How to Build an Exercise Plan

Recently, I had the honor and privilege of participating in Amelie’s 2nd grade “job fair,” where my job as physical therapist was put under the microscope of 100+ second grade students. I had an absolute blast spending an afternoon with these kids and can’t thank my daughter enough for allowing me to participate! I would also like to take this moment to apologize to my mom for depriving her of said opportunity when I was in elementary school – sorry Mom!

My two biggest takeaways from this experience were the following:

• 2nd grade students are obsessed with the age of adults. Every class asked, “How old are you?” and, to a student, responded “Wow!” when I told them my age.
  
  

• 2nd grade students will drill you down with follow up questions and/or blank stares until you explain in a manner that suits them – they are masters of the “Keep it Simple” approach.

“ Keep reading to the end to find out my responses to these questions…

This experience got me thinking about how I can help my community better understand one of my major roles as a physical therapist, how to heal through movement. 

This blog post is meant to help you better understand the following:

• The “why?” of an exercise program

• Key parameters of a foundational exercise plan

• How to select performance metrics to assess progress within the program

Plus—stay tuned for a follow up blog post where I’ll provide insights into some intermediate steps to spice up your exercise plan.

Begin with “Why”

Each of us will have a personalized answer to “why exercise?” but my physical therapist answer is to better handle the physical stresses we encounter each day. 

Physical stress can best be handled when we possess a balance of the following attributes:

Mobility – The ability to move your body freely and easily, through as large a range of motion as possible.

Stability – Demonstrating body control positionally and through movement (especially in end ranges). Stability = ownership of the position and movement.

Strength – The ability to produce greater amounts of force using one’s body weight or external weights (ie db, bb, machines, cables).

Endurance – The ability to sustain activity over a prolonged period.

Power – The ability to produce force as quickly as possible.

 

As described in Mobility + Stability = Prelude to Athletic Performance, my preference is to begin with mobility and stability as the foundation. With regards to mobility/stability, I want to demonstrate a combination of global proficiency (think 7-year-old gymnast that can twist and turn her body in every direction and demonstrate control of these positions) and specific proficiency (I can squat through a full range of motion with control).

When selecting performance metrics, choose wisely (that is, what’s important to you). 

My preference? I want my patients and clients to be able to get up and down from the ground with ease, squat/hinge/lunge proficiently, get their arms fully overhead, and perform some version of a push up/pull up/ring row.

 

Ground Transfer Examples

https://www.youtube.com/shorts/7lB32lxYdZg

https://www.youtube.com/shorts/AOufBECo0QM

https://www.youtube.com/shorts/s1-SPIZXo8Y

Overhead Mobility Test

https://www.youtube.com/watch?v=NkuJp-zMtvc&list=PLtbxeURCQnLJVzDAT5i6jAXekUi1CJ977&index=3

Track your progress using videos with an aim to move through larger ranges of motion with less assistance. Progress is often incremental, and the videos allow for feedback and help you better identify incremental improvements.

Strength^1-3

Whether you are looking for a program for optimal aging or looking to improve body composition, at any stage of life, the following approach can be utilized as a starting blueprint.

Foundation of strength exercises:

1. Pick 8-10 different exercises for the entire body

Use this sample list to get ideas:

Upper Body Pull

• Pull Ups

• Horizontal Row

Upper Body Push

• Push Up

• Overhead Press

Lower Body Hinge

• Bridge

• Deadlift

Lower Body Squat

• Squat

• Hack Squat

Lower Body Split Leg

• Lunge

• Step Up

 

2. Do 1-3 sets for each exercise

For untrained populations (if you haven’t trained before or recently) do 1 set. For trained populations or lower body exercises, do multiple sets.

3. Do 8-12 repetitions per set

This rep range combines and increases strength, endurance, and power.

4. Establish your 10 rep maximum

Your “working weight” should be 60-80% of this number. Older adults (> 65 years) should start at 30-40% and progress towards 60-80% over time.

If you are not able to identify your current repetition maximum, use the rating of perceived exertion (RPE) scale below. RPE is a validated tool to effectively dose exercise intensity.

