of the season you have a much higher chance of winning a date (closer to 1 in 3).  So I chose some dates, submitted and forgot all about it.

Fast forward a month and I got an email saying I had won a permit!

Uh-oh.

I asked the person that recommended the hike some questions.  He completed the hike 25 years prior while living in San Francisco shorty after graduating from college.  His recollection was that you needed a bottle of water and ‘some people may have brought granola bars’.  Feeling confident I consulted Dr. Google and the first site I clicked was this.

A little more reading revealed the last 500 feet of the hike are on slick glacier where you have to pull yourself along two thick cables in the rock surface.  A ranger has to check your shoes before they let you up for grip and you have to wear thick rubber gloves to use the cables.  Some people clip in via harnesses ‘just in case’.

What had I gotten us into?

After convincing Jaclyn the odds against death were in our favour, we set out for California October 1^st.

And then Air Canada happened.  Fast forward 14 hours at the airport, one cancelled flight and another delayed flight and we were off!  (Thank god we left our 3 kids at home!)

We arrived at Yosemite after a day in San Francisco.  Our half dome hike permit was for our second full day there.  Normal people would have taken it easy on the first day, knowing they had over 8,800 feet to climb on day 2.  But normal people are not married to Jaclyn.

Instead, we did a famous hike called The Four Mile Hike which inexplicably is actually a very difficult 9.6 mile (15.5km) round trip hike straight up via switchbacks to Glacier point 7,220 feet, and then right back down.

Was it worth it?  Well here are the ‘yes it was worth it’ pictures.

(My wife overlooking the valley at sunrise)

That bugger in the back is the Half Dome which we inexplicably chose to hike to celebrate her birthday.

And here is a pic from the view at the top of Glacier point.

The case that maybe we shouldn’t have done it was two-fold.

• Here is a quick video of ‘two little friends’ we met about 30 minutes into the hike. For those that don’t click it’s two little bear cubs less than 30 feet from us.  About 15 seconds in I realize if there are two little cubs, there must be a mom somewhere.  I’m the rational one in the video that says “lets get out of here”.  To which Jaclyn replies “No, get a picture”.  Ladies and gentlemen….my wife Jaclyn.

https://youtube.com/shorts/ZWLQxVsqQcI

• I had trouble getting out of bed the next morning because my legs were so sore. Not exactly what you want for what would be the most physically challenging day of our lives.

Half Dome day began as good as any day that starts with a 4:30AM wake up call to hike a total of about 29km to 8,844 feet total elevation (the hike itself is about 5,000 feet from the valley floor).

We made it to the start of the trail right at 5:30AM and started the climb.

We ended up doing a fair bit of reading about the hike.  We knew you wanted to get to the cables early.  It’s much more daunting (and scary) if too many folks are on the cables at the same time.

We were a little alarmed at how many people started before us.  We passed people that started as early as 2AM (they wanted to watch the sunrise from the half dome).  Another group of hikers that we passed started at 4AM.  There were LOTS of people ahead of us, so we started by just putting our heads down and climbing.  We made great time before the sun came up and were rewarded with this view at Vernal Falls.

(Note: most deaths on this hike actually happen here by people trying to get too close to the falls, and not on the cables).  Don’t worry, there was a railing there to protect idiots like me from falling in.

At this point I was drenched in sweat.  I’m not exaggerating. I looked like I had just finished running a marathon.  On one hand this was funny because of how ridiculous I looked but on the other hand it was a bit worrisome.  For the entire 29km hike, the LAST place to get water is just 1.5km up.  You have to wear all the water you think you will need.  Did I mention it was an unseasonably hot 80 degrees outside?  Jaclyn wore 2L of water, and I carried 7L (some was for her…..I’m not a monster!)

We put the headlamps away and continued on to Nevada Falls.

At this point the Half Dome hike kind of gives you a head fake.  You get to walk on a steady incline through a forest of beautiful sequoia trees.  You occasionally get glimpses of the half dome and think you are almost there.

Then you hit the Sub Dome.

This was BY FAR the most brutal part of the day (even worse than the actual cables).  You are already over 8,000 feet up so fatigue sets in a bit early due to the elevation.  There are hundreds of big steps that seem straight up on exhausted quads.  The path is no longer set.  In fact there are sections with no stairs that you just have to pick a piece of granite, lean forward and walk up (making sure you don’t slip!).

But the WORST part by far is that no one is prepared for it.  Every person we met later in the day said the same thing “why the heck aren’t the instagrammers and bloggers warning us about the SUB DOME?!”

One memory that Jaclyn giggles about but I did not find funny at the time was getting over the subdome when the trail was essentially gone.  We had to choose a path as there was nobody around us.  Jaclyn scampered up a route holding on with both hands and told me to follow.  I started to go up, and quickly realized if I slipped things could turn out really badly.  I essentially laid down and came up in an army crawl, with her laughing in the background.

Two young Aussie guys were coming down the mountain after already being up and down the summit.  They saw me struggling and they looked at my shirt, which happened to be my work shirt that said “Expand your comfort zone”.  One of them looked me in the eyes, and said “Don’t stress mate…..every time you worry just think about what your shirt says”.  

I swear on my life that this actually happened.  It immediately put me at ease and off we went (you can see me in my Proactive Athlete shirt here right before going up the cables).

