A common question that comes up for me in the clinic as a physio, as well as in my group strength classes and at my body attack classes is: What shoes should I be wearing for _____? First and foremost, I think it is important to mention that there has been a Cochrane systematic review (highest possible level of evidence) that covers this topic, specific to runners and running injuries. This review found that no type of footwear is better than any other in preventing injuries (from running). You can check out this study here: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013368.pub2/full Now information like this is often quite difficult to implement in the clinic, because you know as well as I that for you as an individual there will be shoes you have worn that feel GREAT, and others you have worn that feel TERRIBLE. Research is quite poor at reflecting this, and as such it can be easy to disregard. But what I take this to mean is simply that you cannot generalise advice to an entire population (e.g. statements like ‘the best shoes for running are ______’ are likely to not apply to everyone) and rather that what suits you as an individual is more important. So my first piece of advice is this: choose a pair of shoes that feel really comfortable for you, as this is most likely as accurate a measure of what is going to work for you as anything else that the shoe store person etc might say. ** note: i am not a podiatrist, who are the experts in this space. If you have foot pain or any major issue with your feet then you should consult a podiatrist for more tailored advice. **  Barefoot shoes: are they better for you? It is true that wearing no shoes, or barefoot shoes, will demand more work of your foot muscles. It can be argued that this is preferable to being reliant on super highly cushioned shoes, and could be better for your feet in the long term. HOWEVER. It requires a LOT of time to get used to this type of footwear. Because we spend so much time on our feet, and our entire body weight is resting down upon them, feet are very sensitive to any changes in footwear. If you do wish to move towards less supportive shoes, it needs to be done extremely gradually. For example, I used to wear off the counter shoe inserts to work, as I got plantar fasciiopathy immediately upon starting full time work and standing all the time (yes, at 21, lots of things are not a feature of ‘getting old’ but rather of introducing something new too suddenly). I can now tolerate barefoot shoes at work, but I would say it took a number of years to get here, and I still can’t wear barefoot shoes for more than a day or 2 in a row or I will start to feel that tell-tale lump under my foot start to reveal itself again. A suggestion of how to gradually work your way into less supportive footwear is to have a few pairs of shoes on the go, and swap into the minimalist shoes for just a few hours here and there per week. If you are thinking of wearing these types of shoes for something more than leisure wear, keep reading for my thoughts. Shoes for running and other repetitive high impact activities (e.g. aerobic classes such as body attack) You have probably heard two completely different narratives regarding the best types of shoes for running: Shoes with less cushioning are better as they mimic barefoot running which is more natural. This is more likely to reduce injuries in the long term. Shoes with more cushioning are better as they support your feet. This is more likely to reduce injuries in the long term. No wonder people are confused when there are these conflicting types of messages out there! Wearing barefoot shoes for impact exercise requires magnitudes more strength and conditioning of the foot to be able to handle it, compared to wearing this footwear for leisure only. It is probably preferable to aim for the least supportive shoes you can get away with, to promote as much strength of your feet as possible. This is unlikely to be barefoot shoes for most people, but it may be shoes with a lower drop (less of a steep decline from the heel to the toe) and a bit less cushioning that you have worked your way up towards being able to tolerate. If you are looking to take up running or another form of high impact exercise for the first time, it could take MONTHS and MONTHS to build up adequate resilience to tolerate minimalist footwear and most people will find that more supportive shoes help support them to take up the new activity more quickly with fewer issues. Research also indicates that having a couple of pairs of running shoes at once and alternating between a newer pair and an older pair is a great way to reduce your risk of injury, as it is common for something to start hurting as your shoes start to get older. This is not ‘proof’ that supportive shoes are in fact better for you, rather, that running on shoes that are becoming less cushioned is something you body is not used to, and doing lots of mileage in conditions you aren’t used to is often how overuse injuries quickly develop. Rotating your shoes (e.g. newer shoes for longer and high intensity/speed sessions; older shoes for shorter and slower runs) is a great idea. You can check out this study here: https://pubmed.ncbi.nlm.nih.gov/24286345/

As part of my job, it is common for me to introduce people to the gym who may have never stepped foot in a gym in their lives before. I understand that it can be very daunting to step into a gym, let alone onto the weights floor if this is new to you. I noticed that a lot of things that seem obvious to me in a gym setting are not obvious at all to people who are new to training, so I thought I’d compile a list of common ones and share them with you. How to take the clips on and off You push down on the little bit (often, but not always, a different colour) in the middle of the clip while pulling up on the clasp part. Hard to describe in words, check out the video!