5. Utilize the superset format

If you’re performing multiple sets of an exercise, alternate between two exercises for each set. Select an upper body and a lower body movement as an exercise pair, which will allow one body region to rest while the other works.

Here’s an example superset:

Superset 1: Squat 8 reps and immediately perform horizontal rows for 8 reps.

Rest: 60 seconds

Superset 2: Squat 8 reps and immediately perform seated rows for 8 reps.

6. Rest intervals 30-60 seconds between sets

For older adults, rest 60-180 seconds.

7. Train each major muscle group 2-3x per week

This frequency builds strength while giving your body and nervous system an appropriate amount of time to recover.

8. Work your training program for a minimum of 6 weeks

9. Aim to progress: 3-10% per week 

This number may fluctuate based on your total volume (workouts, reps, sets, weights, durations, …) of work

 

But how do you assess progress?

Track any of the metrics above and look for change. For example, on day 1 of the program you could perform 5 pull ups. After 6 weeks, you can perform 7 pull ups.

Go strength train, note the changes and progress, and keep it up!

Endurance^3-5

Endurance training is an important tool to improve cardiovascular health and improve submaximal and maximal activity performance (aka: do the things you want or need to do, longer).

The World Health Organization and American College of Sports Medicine state that adults (of all ages) should engage in 150 minutes of moderate or 75 minutes of vigorous-intensity aerobic activity, weekly.

The good news? You pick the exercise modality.

Whatever type of activity suits your interests and your body’s current capabilities is fair game. Examples include walking, running, cycling, rowing, stair climbing, swimming, dancing to Disney songs (take a guess which example my daughter provided).

Remember, you can measure effort using a Rating of Perceived Exertion (RPE) which sits on a scale of 0 (least) to 10 (most).

Moderate and vigorous intensity activity can be defined as follows:

Moderate = RPE 3-4

Vigorous = RPE 5-7

How do you assess progress?

Test your submaximal aerobic capacity with a 30-45 minute continuous activity (using cycling as an example). Track your distance, while maintaining an RPE in the 5-7 range.

Test your maximal aerobic capacity with one of the following tests:

• 2000 m row

• 1.5   mile run for time

• 12-minute max distance run

The intent for each of these tests is a 10/10 on the RPE scale.

Power

Power is an intermediate attribute and I’ll cover it in more detail in the next blog post in this series.

Good news though, by training to improve strength (force production), you are also improving one of the major attributes of power (force). 

Start with a foundational period of building movement confidence (stability) and force production (strength) and this will set you up for success to start adding the speed component in future iterations of your training program.

Conclusion

With exercise—as with most things—consistency is the secret ingredient and the superpower. Take the foundational principles described above and apply them to the exercises that are most meaningful and most enjoyable to you. If you are consistently showing up, you will find that the exercises get easier. And when that time comes, nudge up the intensity.

Keep showing up for your exercise sessions so that one day, when prompted, you can confidently proclaim to a class of 2nd graders that you are young enough to beat them in a race.

 

Bonus: My answers to the two burning questions of 2nd grade students

What’s my age?

Old enough to have a head full of grey hair and young enough to beat you in a race

What is a physical therapist?

A mechanic for the human body

References

1. ACSM. Progression models in resistance training for healthy adults. MSSE. 41(3):687-708, 2019.

2. George Davies – A Master Clinician's Approach to Advanced Concepts in Examination and Treatment of the Shoulder Complex – 2016.

3. Izquierdo M, et al. International Exercise Recommendations in Older Adults (ICFSR): Expert Consensus Guidelines. J Nutr Health Aging. 2021;25(7):824-853.

4. https://www.acsm.org/docs/default-source/files-for-resource-library/exercise-intensity-infographic.pdf?sfvrsn=f467c793_3

5. Lagally KM, Robertson RJ. Construct validity of the OMNI resistance exercise scale. J Strength Cond Res. 2006;20:252–256.