At this point we had finally hit the cables.

(those little things that look like ants in a line are a few people on the cables)

Now I would describe myself as not being particularly scared of heights……but definitely being scared of death.

Jaclyn and I made the decision before hand to wear harnesses and carabiner’s to clip in if we felt uneasy.

We likely passed somewhere between 75 and 100 people on the way up the hike.  When we got to the cables we were very happy we did.  Only about 4 or 5 folks were on the cables when we got there.  It only took us about 15-20 minutes to haul ass up the half dome.  We didn’t end up using the carabiners on the way up as we had the luxury of going at our own pace and holding onto both sides.

Every 10 feet or so there is a piece of wood that spans two poles that sit loosely in the granite.  Despite the face that you can pull the poles out, you can kind of lean into the planks to pause and catch your breath.  Because it was the end of the season some of these pieces of wood were missing, so at times you had to pull yourself up about 30-40 feet at a time.  Our strategy was to just keep our eyes on the next set of poles/wood, take breaks when needed, and not look to either side to reduce anxiety.

Once at the top we breathed a big sigh of relief, and just took in the magnitude of where we were.

(this was a pic from the very top after finishing the cables)

We made friends with a couple of young Aussies and took some of the classic iconic photos people take on the Half Dome.

(If you zoom in really closely on that second picture, that’s Jaclyn and I standing on the edge!)

My wife has no idea how amazing a person she is.  She is the proverbial rock in every relationship.  In our marriage, with our kids, at work, with her family and friends.

Sometimes with people that you are just used to depending on, we forget to thank them and let them know just how important they are.

I ended up getting Jaclyn’s four best friends to write her letters outlining just what she means to each of them and made her read them on the Half Dome.  We met people from Australia, Italy, France, Germany, Asia, and even Burlington Ontario at Yosemite, but Jaclyn was the only one on top of the Half Dome with her shoes off eating a peanut better and banana sandwich nearly choking trying to fend off tears.  What a memory.

The next problem was getting down.  When we got to the top of Half Dome there were around 15 or 20 people up there.  By the time we left that had swelled to over 50.  When we started the descent along the cables there were at least 50 to 75 people on them.

This is where things get dangerous.  You cannot pass people going up the cables as it’s too dangerous so unfortunately you are stuck going at the pace of the slowest person.  But when there is two way traffic (some going up, others going down) things can get hairy.  It is safest when you have one hand on either cable at all times.  When someone is passing on the way down, you both have to hug just one cable.  When it’s really busy, some crazy people go down on the OUTSIDE of the cables because they don’t like the slow pace and the traffic.

The people that were starting as we descended would have been on the cables over an hour to get to the top which would have been exhausting and can be dangerous.  We took our time on the way down (you go down backwards for the most part).  Jaclyn clipped in with her harness.  I found it too annoying and problematic to constantly unclip and clip in around every pole each 10 foot section so while I wore the harness I didn’t end up using it.  At the end of the day it’s about your comfort level.  Most people don’t even wear a harness but we wanted the option in case we felt anxious.

Once back down the cables, we were elated, took some more pictures and then realized we had 16km more to hike……downhill this time.

Intuitively you would think the descent down the mountain would be way easier.  You would be wrong.

We both found this part tougher on our legs (and particularly our knees) then the ascent.

We took a slightly longer route down at the end because it was a trail we hadn’t been on.

I’d say we made the right choice with these views.

We stayed at a famous architecturally protected hotel that night called the Ahwahnee.  I had to book the room in April for a stay in October to give you an idea of how popular it is and that was after checking every day for 3 weeks.

Not a horrible view from our room.

I had booked the formal dining room that night for dinner.  You will notice a few things from this picture:

• We earned our dessert that night.
• I am extremely sunburned
• I can barely keep my eyes open.

And that was that.  29km of hiking.  We both felt an extreme sense of accomplishment at what we had done. People have ascended Half Dome from age 12 through age 71!  Seeing some of the folks along the hike that were doing it was really inspiring.

We met people from all over the world.  Everyone was extremely friendly and communal about sharing one common goal together.

You would think we slept in and ordered room service the next morning, but again you don’t know my wife.

This time, we took it easy and set our alarm much later…..5AM.  We wanted to hit the 800 year old Sequoia trees in Meriposa Valley on our way out of the park.

Yes it was worth it.

A couple of interesting items people have asked me about:

We took over 47,000 steps that day, and climbed the equivalent of nearly 300 flights of stairs.

Those of you that know me know I have a bit of a caffeine addiction.  These little beauties were life saving.  Each bar is the equivalent in caffeine of one coffee.

For food you want light items that are calorie dense.  We packed the perfect amount.  We had items like organic turkey pepperettes, RX protein bars, Larabars, peanut butter and banana sandwiches, and high caloric trail mix.  The only poor choice were sliced apples which spoiled due to the heat in my backpack by the time we summitted.

The 9L of water was enough.  We drank what we needed on the way up and just slightly rationed on the way down but were never thirsty.  We also brought a fancy water purifying pump which is recommended as you can get water from a stream called the Mercer river about halfway up.  We didn’t end up needing to use it.

