To be consumed alongside the Instagram and Podcast series of the same name, this series aims to look through the world of strength training through the lens of mental health and sheds light on different people with different living, working, or health conditions.
What does the current landscape of mental health support look like?
As we know, mental health places a considerable burden on the individual, the social support network, and the healthcare system as a whole. Over the years, research engaging in exercise has been demonstrated to improve mental health outcomes comparable to medication.
Exercise is medicine.
We’ll hear this phrase touted from all parties that practice in the area of exercise for health. There’s already a lot of support in place for someone with conditions like cardiovascular disease or diabetes to begin exercising. There is a growing network of Allied Health Practitioners who are pushing for exercise to be considered among treatment options for people with mental illness.
Despite an impressive body of evidence supporting exercise as a treatment option for mental health, healthcare support systems are yet to catch up, only offering exercise or exercise-related therapies to people with chronic musculoskeletal, cardiovascular, or metabolic conditions.
Who funds support for mental health?
The COVID-19 pandemic jettisoned mental health to the early 2020’s zeitgeist, sparking conversations and actions built to further education and support into mental health. Part of this was the Australian Medicare system adding further funding towards psychological interventions, increasing the rebate sessions from 10 to 20 per calendar year.
This was undoubtedly a positive move but knowing that exercise interventions also improved mental health outcomes, exercise-based professionals were still left by the wayside. Obviously the huge growth in online personal training groups were a positive, financially accessible step but for people without experience or fondness of these modalities, it was difficult to break through into exercise for health.
How else can I get support?
We won’t touch on the NDIS system here as that is going to be covered in a separate blog.
In the case of support for Medicare/DVA, Return to Work or other insurance claims, all too often we see a trend of treatment approvals based on table top tests rather than the mental health of the patient related to either the injury or factors around the injury.
“Range of motion is good? Good.”
“Oh they’re still anxious and in pain? Get them into a psychologist that may be available in 3 months.”
***Just a quick note: I am not saying don’t see a psychologist. I am merely explaining how, as an exercise-based healthcare professional, we are overlooked on the mental health assistance we provide on a smaller but more frequent basis.***
This can obviously be very frustrating on our level of client interactions and the pride we put into our client care.
Good news is that at the time of writing this, The Queensland Mental Health Select Committee released an enquiry to increase opportunities to improve mental health outcomes for Queenslanders. Part of this was a recommendation to integrate dietitians and exercise physiologists within the mental health workforce to provide more holistic care to people experiencing mental and physical health comorbidities.
So how can we use exercise to support mental health?
Short answer from the research perspective is that there’s no specific findings comparing different modalities. The aim is having support in completing Australian Healthy Guidelines of 150min of vigorous or 300min of moderate-intensity physical activity.
My general argument stems from the social support engaging in frequent physical activity through varying modalities. Lifting can be empowering. Running can be exhausting. Yoga can be relaxing. A coach can act as the void you vent into (within reason).
Ok so, how do you create that support for an individual from exercise selection/ specificity?
From a programming perspective, we want to create a program that the client wants to do. Easier said than done. We might spend a bit more time introducing someone to the general feeling of movement, ensuring more difficult exercises can be done under supervision for a short time.
It’s honestly always surprising and a good feeling when a client with no previous enjoyment of strength training actually lights up when a movement feels good.
Perhaps this will become a program staple for now?
Depending on the experience and goals, we may need to employ some level of trickery to balance what we need to get out of the program and what the client wants to do in the program. This might entail;
The famed “shit sandwich” approach
Ascending, descending, tri-, quad-, super- sets
Playing with volume, constraints, load, RPE, set numbers
It’s quite a bit to consider but that’s my role. You just do the thing, self-regulate, and communicate your findings.
There’s a lot to explore in the realm of mental health and secondary comorbidities which is why we’re going to continue plugging these blogs, podcasts, and posts.
Feel free to follow me on Instagram or LinkedIn as well as check out my shows on the Performotion Podcast.