Building the Habit of Movement

I just celebrated the 10-year anniversary of the Brain Trust Book Club (BTBC), which has brought together myself and some of my oldest friends! BTBC was founded at the wedding of our dear friend to bring old friends back together in the name of good books. We have had many iterations of the BTBC – phone chats, FaceTime, and destinations (like my wedding in Curacao!). We’ve enjoyed a sliding scale of participants who read the books to varying degrees (shout out to Joey TLDR) – and one constant is that we inevitably pick some not-so-great books.

After reviewing the list of a decade of BTBC busts, I was delighted to come across a book that has surreptitiously shaped every facet of my life: The Power of Habit by Charles Duhigg.

In The Power of Habit, Duhigg speaks on how subconscious routines shape our individual, organizational, and societal lives. As the text develops, Duhigg highlights the ever-present role of habits in our daily lives, referencing that roughly 40% of our daily actions are habits [1]. 

Reflecting on my list pulled an insight into stark focus: I am trying to help you create movement as a habit.

Because movement is a habit. Every day I engage in discussions about:

• How to use movement for pain relief (with my patients)
• How to use movement to increase activity levels for weight loss or muscle gain (with my health coaching clients)
• How to use movement to release pent up energy (with my children)

I personally rely on movement in the following ways:

• Bookend the day – walk my daughter to school, walk to pick up the kids from daycare/after school
• Fidget – time between patients provides an opportunity to walk around the block
• Exercise preparation – 5-10 minutes before workout to practice the positions of interest in the day’s workout
• Exercise – my lifeblood!
• Monkey see, Monkey do – playtime with my children trying to emulate their myriad movement outlets
• Get the digestive juices flowing – family walks after dinner

 

Movement is versatile, and with the right intentionality, we can even use movement to replace bad habits, like obsessive phone checking (one of my compulsions).

So who is this post for? While many people can benefit from more intentional habits, in this post I’ll focus on examples of:

• People who have pain/want to reduce pain
• People looking to improve overall health
• People who want to improve their movement performance
• People looking to improve their learning potential

First, though, let’s look at what habits are.

 

What Are Habits?

At a basic level, habits are the choices that each of us deliberately make at some point and then stop thinking but continue doing (often daily) [2]. We form habits so our brains can go on autopilot and conserve energy. The brain has a lot to do each day, what with controlling every process involved with our moment-by-moment survival, that it does not have time to perseverate on the act of brushing teeth, putting on underwear, and making kids lunch – and that only takes us to 7 am.

The brain looks for specific cues to trigger the autopilot mode and commences the habit feedback loop:

A cue is a trigger and it can be anything – visual, person, location, or emotional trigger (among many others) – and the first step to rewriting your habit loop is to identify your specific cues. For example, boredom is my cue to pick up my phone.

A routine is the reflexive response to the cue, and it can also be anything – my pitch is to make movement the keystone routine/habit. More on keystone habits below.

A reward reinforces the efficiency of the entire loop – my phone checking reward is the anticipatory excitement that something amazing will pop up in my inbox to distract me from the task at hand!

A key point to remember: Don’t try to eliminate old habits – instead, work to replace them.

Armed with knowledge of how this feedback loop works, we can start inquiring as to how our habits impact our lives, and make changes to them with awareness.

 

Unlocking Movement Through Keystone Habits

Another concept Duhigg discusses is the importance of keystone habits:

Small changes or habits that people introduce into their routines that unintentionally carry over into other aspects of their lives.

Duhigg also references exercise as an effective keystone habit - Preach!

My call to action is that we can all make frequent, brief, purposeful movement the keystone habit to unlock the mother of all keystone habits, exercise!