Yosemite valley was the most beautiful place either of us have ever been.  I would recommend it to anyone and everyone.  There is so much to do you can have any sort of adventure.  There were people there from infants, up to their 90’s.  On the 4 mile trail we even met a guy in his sixties that had both of his knees replaced.  He was hauling ass!  He mentioned he was there to try and do all 7 of the hardest hikes there.  What a beast and it shows you our human potential!

Did our kids survive?  Only my little guy had a rough go, but it was his first time away from us completely.  He had just turned 4 and is very attached to his mommy as he didn’t go to as much daycare as our other two due to COVID.

My parents moved into our house and stayed with the kids.  I think they likely slept for a full week when they got home.  Here’s a pic of me and my boys watching the Jays game the day after we got back.  My little guy essentially had to touch Jaclyn or I the entire day.

Ok, just a few more pics that I liked.

This first one is right when you enter the valley.  It is called “TUNNEL VIEW” and is iconic because during the American civil war when the pioneers from Yosemite tried to protect/conserve it as a national park, they sent a huge package to Abraham Lincoln with drawings, paintings, biological deposits and everything they could think of.  The front cover was this photo (without Jaclyn of course) of Tunnel View to which Abraham Lincoln immediately signed it into conservation stating that something that beautiful must never be ruined.

For climbing fans, Yosemite Valley is considered the ‘mecca’.  If you watched the movie Free Solo of Alex Honnold climbing El Capitan with no equipment or the Dawn Wall, here is a picture of what that mountain actually looks like.  There are numerous climbers on here at the time this was taken, and they are SO SMALL that you can’t even see them.  It is difficult to comprehend the fact that he did this.

Finally, we got a real kick out of this bus.  I think it may just be a permanent feature at Yosemite.  I’m also assuming it has been there since the 1970’s.

The post Pete’s trip to Yosemite Valley first appeared on The Proactive Athelete.

The dogmatic and reflexive answer to that question in the fitness industry is of course higher intensity work can burn fat more efficiently and effectively.  

But when Pete summarized results from an important meta-analysis looking at body composition changes, the effects on fat loss weren’t substantially different.  So was this a devastating blow to the high intensity interval zealot crowd? OR Was that review an indication that we need to better understand the nuance of this issue.   

In that genre of research, fat loss was measured by individual body composition before and after an interval program or steady state cardio program that was 4 weeks or more in duration.  Essentially, how much lean muscle mass and fat mass do you have before and after the study period.  It’s a crude 30,000 foot view of the issue, which is often helpful in pointing us in a direction, but potentially incomplete or insufficient to definitively resolve the issue.      

A recently published meta-analysis took a stab at this same question using a different outcome measure, fat oxidation through indirect calorimetry.  Instead of measuring body composition before and after the research period, these studies included in this review evaluated the ratio of respiratory exchange of oxygen and carbon dioxide.  This gas exchange measurement has been shown to correlate well to fat loss.  

All of the participants included in these studies exercised on a bike or treadmill in the lab, wearing a mask, measuring gas exchange during a specific exercise protocol (mostly) 3 sessions per week.  

You might argue that measuring the primary outcome measure of body fat seems more significant than respiratory measure that correlate well to fat loss…however the advantage of this type of research is it’s conducted in highly controlled lab environment with real time data.  In the research world more rigorous control over the study design means better confidence in answering the primary question being tested.    

18 studies, with over 500 participants, were included in this systematic review and meta-analysis of high intensity interval training (HIIT) and sprint interval training (SIT) versus moderate intensity continuous training (MICT) or no training at all.

High intensity interval training was defined to be as inclusive as possible in this review setting a relatively low threshold of 75% or greater using heart rate or VO2.  Sprint interval training is much higher intensity output, think of it as a supramaximal output, that can be sustained for only 30 seconds or less and requires much longer rest intervals in between bouts. 

HIIT and SIT were both found effective at increasing fat oxidation compared to no exercise at all (didn’t need the study for that conclusion).  The authors categorized that effect as small but much larger for individuals who are overweight or obese or for people who engage in this type of training for longer periods of time (ie. 12 weeks or longer).  Not surprisingly if you have more fat to lose to start with you have a greater potential for fat loss.  This is the law of diminishing returns at work.  The dose specific response for HIIT and SIT on fat oxidation is also important; 4 weeks of training may give you a fat loss boost, but keep at it for longer and the results are cumulative.

9 of the 11 studies that compared HIIT or SIT to MICT found greater fat oxidation with higher intensity work.  The weighted conclusion pointed (although modestly) in the direction of an advantage for HIIT or SIT.

And so, in this alternative review, from an alternative body of research, the pendulum now swings back in favour of higher intensity work offering a (slightly) greater advantage.

This is in contrast to Pete’s conclusion to this same question just a year ago.  Two high quality systematic reviews with meta-analysis, using slightly different outcome measures, and two different conclusions.  Isn’t dissecting the research fun 🙂

From a practical perspective you can argue that adding sprint training or high intensity training offers incremental gains in fat loss over steady state cardio.  And it is a much more time efficient way to get in a great workout.  7 minutes or less, after a warm up, (5 bouts of up to 30 seconds with at least a minute rest between each) and you are on your way.  However, forcing yourself to sprint may not be worth the psychological torment for a minor bump in fat loss.

The enjoyment factor is a very real concern.  It’s so significant that Porteguese researchers have developed a questionnaire to help clinicians better understand client exercise preferences. https://link.springer.com/article/10.1007/s12144-021-01718-3 The perfect exercise routine you don’t want to do isn’t going to last very long.  