Why and When to Use Which Tools & How to Read Your Program
How To Use It
From a glance, programming with RPE can seem lazier than percentages or load prescribed programs. However, if a coach truly knows how to use RPE and knows the athlete they’re programming for, RPE can become hugely advantageous. Programming with RPE can take many forms and include many different things. Oftentimes programming with RPE can even include percentages. This might take its place as percentage-based drops for back off sets.
For example, a set of 4 reps on deadlifts @RPE 7 might be followed by an additional 2 sets of 4 reps @10% drop from the above. This use of percentages within an RPE based program allow for even better fatigue management and an effective way to accrue more volume without pummelling the lifter into the ground with hard work.
Using ascending sets can be very useful in many cases within a program, if lifters feel rusty and like their technique isn’t up to scratch but eventually find their groove towards their last set or two this is a great move to employ. Depending on how you use RPE for these ascending sets, you might technically just be giving the lifter more warmups than normal, thus giving them more time to dial in their tech. You can again start thinking about the individual in front of you, if the lifter is a super heavy weight male who gets tired very easily, maybe ascending sets aren’t for him as he might become tired before he even reaches his top set. However, you might have a middle weight male or female who gets better the more they squat and giving them ascending sets really helps them get the most out of their squat by the time they reach their top set.
The opposite can be true for descending sets, and you may use these to be sure the lifter isn’t doing too many hard sets, or if the lifter doesn’t handle volume well/gets tired very easily (super heavyweight example used previously).
Straight sets are common practice amongst many programs but can often be thrown in without thinking about whether this is optimal for the lifter. I personally like to use straight sets in two situations. The first being at the start of a training block where all sets will be very submaximal and no drop in load is required after a hard set has been done. The second occasion is if I’m just trying to stack up more weekly volume for a lifter without the work being strenuous at all. The first example that comes to mind is an U59kg lifter of mine who squatted 4x/week. I used 1-2 sessions/week of straight sets with very low load (or at a very low RPE). These sessions weren’t there to progress upon or work hard in, they were just in the program because as a small individual he could recover from a ton of training stress.
Let’s dissect the program below and examine what components of the above are included. On low bar squats we have a top single at RPE 5, this single has a prescribed load which requires the lifter to load 100kg for this set. The back off set of 4 is also at RPE 5 but has a load cap of 90kg. The distinct difference between a prescribed load and load cap is that a load cap is a maximum ceiling that the lifter cannot go past. However, they are able to take load below the cap in order to hit the prescribed RPE (RPE 5 in this case). Knowing the difference between these two can be important when reading your program. The following back of sets of 4 have a percentage drop after what was taken for a set of 4 at RPE 5. This is commonplace in a lot of PerforMotion programming and as mentioned earlier in this blog, allows for better fatigue management.
Next we can see straight sets used for all of the accessory lifts, what’s important to note is that a lot of these accessories have prescribed load attached to them (excluding lat pulldown and tricep extensions). This can be done for many reasons such as preventing over or undershooting or to simply prepare a lifter for their next training session without fatiguing them too much.
The second example we’ll look at has a mix of percentage drops, ascending and descending sets. The deadlift sets are similar to the example used above, however we see the use of ascending sets for the bench press here. This is particularly useful for this particular lifter who struggles to get his arch after having his back rounded during the deadlift. This easier RPE 6 and 7 sets allow him more time to spend getting his arch back and having the best possible position by the time he hits his top set. We know this lifter can handle a lot of volume but by the time they reach these high bar squats he will be rather taxed, this is the perfect time to use descending sets to account for this intra session fatigue and ensure we are not taxing him too much in any one session. We still have 4 sets of 6 reps total here to keep volume high but the RPEs are very low and descend to account for the fatigue accrued.
Ultimately, any program will work and get you strong, however, the intelligent use of the RPE system will typically get you stronger, faster and with less niggling injuries than most other load prescribed programs. Now that you know what you’re looking for within a program and the thought that goes into choosing ascending sets, descending sets, percentage drops or even just selecting the RPEs you can be sure there is a why and a reason behind every exercise, set and rep range put into a program.