On the third anniversary of opening FKB Physio I thought it would be timely to reflect on my journey and share some of it with you. It may surprise you to know there was a time when I truly believed I had made the wrong choice in selecting physiotherapy as my career and was on the brink of quitting! How much things have changed since then. Why I became a physiotherapist I decided to study physiotherapy when I was actually in first year engineering. It never occurred to me at school that I might want to be a physiotherapist. I associated physiotherapy with girls who were sporty, which I was not. I was always more interested in the academic side of school. That said, I did play sport. I played tennis consistently (thanks to dad who took me to all my games on the weekend and encouraged me to keep it up!), and from memory I also played softball and volleyball, though absolutely did not take them seriously and probably selected them because they were easy. I was also lucky enough that my parents somehow introduced me to the local gym (what is now Goodlife Ashgrove but was then Ashgrove Body Designers) and I think from about grade 10 I had a membership and would go to body combat, body balance, and body attack. I remember my fitness gradually going up each year so that by year 12 I actually placed in the top 10 in the cross country, simply because I ran the whole way and almost no one else did! I was all set to become a software engineer when I finished school, however, I found the course extremely boring and the mathematics was beyond me, despite thinking I am a fairly mathematically oriented person. I went along to a lecture with a friend who was studying human movements (a biology lecture, from memory), and found it more interesting than anything I’d learned in my course! At the 6 month point, halfway into my engineering first year, I decided it wasn’t for me. At that time, I’d also started going to Body Attack and Body Pump ALL the time at the gym, as well as running to and from classes in my dunlop volleys that I wore to work (in the Coles Deli). Unsurprisingly, I developed shin pain and went off to the physio to sort it out. This event, combined with my dissatisfaction with my engineering degree, and attending that lecture with my friend, made me decide to try swapping to physiotherapy instead. I also became a group fitness instructor in the 6 months between finishing engineering and starting physio, a job which I still do now. The course change was absolutely the right decision. I enjoyed physiotherapy immediately, though I found having to interact with people in such a close and fairly intense manner extremely challenging. I am an introvert and a perfectionist, and those things are pretty hard to manage at 18 as it is, let alone in a university course that demands you perform assessments on your classmates in exams! I repeatedly was called out for being too blunt, too rude, too cold, unapproachable, unfriendly, and being unable to form a rapport with clients. In fact I think I actually had a ‘fake’ patient that we had at uni (for practice) complain about me to one of our lecturers. Not off to a great start in the profession! Here's a few photos from back in the day!

An introduction to exercise for bone health to reduce the risk of or help to manage osteoporosis or osteopenia.

I am writing this blog as a guide for some of my patients with tendinopathy so that I have a resource that is easy to refer them to to read in their own time. While I will do my best to make sure the information is accurate and evidence based, I will not be delving deep into the research as this is more interesting for clinicians than patients and that is not who this is directed at.

Lifting heavy weights is recommended for bone health. But how can you do this with older adults? In this post I explain how I have gradually progressed the weights lifted by the older adults in my Bone Density Classes in Clayfield and Fortitude Valley in Brisbane, Australia.