We’ve said this many times before: consistency in your program trumps all.  Do a form of exercise that excites, motivates and/or inspires you.  Because without that foundation you can’t provide a frequent enough stimulus to develop the physical quality you are looking to improve (whether it’s flexibility, strength or cardio).

So what’s the best type of cardio for fat loss?  It’s the one you love doing the most; and if you love them all, then HIIT and sprint for the fat loss win!

The post What type of cardio exercise is best for fat loss? Sprinting (if you want to) first appeared on The Proactive Athelete.

The post The Stability Row – video first appeared on The Proactive Athelete.

While most people go to Costa Rica for the climate, the ocean, and the Pura Vida,  Dave and I got most amped up at a coffee demonstration.  That’s us wafting the aroma while our kids are likely somewhere in the background bored out of their minds.

I have a long history with coffee.

Throughout high school I worked at a little golf course in Oakville.  Being the youngest on the crew I was frequently assigned the best and most challenging tasks (getting coffee for everyone).

I always remember one of the grounds crew guys named Abe specifically for his coffee order.  Most of us 5:30AM workers would order an extra large black coffee, some would order a regular and the occasional person would order a double double.

Abe would order a double, quadruple.  That means 2 creams and 4 sugars.  He would drink at least 3-4 extra large of these daily.

We used to tease Abe and say the consistency of his coffee was more like sand than liquid.  He said he ‘needed the sugar rush’.

Over the past handful of years numerous studies have been published showing that drinking coffee has a positive impact on longevity.  Typically they have a catchy headline like “drink more coffee to live longer”.  As someone who automatically assumes a catchy headline like this means the underlying studies are flawed, I have been pleasantly surprised to see the consistency in this research.  In general we don’t know the mechanism, but on observational studies, drinking coffee (not just having caffeine, but actually drinking coffee) seems to reduce your risk of dying.

But not all coffee is created equal.  What about Abe and is double, quadruple compared to my black coffee?  What about the exponential rise in caramel macchiato’s and other drinks that better resemble dessert than a morning cup of joe?

Recently a headline catching study was completed in a prestigious medical journal looking specifically at how many cups of coffee you consume and your risk of dying. But this has been done over and over so who cares?

The important difference with this study compared to all its predecessors is for the first time ever it also looked at your risk of dying by regularly drinking coffee with sugar versus black coffee.

Read below for the very (and non-intuitive) findings, but as an added bonus at the end of this article, we reveal how much coffee each of our staff at The Proactive Athlete drinks, and how much sugar they have in it.  The reason I have included this is entirely for your benefit so you can judge us.

This study utilized data from the U.K. Biobank, one of the largest health databases ever created.  The Biobank is a huge cohort study of over 500,000 people aged 37-73 from 22 centres across the UK.  From 2006-2010 this project saw volunteer participants complete massive amounts of questionnaires, family history data, nutritional data, as well as physical and medical tests.  These participants were then followed for years to assess health outcomes and to allow researchers a massive dataset to use in a prospective manner allowing them to draw high quality conclusions.  Essentially it means they can group people together based on any kind of variable, create a hypothesis and then follow them along to see what happened in real life.  Very cool.

For this study, they included folks that completed at least one 24 hour dietary recall questionnaire as part of their intake.  In total, 171,616 people were included.  From the questionnaires, they found out how many cups (250ml) of coffee people drank in a day, the type of coffee (instant, ground, or decaf), and how much sugar was added to their coffee.

The outcome measure was simple.  Death.  That sounds bad, but it is simple, straightforward and easy to follow.  The researchers simply looked at death certificates in England and Scotland to corroborate this.

Before getting into the mortality results, here are some interesting facts about coffee intake across a broad spectrum of a population in the UK:

• Of the 171,616 participants, 75.8% were coffee drinkers (Tea drinkers were excluded).
• The average person has coffee with 1.1 teaspoons of sugar or artificial sweetener added (more on this later).
• Non-coffee drinkers were more likely to drink tea (but remember the study was in the U.K where tea is part of the social fabric).
• Males were more likely to drink coffee with sugar. The same goes for smokers, those with less healthy diets, and those from a lower socioeconomic class.
• Those that used artificial sweeteners were more likely older, former heavy smokers, and obese with hypertension, diabetes, depression and had a family history of cardiovascular disease.
• Those that drank unsweetened coffee (black coffee) ate a healthier diet and were from a higher socioeconomic class.

That is great, but what about the risk of mortality?  Well here is where the data became quite interesting.

• Over the 7 year follow up there were 3177 total deaths. Of those, 1725 died from cancer, 628 from cardiovascular disease and the rest from all other causes.
• Overall, the amount of coffee one consumes creates what is called a U shaped distribution. Those that drank no coffee obviously had the same risk of dying as the control group (because the control group were people that did not drink coffee).  With each successive cup of coffee one drinks, the total risk of dying decreases.  This decrease maxed out around 3 cups of coffee for the unsweetened group and about 2 cups for the sweetened group.  and then slowly crept back up towards the control group after about 4.5 cups of coffee for the unsweetened group and after 3 cups for the sweetened group (see chart below).
• Very interestingly, the U shaped association with sweetened coffee was very similar to unsweetened coffee (more on this later).
• Overall, drinking about 3 or 4 cups of coffee, whether sweetened or not, reduced your risk of dying by about 30% in the study period compared to those that did not drink coffee.
• The association with artificially sweetened coffee was less consistent and non-conclusive statistically.
• The risks for different types of coffee consumed (instant, ground, and decaf) were consistent. So this means it did not matter which type of coffee you drank, the lowered risk of dying was the same across the board meaning it is not the caffeine that is causing this outcome, but something else about coffee that lowers your risk of death.

