I frequently write about client success stories. In this article, we’ll do the opposite: a client failure story. I won’t name the client, because the purpose isn’t to assign blame. It’s to serve as a cautionary tale.
First, let’s start with some background info. This is a client who hired me because she had severe knee osteoarthritis. Severe osteoarthritis cases like this are actually a large part of my practice, because most trainers aren’t trained to work with advanced joint degeneration.
She might be the worst case of osteoarthritis I’ve ever seen (and I’ve been a personal trainer since 2006, so I’ve seen a lot of cases). In fact, her knees were so bad, she was knock-kneed, and every time she’d bend her knees, it sounded like a door creaking.
But she didn’t want to have surgery or go on medications for her arthritis. Eventually, she saw a story about me in a magazine (The Tonic), saw that my team and I have a great track record with osteoarthritis, and decided to hire me to help her.
So to give credit where credit is due, she was proactive about it.
Her Life Beforehand
For the sake of this article, let’s call her “Mary.” Mary was a 78-year-old mother of 4 grown boys, and a number of grandkids as well. She lived in one of Canada’s most affluent neighbourhoods. Before her arthritis got so severe, she enjoyed going to fitness classes, yoga, cooking marathons with her daughters-in-law, etc.
Fast forward a few years, the arthritis had progressed, and along with that, Mary had lost a lot of her mobility. She was now shuffling her steps, and walking with a cane (and occasionally a walker). Her balance was terrible as well. After she got out of a chair, she’d have to lean on her cane for a few seconds, to get her balance to catch up. She also couldn’t turn her feet to look behind her. She’d have to walk in a wide loop in order to look behind her.
As you can imagine, with such significant deteriorations in both balance and strength, she could no longer do the daily activities that she took for granted before. Fitness classes and yoga were done. She also couldn’t do her cooking marathons with her daughters-in-law, because her knees hurt if she spent any more than 5 minutes standing.
She even stopped grocery shopping and driving, and by the time she hired me, she was completely housebound. She even had to hire live-in help around her house to help her get around. It was a bad situation.
Her Exercise Program
After doing an assessment with her, I had my work cut out for me. As I always do, I ask my clients how many days per week they had to dedicate to exercise. She responded back with “what’s optimal?” I explained to her that when it comes to arthritis, frequency is key, so 5 days per week.
Of course, just because something is not optimal doesn’t mean it’s still not beneficial. In my arthritis book, I explain that the optimal protocol is 5-6 days per week, but you can still get 60-70% of the results, but with only 30-50% of the time.
She didn’t want to commit to 5 days per week, but she agreed to 2 days per week.
Strength Training
In her initial assessment, I noticed that she had basically full-body weakness. Just getting out of a chair took a lot of effort.
Besides that, her upper body was extremely weak as well. But the top priority was knee pain reduction, so we had to put any upper body work on the backburner. If we could dedicate 5-6 days per week to exercise, I would have definitely included upper body strength training. The less time available for exercise, the more carefully I have to prioritize what matters most. Inevitably, I had to leave out a lot of beneficial exercises because she only wanted to exercise twice per week.
The first thing people think about when it comes to knee arthritis is strengthening the quads (front of the thighs). We did that, using assisted squats – she’d hold on to her door handle to help herself out of a chair, because initially, her quads weren’t strong enough to do the job on their own.
However, research shows that when you strengthen other muscles around arthritic joints, the pain reduction is greater, and the improvement in function is greater. So we strengthened every muscle around her knees, not just the quads. We did:
- Hip lifts on her couch (which strengthened the glutes and hamstrings. That’s the butt muscles and backs of the thighs).
- Calf raises
- Toe raises (which strengthened the muscles on the front of her shin, the tibialis anterior).
There are many different exercises for each muscle group, so why did I select the exercises that I selected? Because the goal of exercise for most of my clients is carryover to their life outside of the “gym” (the actual gym, or their home gym).
Proprioceptive Exercises
This is a group of exercises collectively aimed at improving coordination and body awareness. The brain contains a “map” of the body. But the more pain there is, the blurrier that map becomes. The way to “clear up” the map is to make the body move with great precision.
The research shows just how potent this form of training is for osteoarthritis. One meta analysis showed that proprioceptive training reduced joint pain by 56% in 8 weeks. Considering how little time and physical effort it takes, that’s remarkable.
So we did exercises like ankle circles, knee circles, and others.