Podcast episode 2: women and bone health https://open.spotify.com/episode/17EaWhxNMWNXi3655qeg4w?si=uIRQYY5WS7Cb79kcGfDdsg [00:00:00] Hi everybody. And welcome back to FKB physio podcast. So today's episode is just me and my own not interviewing anybody today. Because I have a lot to say about bone density. And in particular, I really wanted to talk about the importance of bone density in women. So bone density is important for everybody, but problems with bone health or having poor bone health seems to be more of an issue in women. The reason for this there's a few, one of them is just simply the fact that men seem to start off with a higher bone mass than women. And I'm not sure why that is, but if you look at the research about this. Men have a higher bone mass initially. For both men and women, our bone density will decline across the lifespan. But because men have a higher bone mass to begin with, that slow decline might not push them into the osteoporotic range. Like it will for women. Uh, and the other thing is that when women go through menopause, they have this sudden drop off of estrogen. And that is quite bad for your bones. So I think I read that women can lose as much as 10% of their bone density in the first five years post-menopause, which is pretty significant. Those are two of the reasons why it does tend to affect women more often than men. Just as a statistic. I think for people over 50 one in three women will develop osteoporosis and one in five men so it's not that rare in men, but it is definitely more of an issue for women. I also think that women are disadvantaged because women are told constantly their whole lives, that they should be smaller and smaller. Low [00:02:00] body mass is a risk factor for poor bone health. And that annoys me because women are told their whole lives, lose weight, eat less, be smaller. And then when they get older, It's them who suffer the consequences of such choices. And then things such as, you know, there's all these so-called health social media accounts out there. Claiming that dairy's bad for you, giving women these ideas of how they can get away with eating less and less and less. And on top of that, then women are discouraged often from heavy lifting. And it's seen as a masculine thing and jumping and high intensity sports. So here are all the things that are likely to help you build your bone density, adequate food, maybe being a bit heavier, maybe having more muscle mass, maybe getting enough dairy, enough calcium. Lifting heavy, jumping, playing sports, and they are things that women are discouraged from over [00:03:00] and over and over. I want to fight all of those ideas. We shouldn't constantly be striving to be smaller as women. We shouldn't be told to be afraid of lifting heavy or jumping or building muscle. There's nothing more empowering than these little ladies, over 60, all of a sudden realizing that their bodies can do these pretty epic things that they never thought they could do. There is evidence that suggests that improving your bone density a younger age can delay the onset of osteoporosis or osteopenia. Having a 10% higher bone mass to start off with can reduce the onset of osteoporosis by 13 years. So basically you build 90% of your bone mass by age 20. Which is a massive advertisement to have active children because it's active kids that are jumping, running, eating enough that are going to reach a higher bone mass by the time they're 20. Then you [00:04:00] keep building that final 10% throughout your twenties. And from what I understand till about mid thirties and then your bone mass starts to go down. I remember at uni, we learned that you can't improve your bone density after that, which has been somewhat disproven. But I think the reality is, you probably can make little changes to your bone mass but I do think that building as much as you can before mid thirties makes sense. Of course there's all the co-morbidities that negatively influence bone density that no one has any control over like, kidney failure, celiac disease, h aving to take steroids for a prolonged period of time, as in corticosteroids, like for asthma things like that. , So there's a bit of a background of the whole situation. So why does this matter? The reason that matters is it's actually fracture risk. So the stats in Australia are that one in two women over 60 will sustain a hip fracture in their lifetime. Which is quite staggering, really. It's thought that [00:05:00] 66% of all Australians over 50 have poor bone health and that's from the Australian Institute of health and wellness. So it's the bone health as well as falls risk that are fracture, risk factors, especially fractures of the hip. So in order to reduce the risk of having a fracture, we need to target improving bone density and bone health. And also look to reduce falls risk in these people. There are medications out there for osteoporosis. The problem is you can't get those medications until you've had a diagnosis of osteoporosis. So often the first sign that someone has osteoporosis is that they have a fracture from a low trauma, like they sneeze and they break a bone. So often waiting for diagnosis of osteoporosis before you start trying to do something about it is a bit too late. Something I really like about exercise for bone density is you can start without a diagnosis. There are also some negatives with the [00:06:00] medications. Like, I know that some of them they don't really know the longterm outcomes and a lot of them, it sort of suggested that you might only go on them for 10 years at a time. But as soon as you stop taking it, i t reverses everything good that it did. And there's a small risk of these really adverse side effects that are nasty. I often think that those medications might be reserved for those people that are very frail and very high risk of fracture and the benefits outweigh the risks. But a lot of people who might be late fifties, early sixties who have osteoporosis or osteopenia