This is the ‘U-shaped’ distribution from drinking coffee and your total risk of mortality.  The left side of the line shows something called your hazard ratio which you can think of as a statistical comparison with a control group (in this case non-coffee drinkers).  So if you drink no coffee, and are compared with a group that drinks no coffee, your hazard ratio is 1.0.  As you move along the X axis, showing more cups of coffee drank, you will notice a lowering of the hazard ratio.  At about 3 cups, you get your maximum lowering for both unsweetened (2 cups for sweetened coffee).  After this it levels off the more you drink for unsweetened, but there is a sharp incline for sweetened, showing that drinking too much sweetened coffee is not great for longevity.

Before the big reveal of how much coffee we all drink, let’s talk about a few huge caveats to this important paper.

The editor of the journal (the annals of internal medicine) actually wrote an accompanying letter to the article which shows just how important this paper was.  One interesting point that she brought up was that this study was from data collected on average 10 years ago and from the UK.  ‘Sweetened coffee’ was defined as coffee with just 1 teaspoon (4 grams) of sugar.  As a comparison, one of Stabucks most popular drinks (a grande Caramel Macchiato) has a whopping 33g of sugar.  With whipped topping it is over 44g.  That is 8-11 times the amount taken from the data in the study.  Even a delicious plain old latte has 17g of sugar.  So just a single latte is the same as drinking 4 cups of sweetened coffee in this study data.  A caramel macchiato puts you off the chart above.  So interpret this data with caution.

Another important point is that in general those that drink sweetened coffee often drink this in lieu of other very sugary drinks such as power drinks and soda.  Overall the total sugar ingested in their diets is much higher so it becomes more difficult to draw conclusions about the coffee specifically.

So what have we learned?

• Drinking coffee seems to have a decrease in mortality.
• This is maximal at around 3 cups for unsweetened coffee drinkers and levels off the more you drink.
• This is maximal at around 2 cups for those drinking sweetened coffee (1 tsp of sugar) and then rises the more you drink after that.
• The cumulative decrease seems to be about 30% at its maximum which is quite significant.
• Interpret the sugar data with caution. Though the headlines are catchy (“drinking coffee with sugar makes you live longer”) this is from 10 year old data.  Today’s drinks have WAY more sugar and you have to look at total sugar ingested to draw meaningful conclusions.

Ok, time for the big reveal in order of least to most drank.  Remember there is a U-shape where drinking too little or too much have minimal effect on longevity, with around 3-4 cups as optimal.

Carolynn: 2 latte’s per week total so roughly 0.33 cups per day sweetened.

Larissa: 3 cups per day unsweetened

Cara: 3-4 cups per day unsweetened

Kate: 3-4 cups per day unsweetened

Dave: 4-5 cups per day unsweetened

Adam: 2 fancy turbo Americano’s from Tamp (6-7 cups equivalent)

Pete: 6-7 cups per day unsweetened

Alex: 3-4 cups per day unsweetened

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It’s no surprise that our fitness takes a hit when we get sick, with any illness.  Generally just the time on the couch will have its deconditioning consequences.  But this coronavirus and it’s many mutations, seems to do a special number on our cardio-respiratory system and our overall fitness.

Pete knows this struggle first hand.  He was in the early phases of a run training plan for a half marathon, when he and his family had a bout with Covid.  It was a fairly unremarkable course, but getting back up to speed for his training plan has been a bit trickier.  The legs aren’t there, the lungs aren’t there, and any short quick increases in intensity forces him to back right off, feeling unwell and forcing him to stop.

Pete is not alone in his struggle to get back to regular training and more generally get back to their pre-infection fitness level.  Many of our patients recovering from Covid are also in the same boat.  They have tried to jump back in, but hit a wall, get frustrated or demoralized, and some unfortunately give up.  This of course compounds the issue, as time ticks on and the mountain to get back in shape seemingly gets steeper and longer.

We don’t have a cookbook formula here, but we do have some thoughts worth sharing to give you some action steps.

What do we know about exercise and Covid-19?

Physical activity can play an important role modulating some of the comorbidities associated with poor outcomes from Covid-19 such as hypertension, cardiovascular disease, diabetes and obesity.  It is therefore not a surprise that a large observational study found that physical inactivity is directly associated with higher risk for severe Covid-19 outcomes.

Some authors have proposed mitochondrial fitness (the energy producing powerhouses of our cells) are the key to our antiviral defence.

And how do we build up this mitochondrial efficiency?  Through training, specifically training that challenges our aerobic (oxygen utilizing capability).  This is sometimes more broadly called cardio-training or cardiovascular fitness which can come in many forms (yes some weight training programs can have a cardio focus!).

Cardiovascular fitness may in fact be one of the most impactful modifiable health factors you can address to prevent complications from contracting Covid.  I cannot stress this enough.

When should I start?