Rate of perceived exertion (RPE) is a useful system in programming that allows both the coach and the athlete to effectively drive adaptation relevant to the athlete’s goals. The primary driver of adaptation in RPE based programming is proximity to failure whereby optimal strength and hypertrophy gains are made with considerations to internal and external loading, fatigue, and stress management.
Why Do Coaches Use RPE Based Programming?
RPE based programming systems allow the coach and the athlete to identify how the external load (weight on the bar) is affecting the internal load (system’s response to load). Internal load considers the variables outside the training program that will affect an athlete’s performance day to day. How is the athlete’s nutrition? Are they sleeping well? Do they have a big project coming up at work, leading to a high-stress response? Allowing ourselves to consider the internal load will create a more positive coach-athlete relationship while driving adaptive processes with external load.
How do PerforMotion use RPE Based Programming for performance and rehab?
The most consistent improvements are made when the client wants them. RPE-based training allows the client to take ownership of their program, irrespective of training for performance or rehab.
In athletes, systemic fatigue is expressed through compound movements. So how does this work in a rehabilitation context? RPE based programming works with rehab clients where proximity to failure is in the context of isolated failure, pain, or excessive compensation strategies. Rehab is very rarely a linear progression. We need to factor in internal loading the same way as we would for athletes.
Any athlete or rehab client will work well with RPE based programming, provided they are educated about how it works and how their body reacts to load. The system allows clients greater control in what they do with their program based on how they feel on the day, ensuring greater program adherence and long-term health behaviour change.
Cons of RPE Based Programming
As with anything, there are pros and cons to consider before administering an RPE based programming regime. The primary cons with this are the classic overshooter or undershooter.
Do you identify with any of these statements?
“I wanted to see if I could do it.”
“I did less weight last week.”
“I overshot completing 5 reps instead of 10 so I dropped the weight and got out another 5 reps. I had to drop the weight again because I could only do 6 at the new weight.”
Congratulations, you are an over-shooter with a balls-to-the-wall approach. You need to work on pulling yourself back when needed. Proximity to failure drives adaptation. If you’re going to failure or leaving yourself gassed before completing the accessories of your program you are going to consistently push shit uphill in an endless cycle of long lasting fatigue and lack of gains..
On the flip side, do you identify with these statements?
“The weight felt really heavy” (After every rep moved like a warmup)
“I wanted to save myself for the other lifts.”
“I started to feel it working so I thought it was enough.”
Ahhh yes, the undershooter. We will see you more frequently in your novice years where your skill level and understanding of true muscular fatigue are still being developed. You’ll need more of a push from yourself, training partner, or coach to drive the most out of your training.
Now To The Pros of RPE Based Programming
Provided that you are educated on your body and how you perform with different internal loading patterns, the pros of RPE based programing are far reaching.
– Takes internal load consideration; when you have had a rough day at work, it is normal for our training to take a hit.
– Capitalizes on days where you have had sufficient recovery from training; these means you’ve enough good quality sleep, nutrition, fatigue, and stress management.
– Improved autoregulation; an understanding on how your body and training may differ day to day
– Reactive; you can change external loading to match your internal loading.
– Transferable skillset
So you’ve learnt what RPE Based Programming Is About and How We Use RPE Based Programming.…
How Can We Apply The RPE Based Programming Method?
RPE based programming can be used in a variety of settings, be it powerlifting, bodybuilding, or rehab, within macro and micro-cycles. RPE can be used with programming on and off seasons in strength sports.
Remember the key aspects of RPE based programming that make your programming bullet-proof are…
– Proximity to failure is relative to everything in and out of the gym.
– Failure can be derivative of systemic fatigue, isolated fatigue, pain, or compensation strategies.
– Client has more control over their programming. It is their goals they are trying to hit, not the coaches.
– Understanding of how internal loading affects external performance.