who are hoping to live until their nineties, it might not be a great option for them yet, but that's obviously for people to discuss with their doctor or I guess endocrinologist. What can we do to improve bone health? So then ESSA guidelines, which have been put out that basically very clearly outline what type of exercise you should do for people with osteoporosis and how often. The main things are high [00:07:00] intensity lifting and high impact loading, i.e. Jumping. And these are things that have traditionally been avoided with people with osteoporosis, because the thought was that you're at risk of fracturing something. And again, with very frail individuals, you would have to be quite cautious about how you begin. But I think what's really interesting is that. In the research where they've trialed these programs on people with osteoporosis or osteopenia, there hasn't been any reported. Adverse side effects. So Belinda Beck, who runs a bone clinic, she just authored a paper this year in April. And she basically states in there that of the seven years they've been running the bone clinic, there hasn't been any adverse side effects , which is pretty good evidence to show that it's relatively safe. So the recommendations are that people should be lifting 80 to 85% 1RM on compound movements, such as squat, deadlift, bench press, this type of thing. And that they should be including high impact moves like jumping. And that [00:08:00] over time they should get progressively harder. So moving from say, two foot jumps to one foot jumps. To jumping from height, multi-directional jumping and jumping with weighted vests. So I have managed to get some of my ladies in their late sixties, up to hopping with weights in their hands, multi-directional and from Heights, obviously, no, one's going to just start out doing that. It's a very slow progression over time. But it's interesting to see that this is what's advised. And the reason is because your bones apparently get used to cyclical things as in like running or cycling where it's this repetitive cycle very fast. So they need short, sharp intense bursts of load. And it has to be quite different, which is why the multidirectional comes into it. Unfortunately, swimming and walking, don't improve your bone density and running actually doesn't either. Because of that repetitive nature. There's this article by warden and colleagues in 2021. And it [00:09:00] talks about this concept. It says basically that in order for your bones to remodel, you need to... It's about the mechano sensitivity of the bone. So I suppose that's the.. the sensitivity of the bone to a mechanical stimulus applied to it like an impact. So bones become, he says deaf to repetitive loading. . So basically, after a few minutes of running, that constant same load on the bones, your bones just get used to it and they don't get any stronger after that. Another sort of interesting point raised in the article is that swimmers and cyclists have lower bone mass than other athletes, but they actually don't have a high risk of stress fractures because those sports don't have any impact associated with them. So while you might have poor bone health, you won't necessarily get a stress fracture because there's not that bony stress there. But if we're thinking about [00:10:00] longterm, Implications for those athletes. Then once again, we're coming back around to looking at trying to optimize bone health for the future and reduce the risk of osteoporosis. So. For people who do those endurance style sports. This is obviously a consideration that I think i s really important. And I guess something else to consider with these sports is that. They're also not great for bone health because you also have a really high energy demand while you're doing them. And so your body needs energy while you're exercising and performing those tasks and it has to get that energy from somewhere. It's interesting that those sports where, you know, something like a triathlon where you might be doing all three of those things and exercising for four, six plus hours, it can actually be very hard for your bones. Again, that's why we need that heavy, short, sharp, heavy lifting, jumping, and I honestly think that everyone should be incorporating this stuff as [00:11:00] soon as they can. And again, in the Warden article, it does actually state that incorporating some jumping training or some plyometrics at a different time of day to the running could be quite helpful in the case of endurance runners. Indicating that this concept of multi-directional jumping and landing is consistent across lots of different types of research about bone density. It's not just for people with osteoporosis. And just as a side note to that, for those people that do do running, in the same article, a strategy suggested to help manage it among other things is to incorporate a week off that repetitive sport one week out of every 12. I think it says just to give you a skeleton, a bit of a skeletel reset before you re-introduce the loading again. And it does talk about in the article about how people with a b ackground of heavy resistance training, [00:12:00] have a lower likelihood of sustaining a bony stress injury. So a few things to consider there as well. So going back to the exercise for people who might have osteopenia or osteoporosis. And just for a bit of clarity around those terms, osteopenia is the precursor to osteoporosis. They're basically diagnosed based on your T score, which is determined by a DEXA scan. People often say, okay, I'll lift weights, but why do you keep asking me to lift heavier and partially it's because of the bones needing that new load that they haven't experienced before in order to continue to increase but there's another thing as well that i think is really relevant. A concept that I think is quite interesting, the thought of a 1RM So. A 1RM a one repetition maximum. So for me, That would be going in a power lifting competition and lifting the