 

A Habit to Reduce Pain

Irritated tissues respond well to frequent and gentle motion, and this can often be a valuable tool to alleviate pain. If you are in pain, try the 20/20 rule – every 20 minutes, take a 20 second break to get up and move. Pick a movement that targets the irritated tissues in your body and move gently for 20 seconds, focusing on a relaxed breathing pattern throughout the movement. By focusing on your breathing, you override the tendency to tense up/hold your breath when you are in pain.

https://www.youtube.com/watch?v=OUlMJ0T2DDo&list=PLtbxeURCQnLIQLrjXI8cW7SVsgJPYuWWb&index=3 

 

A Habit to Improve Overall Health

In his book Exercised: Why Something We Never Evolved to Do Is Healthy and Rewarding, Daniel Lieberman discusses the impact of physical activity on health and wellness, including the fact that a reduction in physical activity is an independent risk factor for morbidity and compression of health span⁵. Lieberman highlights the fact that Americans spend less than 1 minute daily engaging in vigorous activity, while modern day hunter gatherer tribes spend 20 minutes daily, by comparison (vigorous activity defined as 70-85% maximal heart rate) ⁵. Why not use my boredom cue to trigger 30-40 seconds of mountain climbers in the name of health?

https://www.youtube.com/watch?v=xRYEcueW-XY&list=PLtbxeURCQnLIQLrjXI8cW7SVsgJPYuWWb&index=3

 

If the mountain climber is a bridge too far at this stage in your movement journey, can we compromise with some seated heel raises? According to an experimental physiological study⁶, engaging in a fidget routine of seated heel raises throughout the day can lead to an improvement in several biomarkers, including markers of metabolic health such as post prandial (meal) glucose tolerance and insulin secretion. In layman’s terms, average sedentary individuals (without any training required) were able to complete 270 minutes of heel raises during an otherwise sedentary day and created noticeable changes in biomarkers compared to themselves on a day in which they completed no seated heel raises. Why not use sitting as a cue to trigger a heel raise movement habit?

https://www.youtube.com/watch?v=KBibSg9Wh7I&list=PLtbxeURCQnLIQLrjXI8cW7SVsgJPYuWWb&index=4

 

A Habit to Improve Movement or Skill Performance

Anders Ericsson was a psychologist and researcher who studied the psychological nature of expertise and human performance. He described the value of purposeful practice in building new skills and abilities:

Purposeful Practice³ has well defined goals, is focused, involves feedback, and nudges you out of your comfort zone.

While this type of practice is intended to be intense – high level of focus and demand in a 60-minute block of time – why not set the foundation for purposeful practice with a couple of minutes of movement practice every 30-60 minutes?

Let Amelie and Anders be your gymnastics guides!

https://www.youtube.com/watch?v=7Rzb-aNV5W8&list=PLtbxeURCQnLIQLrjXI8cW7SVsgJPYuWWb

Or follow the path to improving athletic performance in my previous blog post https://movement-x.com/sports/mobility-and-stability/

 

A Habit to Improve Learning and Productivity

Brain coach, Jim Kwik, has dedicated his personal and professional life to helping people learn better.  In his book, Limitless, Kwik laments the oft used and less-than-stellar approach of burning the midnight oil the night before the exam, trying to “learn” as much as you can in one block of time. Kwik teaches about the value of learning in chunks and espouses the approach of breaking up your learning time into 25 minutes of work followed by a 5-minute brain break. This approach builds on the Serial Position Effect to enhance learning⁴.

Serial Position Effect: The tendency to most frequently remember the first and last chunk of information we are presented with.

Using the chunking approach, the learner can take advantage of multiple “first and last” chunks of information to enhance the learning experience.

The 5-minute brain break can be the learner’s cue to insert a movement habit, such as a walk around the block/office/etc. Or 5 minutes of mountain climbers?!

 

Movement Routine: Keys to Long-Term Sustainability

Establishing a new habit loop may seem simple, but it is not easy. Duhigg paves the way by highlighting some keys to successful habit change [2]:

• Start by identifying a habit loop you are trying to replace.
• Use the same cue, insert a new habit, and provide the same reward
• Build belief that you can accomplish your habits—belief is what makes habits stick in the face of stress
• Build your community—it’s easier to make a habit stick in the face of stress when you have a movement support system. Two can be a community, so recruit a movement buddy to embark on the journey with you.

 

Here’s what my habit loop looks like:

• Identify the habit loop: Checking my phone due to boredom anticipating the reward of something exciting on my phone.
• Using boredom as my cue, I insert a new habit: a calisthenic movement chosen by my daughter.
• Provide the same reward: Anticipatory excitement that I can tumble with my gymnastics-loving daughter.
• Belief—There is a movement ninja inside every one of us. Set your ninja free!
• Community—The MovementX community, my family and friends.