Early guidelines published in the Lancet Respiratory Medicine recommended prolonged rest after infection, 10 or more days from symptom onset, plus 7 days from symptom resolution.  In our experience, that’s on the conservative side of too much rest, especially considering how and when symptom resolution is defined.

A more recent recommendation from the American College of Cardiology (ACC) recommends 3 days of rest for those who have asymptomatic cases after a positive test.

In mild symptomatic cases the ACC recommends waiting until symptom resolution, before starting to think about getting back into an exercise routine.

We agree with the ACC recommendations, but in addition, there are a proportion of people with long-haul Covid symptoms.  In these patients, symptoms can linger for months, and overall recovery appears to plateau.  In these cases we may recommend re-initiating your exercise plan before full resolution of symptoms, although the exercise plan may be slightly more conservative.

How should I start?

A recent article in the Washington Post promoted the NSCA guidelines for safe return to training following inactivity as a guide for return to activity after Covid infection.  In general these guidelines recommend a progressive return to full intensity exercise over a period of 4 weeks.  Starting out the first week your volume and intensity should be no more than 50 percent of your maximum usual exercise, followed by gradual weekly increases to 30 percent less than usual, 20 percent less and 10 percent less than usual by week 4.  We agree entirely with the overarching message: start slow and progressively build up your fitness.

However, getting back in shape in 4 weeks is not straightforward post Covid.  Symptoms such as chest tightness, coughing or difficulty breathing are common in these cases with higher intensity efforts.  This recovering cardiac and respiratory functioning is quite different than just inactivity.

The NSCA guidelines were published in 2019, and were not designed as a Covid specific recovery plan (it was designed to prevent sudden cardiac death, exertional heat illnesses and exertional rhabdomyolysis), although it is a nice framework that could work in cases where covid complications were minimal.

Cardio Zone training

As an alternative to the NSCA guidelines, we recommend a cardio zone training approach.  If you are an endurance athlete you will be familiar with this training method.

All you need is a heart rate monitor and a cardio plan.  That could be a bike, treadmill, rower, elliptical etc.  Something to allow a consistent effort over a prolonged period of time.  If you are an experienced runner, running could be an option as well.

Heart rate zones are heart rate ranges relative to your maximum heart rate that signify levels of cardiovascular exertion.  Each level has a physiological cost or stimulus which we can harness to train certain energy systems.  This chart below from Whoop details the typical zone ranges and typical fitness goals attached to those zones.

The first step to utilizing zone training is to calculate your maximum heart rate.  The traditional, old school, method is to subtract your age from 220.  However this over simplified equation does not take into account the many variables such as genetics, training history or other modifiable health decisions (smoking etc).  Other similar formulas have been tested such as the Tanaka (208 – 0.7 x age) or the Gulati (206 – 0.88 x age for women), but again broad generalizations limit the accuracy.

The best way to test max heart rate, is to measure your heart rate under maximum cardiovascular exertion conditions.  However, we would not recommend testing your maximum heart rate capability if you are recovering from Covid.  So one of the formula’s above will suffice to start.

The foundation of cardio training is Zone 1 and Zone 2 training and to a lesser degree Zone 3 and Zone 4 and very infrequent sprinkling of Zone 5.  One example of an endurance program’s percentage of time spent in each zone is seen below.

Zone 1: 30%-40% of your time

Zone 2: 40%-50% of your time

Zone 3: 10%-15% of your time

Zone 4: 5%-10% of your time

Zone 5: 5% of your time

For recovery from Covid, there is some risk of symptom re-aggravation and system overload (for example myocarditis) with high intensity training.  Although estimates of post Covid myocarditis have now dropped to as low as 1-2% , it is still generally agreed that “too hard, too quick” is the biggest risk for a severe outcome due to exercise.  And unfortunately there have been many cases of athletes having sudden cardiac events (post infection and post vaccine), so it is important to err on the side of caution.  In addition to an acute cardiac event, more commonly it may re-ignite chest tightness, respiratory distress or a coughing fit that is uncomfortable and undesirable.

Zone 2 to get through

Zone 2 is the maximum level of exertion that is entirely mitochondrial oxidative phosphorylation before you start to accumulate lactate.  This means you can go longer and won’t require the same length of recovery before your next training session.

Training at zone 2 subsequently improves mitochondrial efficiency and mitochondrial density, which is key to building cardiovascular fitness.  Other physiological adaptations subsequent to Zone 2 training are improved stroke volume (amount of blood volume pumped per heart beat), improved oxygen delivery and utilization and improved V02 max.  In essence better heart and lung function combine to result in improved cardiorespiratory fitness.  It is these adaptations, among others that we believe can help nudge you forward, while preventing the big setbacks or consequences of going too hard.

So what did this process look like for Pete?

After a 2.5 week hiatus from running Pete started at the lower range of his Zone 2 with a slow paced 5km (remember he was training for a half marathon pre infection).  For the first 2 weeks, he did 6 runs all within Zone 2 with minor variations in pace and distance.

Of note: he did test an interval run in Week 2 as well but was forced to stop as he “felt like crap”.

Week 3 he started the week with another 5km run keeping a zone 2 pace.  This is the first run he felt really good.  Because of this renewed feeling in week 3, later in the week he did an interval workout on the bike with some of the spikes entering zone 3 and 4 for very short periods.  This also felt good.  For his last training session in week 3 post infection he increased his running distance to an 8km run with a portion of the run at a quicker tempo.