Traction
Another exercise we did (if you can call it an exercise) is called “traction.” What is traction? It comes from the word “distraction,” as in “pulling 2 bones apart.” The idea is to do the opposite of what arthritis does. If arthritis decreases the space between 2 bones (i.e. you lose cartilage), traction does the opposite – increases the space between 2 bones.
For Mary, I’d pull her shin bone away from her thigh bone while she was seated. It doesn’t really feel like anything – there’s no pain, there’s no stretch, but substantial research does show that it has the potential to reduce pain by as much as 35%.
A truly comprehensive approach to reducing pain and improving function with osteoarthritis should involve all 4 of the clinically proven exercise types, at the proven “dosages.” When it comes to strength training, “dosage” consists of number of days per week, amount of weight lifted/resistance, number of reps, and number of sets. When it comes to traction, dosage consists of degree of tension (how many pounds of force you pull with), duration, and frequency. I go into complete detail in my osteoarthritis book.
Her Results
The reasons that I love using scientific methods to train clients are:
- Precision: knowing the exact exercise prescription for each type. The right exercise, used at the wrong dosage can be ineffective at best, and harmful at worst.
- Knowing what not to do: there are so many methods out there that should work in theory. Or some guru claims that it works. But when you dig deep into the science, those methods are either unproven or disproven. Scientific training allows me to save clients time on ineffective methods. For example, stretching and yoga are common exercise types frequently recommended for osteoarthritis. Yet, conclusive research shows how ineffective they are.
- Speed: if we can use the right exercise types, at the right dosage, we can get results fast.
…and get results fast, we did.
When I first met Mary, her knees hurt nearly 100% of the time, and she used her cane 100% of the time. By only the 4th session with me, she was only using the cane about 50% of the time, and the pain didn’t go away, but she no longer described her knees as painful – just stiff (that’s huge progress in my mind).
The Mind Virus
Despite this progress, she decided to reduce her training time to just 30 minutes twice per week. Since exercise dosage is such a major part of effectiveness, you can see how that hurt her progress. She was still making progress, but slower than previously.
Her claim was that it made her too tired. But the clear evidence was contrary to that. I consider a client truly fatigued if performance drops between the first and last sets of a workout. I also truly believe that a client gets too fatigued if we really push the intensity, and get close to muscular failure.
But with Mary, her performance between the first and last sets didn’t decline at all. We also stayed pretty far away from muscular failure.
So why did she claim that a full hour fatigued her too much? Was she lying? I don’t believe so. There was obviously a difference between what I was seeing objectively, and what she was feeling subjectively. My belief is that what was happening is her self-image got in the way. When she started walking with a cane, she (rightfully) saw herself as frail. And despite the rapid progress, the self-image didn’t catch up to her body. So she started engaging in self-sabotage, to make her body match her self-image.
Limited Exercise Options
With only half an hour, twice per week, we had to cut out 2 beneficial forms of exercise: proprioception and traction. Too bad. I informed her of the risks of reducing her exercise, and she decided to go in that direction anyway.
Despite making great progress, it still wasn’t enough, and she had a fall, along with a bad injury. She was hospitalized for her hip, although fortunately, nothing broke. But her hospital stay was long, and her post-hospital recovery was long as well.
Do I believe that this could have been avoided with appropriate exercise dosing? While I can’t say for sure, I’m reasonably certain that if she hadn’t reduced her exercise, we could have incorporated more training for balance, more work for the upper body, etc.
The Right Mindset
When someone is as frail as Mary was, exercise shouldn’t be viewed as fitness. It should be viewed as treatment. When someone is in bad condition, they need aggressive treatment. That means more exercise, not less. As I argue in my article, Frail to Fit Fast, and in my video, Why Frail People Should Exercise More Than Fit People, people who are frail need to exercise more frequently than fit people – not less frequently. Fit people are chasing new strength gains. Frail people are trying to regain lost strength. Big difference. The former requires a higher intensity with a lower frequency. The latter requires a lower intensity and a higher frequency.
When someone becomes frail, exercise shouldn’t be treated as optional fitness. It should be treated as targeted therapy.
Unfortunately, most people with osteoarthritis are left to guess which exercises to do, how often to do them, and how much resistance to use. Most personal trainers, physical therapists and doctors don’t know.
If you’d like professional guidance with an evidence-based exercise program for arthritis, just fill out the application form on our home page. Doing so doesn’t obligate you to anything. It just sets up a quick, 10–15-minute chat where we discuss your situation, and see whether we can help. There’s no obligation, pressure or sales pitch.