At the end of the day it’s ok to hit the same number over and over while you’re learning. It’s the fixation on perfection for performance that will play a role in how you feel about your numbers.
Have you been going to different practitioners trying to find the answers to your sore knee, hip, back, or shoulder? Are you getting enough sleep at night? Are you feeling stressed, managing your nutrition?
Have you blamed a muscle or body part for your patients’ sore knee, back, or shoulder?
We as practitioners need to stop trying to find an easy solution to pain. This is something all of us are guilty of, at one point or another. A patient is presented to us with a problem that has been affecting them for weeks, months, years – it’s only natural that we want to make them feel better as quickly as possible. As a consequence, promises of quick fixes have led many people to bounce between practitioners trying to find that one solution to their pain.
On the flip side, patients need to take responsibility for their own education and understanding of their pain.
At uni, we are taught that the body is made up of levers. There are uses for this model but when it comes to chronic pain, structuralism is not always the answer.
There may be movements that feel like they cause an immediate reaction (back pain when bending over to pick up your keys or tying your shoes). However, contrary to social media/family/friends/next door neighbours, the answer is not going to be a single area that “didn’t activate” or “is overused”. This has led many to believe if you’re hurting in this spot, you need to work on that area to make it feel better. This unfortunately, has led to many of the problems practitioners and patients alike face when addressing pain.
If pain is not structural, where does it come from?
This is difficult to answer as there really isn’t an answer.
Introducing… The Biopsychosocial Model!
The biopsychosocial model asks us to consider the biological as well as the psychological and social aspects of your, or your patient’s, lifestyle.
We can consider biological factors like inflammatory markers, nociceptor sensitivity, pathoanatomy, or neuropathology, however, this does not create a holistic image when we look at pain. Following a traumatic incident, there is upregulation of nociceptors and inflammatory markers near the trauma site that acts as a protective alert system to tissue damage in the area. The body is meant to heal itself and these inflammatory markers help to do that. This is what makes us more sensitive to movement. It is important that biological factors are taken into consideration when treating patients, however markers such as tissue damage are not the only explanation for what makes patients perceive pain.
This is where the biopsychosocial model is utilised to allow us to better explain pain. The BPS model incorporates contributing factors that help explain why an individual may feel varying degrees of sensitivity day to day. @hannahmoves has an incredibly effective tool for explaining how we utilize the BPS model with our patients as seen below
Poor nutrition, stress, anxiety, fear avoidance, poor sleep, training volume and past experiences will all contribute to how your patients feel day to day. It’s important that we address all of these factors when it comes to communicating with our patients, not just focusing on a single issue. Explaining pain science and incorporating motivational interviewing techniques with our patients is how we ensure long term results.
How do we relate this to a patient experience?
Take for example this scenario; a patient books in for a consultation with a history of non-specific lower back pain. They are a young professional used to training in the gym 4-5 days per week with preference to HIIT-style group classes. They have seen doctors for scans, chiropractors, physios, and osteopaths, and have yet to come across a consistent answer that will fix their problem.
The difficulty with this scenario we see all too often is that there is no real answer and trying to educate someone that after several weeks, months, or years of bouncing between professionals, is a challenging task. Scan reports can be useful in some instances for diagnosis but they can not explain a sensitivity experience. The holistic view of understanding pain science helps us understand our patients.
Being able to better understand the multi-faceted nature of pain, how and why it occurs, will help every allied health professional (and their patients) become better practitioners.
How do we become better at what we do?
Continue your educational journey and listen to your patients. There is always going to be something to learn but finding the right resources can be tough. Education is not just for practitioners but for anyone experiencing pain.
I met Tom about 8 months ago on referral from my coach to sort out issues I was having with my knee post-surgery squatting. I tried really hard not to make this solely about squatting but couldn’t help myself, we talk about movement dysfunction what that looks like for strength athletes and what to be aware of when it comes to lifting. Tom has done wonders for me and many others and his approach to training is amazing. So hopefully you enjoy his wisdom while drowning out my rambling nonsense.