Now entering week 4, Pete is back in the saddle training for his half marathon.

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My favourite book is Fooled by Randomness.

In another life I would have studied mathematics or physics.

My favourite games are games of probabilities.

I believe it stems from being a kid and obsessing over sports statistics.  I recall every morning over cereal made completely of sugar (fruit loops and captain crunch were personal favourites) having the sports section of the Toronto Star spread out and studying every statistic imaginable, often missing my bus and driving my parents insane.

Because of this, the lens with which I view the world is typically governed by probabilities, both for the upside and down.

Recently a study came out that likely has the strongest statistical evidence for a single factor to reduce all-cause mortality
(essentially your risk of dying) that has ever been published.

It likely has a stronger association than smoking, or your body composition.

The thing I love the most about it, is that it is an extremely simple variable that nearly everyone can control in their daily lives.

That factor?  Walking.  Get ready for a completely wild ride into just how important walking is to reduce your likelihood of dying.

This study was a meta-analysis of prospective cohort studies.  Simplistically, meta-analyses are where you take similar studies and group their data together to be able to draw stronger conclusions then taking a single study in isolation.

Prospective Cohort studies are considered some of the highest quality research out there.  It is when you provide an intervention or observation (like walking), and follow groups over a time period to evaluate a particular variable (like dying).

Combining the 2 in a meta-analysis of prospective cohort studies is as high quality research as you will find.

This particular study looked at something called a hazard ratio.  In an overly simplistic definition, this is the chance of an event happening in a study arm versus a control arm.  (Keep this in mind for later).

This study grouped 7 prospective studies together for a total of 28,141 participants.  There were 2310 cases of all-cause mortality (meaning 2310 people died).  The studies were between 5 and 10 years long so had a decent amount of time attributed to them.  Typically, they measured step count via a pedometer or accelerometer over 7 consecutive days as this is considered a good proxy for how much somebody walks.

Based upon all of this information they were able to create hazard ratios (your risk of dying) for every 1000 steps walked.

Here is what was found:

That’s a messy graph and chart.  Let’s explain.

The chart on the right shows the step count per day and your hazard ratio for all cause mortality.  The lower the number the better.  They used 2,700 steps as a baseline to compare the risk to.  An example at the extreme would be the 16,000 step group.  The hazard ratio from walking 16,000 steps compared to 2,700 steps is 0.34.  This means you have a 3 fold higher chance of dying by averaging 2,700 steps per day compared to 16,000 steps per day!

That may seem extreme (because it is), however if you look at the chart and accompanying graph, you will notice a very straight, linear relationship between hazard ratio going down as step count goes up.  In fact;

“….we found that each 1000 steps per day increment was associated with a 12% lower risk of all cause mortality in the general adult population and a 13% lower risk in adults older than 70 years.” 

That is absolutely astounding.  Something as trivial as average 5000 steps per day versus 4000 steps lowers you risk of all-cause mortality by 12%.

Right away, my brain went to the fact that correlation does not imply causation.  Perhaps it’s just that healthier people tend to walk more.  Maybe walking is an overall indicator of somebody’s health and is not a targeted ‘intervention’ and this just reflects people’s general health status.

In reading for this article, Greg Nuchols who is interestingly a massive body builder and far from an endurance athlete pointed out that a 2015 meta-analysis looked at walking as an intervention.  They found over just 1 year, participants had a decrease in blood pressure, resting heart rate, body fat %, BMI, cholesterol and depression.  Walking also increased VO2max, a 6 minute walk distance test and overall scores of physical functioning.  Every one of these things can be associated with all-cause mortality.  The positive effects of them all together would be massive.

It was at exactly this point that I realized I’m wrong as usual.  Walking likely can indeed be used as a specific intervention to reduce your risk of dying.

In fact Greg must think like I do…..in probabilities.  To put further emphasis on the importance of the above statistics, he compared the article to known risks with smoking and Body Mass Index.

Cigarette smoking puts you at a 70-80% higher rate of all cause mortality.  I doubt I’m blowing anybody’s mind with that one.  BUT, remember earlier in the article were I noted that walking 16,000 steps compared to 2,700 steps had a THREE FOLD increase in all cause mortality.

While you stew on that one, he also pointed out that a BMI above 30 is ‘only’ associated with a 4% increase in all-cause mortality compared to a BMI of 23.  And a BMI of 40 is associated with a 74% higher risk.

So statistically, the argument for being sedentary as an independent risk factor for all-cause mortality (walking just 2,700 steps compared to 16,000) MAY BE a larger risk for all-cause mortality then smoking OR obesity.

And what about the 10,000 steps that I feel every single patient I see strives to hit?

One thing I found interesting is that the strongest statistical evidence for a hazard ratio is if it is over 2 or less then 0.5.  Look back at that chart.  You will see the hazard ratio dips below 0.5 at the 10,000 step mark, making this the ‘cut point’ for the strongest evidence.  It also means you have a roughly 2 fold higher risk of dying if you walk only 2,700 steps per day compared to 10,000 steps.

Then I went even further down the rabbit hole and wanted to know how much the typical person walks.

Take a guess.  I’ll wait.