max [00:13:00] weight I could possibly lift for one repetition. And I wouldn't be able to repeat that. that I wouldn't be able to repeat it on the day. I wouldn't be able to do it for two reps. I wouldn't be able to do it the next day. It would really tire me out. And the recommendation for this bone health stuff is that people should be lifting 80 to 85% of that, which means the amount you could lift five times, but then not six times. So it's like really heavy. And people might say, you know, why would you be getting older people lifting that heavy? And my sort of counter to that is... you've probably all seen an elderly relative. Try to get out of a chair that might be a bit low. And it might be close to impossible for that person to get out of that chair. And once they've done it, it's a max effort. And really, could they repeat it again straight after? Probably not. That person's doing a one RM to get out of their chair and they might do that multiple times a day. Imagine how exhausting it would [00:14:00] be to be maxing out your capacity multiple times throughout the day. That's where I think these intense forms of exercise. You can really see the benefit because you are going to improve that person's capacity so that they're not maxing out day to day. Like for me, I only max out or come anywhere, close to maxing out my movement capacity at the gym. But day-to-day, I don't come close, so it's not going to have a huge effect on my energy levels. Whereas if you're going up the stairs, holding your laundry, sitting down on the low couch and getting out a few times, if that's almost max effort, you want to improve your capacity so that that's not a max effort anymore. So I think that's a really powerful way to see why it's worth doing more intense forms of exercise, even if you are an older adult. If people are coming to gym classes or physio led classes or whatever you want to call them to improve their bone density. And in the [00:15:00] process, they're doing this heavy lifting. You can kind of tell how the benefits are deeper than just improved bone density, but there's also reduction in sarcopenia which is basically muscle wasting, age-related. And there's an improvement in strength, which is going to be worthwhile, not just for bones, but for fatigue levels. And to reduce risk of falls. , and to keep body mass muscle mass high, which I think is a really important marker of health as well. One final thing that I thought was interesting from Belinda Beck's 2022 article was that sometimes bone mineral density alone isn't a great measure of bone health. I read an article that said it's only about 60% of the story, and it doesn't tell you about the structure of the bone, which is actually apparently quite important. And Belinda talks about cortical thickness. So my thought is that the cortex is like the. Outside of the bone and it's not the kind of lattice-y stuff [00:16:00] on the inside. Cortical thickness is quite relevant and the LIFT-MOR trial, which is the one the bone clinic is based on in that study the bone density didn't necessarily get that much better, but the cortical thickness of the femoral neck, so like your hip bone, improved. So just bear that in mind, that bone density is about 60% of it. But if you do embark upon some efforts to improve your bone density and you don't see great changes on that it's not necessarily the whole story. Just as a final note to kind of recap what I've talked about here. You build most of your bone mass before your 20, you build 90% of it. You can continue to build it until your mid thirties. And from there things start to decline and I'm not a hundred percent on what that looks like if you're someone who does lots of resistance training or anything like that, this is just I suppose the average adult living in [00:17:00] average lifestyle., It's really important to take an interest in your bone health, because as you get older, that slow decline in your bone density over the years can present as osteoporosis or osteopenia as we get older. And people are more at risk of this if they have certain health conditions, but particularly women are more at risk. With at least one in three developing osteoporosis in their lifetime in Australia. I think that s drastically under reported that statistic as well. And the risk of having poor bone density is sustaining a fracture from something that's not a very big incident. This is often a fall in older adults. There are ways to reduce the risk of you losing your bone density. And the earlier you start it the better, because the more bone mass you can build or maintain the more you can delay a diagnosis of osteoporosis. So in order to build your bone density. And also just the health of your bones in general which [00:18:00] goes deeper than just the bone density. Heavy resistance training. That's very hard, 80 to 85%, one RM of compound movements. And multi-directional jumping is really important as well as other things such as adequate food intake. And avoiding things that mean you intentionally aim for a low body mass. You can start this at any age. There's any number of ways you can start slowly and build up, but it's definitely best to do this under the supervision of a professional. So at my clinic, I run bone density classes. They are supervised three or four people to one physio. There would be many physios and exercise physiologists out there running these sort of classes. So it is in your best interest to find one of them and start improving your bone health as soon as possible.[00:19:00] Thank you so much for listening to this podcast, I'm going to try and alternate between one episode where I interview somebody, I've got lots of Instagram lives to go back and convert into podcasts and every other one. Me talking about something. So. Hopefully that works out all right!

What is bone density and why does it matter?

Here's the conversation i had with Louis earlier this year on IG live in text and youtube format for those who missed it!