 

Final Pitch

Movement can be the mother of all keystone habits. Whether you are attempting to reduce pain, improve your health, or alleviate your boredom, choose movement (until it becomes a subconscious habit)! Just identify the cue -> habit -> reward loop that you can replace with movement, mix in some belief, with a dash of community, and a world of opportunities awaits!

 

References

1. Neal DT, Wood W, and Quinn JM. Habits – A Repeat Performance. Current Directions in Psychological Science 15, no 4 (2006): 198-202.

2. Duhigg C. The Power of Habit: Why We Do What We Do in Life and Business (2012)

3. Ericsson A and Pool R. Peak: Secrets from the New Science of Expertise (2016)

4. Kwik J. Limitless: Upgrade Your Brain, Learn Anything Faster, and Unlock Your Exceptional Life (2020)

5. Lieberman DE. Exercised: Why Something We Never Evolved to Do Is Healthy and Rewarding (2021)

6. Hamilton, Marc T. et al. A potent physiological method to magnify and sustain soleus oxidative metabolism improves glucose and lipid regulation. iScience, Volume 25, Issue 9, 104869 (2022).

Blood Flow Restriction Training – The New Americana?

Strength and big muscles are as “Americana” as football (sadly, knocking baseball off of this list) and rock ‘n roll. If I had a nickel for every time I heard my daughter argue with her friends that “my mommy is stronger than your daddy,” I could have funded my Blood Flow Restriction unit purchase..

Perfect segue…

What is Blood Flow Restriction?

Blood Flow Restriction (BFR) is a type of strength and hypertrophy (muscle growth) training that uses a cuff around the upper arm(s) or upper leg(s) to reduce blood flow going into the limbs and reduce blood flow return from the limbs.

***Good news – this is not a tourniquet, so blood flow is not completely occluded.

Blood Flow Restriction (both in and out) allows for significant gains in muscle strength and size1 while training with lighter loads than traditional strength and hypertrophy weight training programs. 

***When BFR is used in conjunction with an endurance program it has also been shown to improve aerobic capacity as measured by maximal oxygen uptake VO2 max (the specifics of VO2 max are beyond the scope of this article)4.

How Does BFR work?

Short answer – While the exact mechanism(s) is yet to be determined, proposed theories abound!

A bit of context on muscle growth, in general: Brad Schoenfeld (world renowned muscle hypertrophy expert) describes three overlapping mechanisms to muscle growth (hypertrophy) – mechanical tension is most important in traditional hypertrophy programs (size and duration of loading stimulus), metabolic stress (accumulation of metabolite byproducts in response to exercise), and muscle damage (short term muscle break down induced by exercise)1.

Put in simpler terms: hypertrophy is maximized with heavy weights and lots of reps.

While a typical high load/intensity weight training program relies heavily on the mechanical tension mechanism of muscle growth, BFR training seems to rely more on the metabolic stress pathway for muscle growth.

The current theories described in BFR literature involve some combination of the following2:

• Increased swelling in the muscle cells lead to metabolite accumulation and increased muscle fiber recruitment (especially the fast twitch, type II fibers, that are targeted with high load/intensity weight training) *** really important for aging populations as this fiber type is quickest to degrade with age1

• Increased swelling in the muscle cells leads to metabolite accumulation and upregulation of localized and systemic anabolic hormones, such as Growth Hormone and Insulin-like Growth Factor-1 (processes associated with muscle hypertrophy) *** really important for aging and injured populations

Is Blood Flow Restriction Training Safe?

Yes (referencing 24 studies on safety of BFR2) – BFR is a safe training tool that does not increase risk for blood clots in the general population, nor does it increase (transiently) blood pressure as high as traditional high load/intensity weight training. Having said this, the following people should not use BFR training:

• Blood clotting disorder

• Lymphedema (in affected limb)

• Impaired circulation

• Pregnancy

*** Medical disclaimer - Consult your physician and physical therapist prior to starting BFR

Who should use BFR? 