In the US, it seems it’s about 5,000-6,500 steps per day.  Increasing that number by say 2,000 steps would drop all-cause mortality risk by about 25%!!!!!!

What is the conclusion here?  The Kissel family is getting a dog.  I’m not kidding.  I finally got approval from the wife.

The post How walking is more important than not smoking too make you live longer first appeared on The Proactive Athelete.

This is a typical question that all of our therapists get on a near daily basis.  It tells us two things:

• We better stay on our science game so we can answer the question truthfully
• We have an amazing, intellectual and inquisitive client base

The science behind any form of manual therapy is quickly evolving.  If you asked us the above question when we opened our clinic in 2009 (yes we are getting old), we may have responded with the ability of massage/manual therapy to ‘flush out inflammation’ and ‘change the environment around an injury to better enable healing”.

Not a bad explanation, but it leaves some ambiguity to us science nerds.

Thankfully, a group of research scientists and bioengineers at Harvard have been tackling the “what does massage actually do” question head on in recent years, and just published the single most important paper to date in a great journal called Translational Science.  They even used a REALLY reader friendly title “skeletal muscle regeneration with robotic actuation-mediated clearance of neutrophils’ .  (If you can’t tell that last sentence was sarcastic).

The study was multi part and answered many questions.

The researchers incited an injury in the legs of mice.  They created a robotic system to then deliver a consistent and tunable compressive force to the injury site twice daily for just 5 minutes over 2 weeks.  This allowed them to change variables like the amount of force the robot used.  The effect was to recreate ‘mechanical force’ which is science speak for pressing on a muscle, the same way that a massage therapist, chiropractor, or physiotherapist does during your treatments.

Interestingly they also created what must be the world’s smallest ultrasound unit that showed a shockingly precise image of what was happening in the mouse’s tiny little muscles during the compression from the robot.  SCIENCE!

Seriously, look at that image.  I swear it’s clearer than any of my 3 kids ultrasounds who were all over 8lbs in weight.  And remember that is of a single muscle in the leg of a tiny mouse!

This mechanical force was repeated twice daily starting one day after injury and continuing until day 14.  They also left a control group of mice injured, but then left them untreated as a comparison.

Here is a summary of what they found with explanations:

1. Muscles experience anywhere from 10-40% mechanical strain with mechanical loading (massage).

This one was a bit surprising.  It means there is a lot of variability likely between therapists.  The good news is that when they looked at the resulting cell changes in the mice, it didn’t really seem to matter much how much force was used.  In fact, they used 3 different ‘force levels’ measured in Newtons.  They just used the middle one because all 3 ended up with similar results.

2. Both the treated and the untreated injured legs had a significant reduction in damaged muscle fibers but the reduction was MUCH more pronounced and the resultant cross sectional area of the fibers was larger in the treated muscle.

This simply means the leg that had the massage had less damage, and the muscle was stronger after recovery!

3. Looking at the different groups after 14 days of treatment, they found that the treated group had more type IIX fibers which can be thought of as healthy muscle BUT the untreated group had small amounts of it, and had more type IIA fibers which can be thought of as unhealthy muscle fibers.

This explains why after the 14 days, the mouse’s that underwent treatment had stronger legs then the ones that did not as the better fibers can produce more force.

4. A subset of cytokines (inflammation markers) was dramatically lower in the treated muscles after 3 days of treatment. These cytokines attract another cell called neutrophils which play a big role in inflammation. 

This means the muscle that underwent massage ended up with fewer neutrophils.  The researchers think the massage essentially ‘squeezed’ the cytokines and neutrophils out of the injured tissue (which is good as it means less inflammation).  To confirm this, they injected fluorescent molecules into the muscle and were able to actually see the movement of the molecules.  They literally watched the force of the robot flush the bad cells out of the muscle!  Here is cool picture of the fluorescent cells (isn’t science beautiful?)

5. To squash any potential questions and make their study findings more robust, the researchers then literally grew muscle cells in a lab in a medium with neutrophils (remember those are the inflammatory cells). What they found was that the number of cells did increase as expected, but the rate that they differentiated into specialized muscle cell types decreased. 

This is a complex one.  Essentially what they proved was that in the presence of inflammatory cells (neutrophils), the ability for cells to form new muscle fibers is weakened.  It is proof that with massage, by decreasing neutrophils (inflammatory cells), you increase the repair ability of your muscle once it’s injured!

So what have we learned?

It turns out our crude explanations from 2009 were at least somewhat accurate.  The above study shows that mechanical force via massage does indeed help ‘flush out’ inflammatory cells and this does lead to faster healing and better tissue growth.  They proved this by lowering the presence of neutrophils in the injured tissue starting on day 3, and this had optimal muscle regeneration.

They note that inflammation is very important…..but only at the beginning of the injury.  After that, the quicker you get the inflammation out of there, the better the healing response and outcome.

Here are 2 quick quotes that capture these monumental findings from the researchers:

“These findings are remarkable because they indicate that we can influence the function of the body’s immune system in a drug-free, non-invasive way”. 

And

“This provides great motivation for the development of external, mechanical interventions to help accelerate and improve mm and tissue healing that have the potential to be rapidly translated to the clinic.”

The single most important finding from the study?  Never feel guilty about going for a massage or receiving therapy……it turns out you are just improving your recovery and ability to come back stronger.

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