Anyone that is looking to improve muscle strength and size but cannot handle the high mechanical tension of resistance training3.

Put in simpler terms: cannot handle heavy weights/lots of reps

Three target populations come to mind:

• Older adults need to retard the age-related loss of muscle mass that leads to sarcopenia. According to research1 normal adults over 60 years old have lost 10% of their muscle mass from their 20s (15% loss of muscle mass is associated with sarcopenia). While regular resistance exercise can help abate age-related muscle loss, older adults require a greater weekly minimum training dose to maintain (hopefully gain) muscle mass1 and this can be hard to achieve in conjunction with the high loads associated with typical hypertrophy training programs.

• Injured population (ie MovementX patient) that wants to stay active while recovering from the current injury that leaves their tissues unable to handle high load/intensity weight training. A key goal of any rehabilitation program is to improve tissue strength. This is a simple, but not easy goal, as it is difficult to appropriately load a tissue for strength (or hypertrophy) stimulus when a person is in pain. BFR makes this goal easier to achieve because you do not have to expose the person to heavy loads (more on this below).

• Anyone trying to maximize hypertrophy (in conjunction with high load/intensity training) without overtraining. There is a fine line between overreaching (positive response to training that leads to improved performance) and overtraining (negative response that leads to exhaustion or injury) 1. While mechanical tension (size and duration of the loading stimulus) is the most important mechanism for muscle hypertrophy1, a common driver of overtraining is a sharp increase in workload that exceeds a person’s training history. BFR provides the duration stimulus (more on this below) and its heavier reliance on metabolic stress with minimal muscle tension/damage stress can be an effective adjunct to a hypertrophy protocol. 

Who should use BFR in simpler terms:

People who cannot tolerate this:

***Photo credit to my 6 year old daughter

 

People who want to look like this:

***Photo credit to Arnold: The Education of a Bodybuilder

What is the Best Dosage for Improving Strength & Hypertrophy With BFR2? 

***Keys for driving a metabolic response = lots of sets/reps and light loads.

Load: 15-30% of a 1 repetition maximum for working sets. This is the beauty of BFR that makes it applicable to older/injured populations that might not tolerate high loading resistance protocols.

Set Volume: 4 sets of 30/15/15/15 repetitions

Rest periods: 30 seconds between sets

Frequency: 2-3 days a week. Due to the low loads associated with BFR, there is little/no exercise induced muscle damage and, in theory, it can be done as frequently as 1-2 x daily.

Training duration: Longer durations up to 10 weeks have the greatest positive impact on strength/hypertrophy.

Number of exercises performed with BFR: start small (1-2 per session) to assess tolerance and then build, per your personal goals.

Is BFR here to stay? Where can I go for BFR?

Research on BFR began to be published in the late 1990s after being invented by Dr. Yoshiaki Sato in 1966. As of 2018, the American Physical Therapy Association officially stated that BFR training is part of the professional scope of practice for physical therapists.

Interested in BFR to stave off sarcopenia, rehabilitate an injury, or supplement your hypertrophy protocol? Look no further than your favorite BFR MovementX provider!

***The author of this article provides BFR services (and according to his daughter, should implement the protocol more frequently in his fitness routine).

Disclaimer – the information provided is for educational purposes only and does not substitute for professional medical advice. Users should consult their medical provider for specific advice and/or treatment. The author and company are not liable for risks or issues associated with using or acting upon the information in this article.

References

1.  Schoenfeld B. Science and Development of Muscle Hypertrophy (2nd Edition). Champaign, IL: Human Kinetics, [2021]. Chapter 2 – Mechanisms of Hypertrophy

2.  Blood Flow Restriction by Owens Recovery Science (2018)

3.      The Drive (Podcast) #179 – Jeremy Loenneke, Ph.D.: The science of blood flow restriction—benefits, uses, and what it teaches us about the relationship between muscle size and strength (October 11, 2021).

4.  Foundations of Blood Flow Restriction Training. Ed Le Cara (2024)