15. After 50, what you don't know about exercise can hurt you: Andy Baxter, Medical Exercise Specialist

Andy Baxter (00:00)

The COPD patient is going to put the primary emphasis on strength training initially because they can tolerate higher intensities in very short doses before the aerobic requirement takes over. The opposite is going to be true with our cardiac patient. They're going to try to increase their aerobic base in a low level, 3 to 4 out of 10 way so that they can broaden the base, more highly innervate the muscles to use the oxygen, but without stressing the aerobic system. So they're going to get their adaptation through increasing the volume of the work, not the intensity of the work. The COPD patient is going to increase the intensity of the work, not the volume. It's a complete opposite.

Dr. Lemanne (00:43)

You have found your way to the Lemanne Gordon podcast, where Docs Talk Shop. Happy eavesdropping. I'm Dr. Dawn Lemanne. I treat cancer patients.

Dr. Gordon (01:01)

I'm Dr. Deborah Gordon. I work with aging patients.

Dr. Lemanne (01:05)

We've been in practice a long time.

Dr. Gordon (01:06)

A very long time.

Dr. Lemanne (01:09)

We learn so much talking to each other.

Dr. Gordon (01:11)

We do. What if we let people listen in?

Dr. Lemanne (01:20)

Today, Dr. Gordon and I have the distinct pleasure of speaking with her friend and rowing coach, Andy Baxter. He's a specialist in the unfortunately obscure field of medical exercise. Today, we go deep into the ways exercise not only improves musculoskeletal and cardiovascular health, but also how it's a treatment for inflammation and can improve conditions such as rheumatoid arthritis. But unless very particular protocols are used, you'll learn that exercise will worsen symptoms of such conditions. Another surprise was learning that lung patients and heart patients require completely different exercise protocols. Of course, we discuss how exercise improves the brain, nervous system, and cognition. We also discuss a chapter in Andy's book about a patient who's fitness did not improve with Andy's program and the surprising discovery that her medications, a statin, a high blood pressure drug, and a diabetes drug, were actually blocking the effectiveness of her fitness efforts, and how switching to a new doctor who stopped those medications and celebrated her exercise program allowed her to benefit from exercise and recover her health. As a competitive oarsman, Andy has amassed multiple US, Canadian, and World Championships, and in 2008, at the relatively advanced age of 41, he competed in the Olympic trials.

Dr. Lemanne (02:53)

Andy has published articles for Physical Therapy magazine, Spirituality and Health magazine, sciFit, and Kaiser, and has authored two books, Racing Yesterday and The Exercise Prescription, which Dr. Gordon and I heartily recommend you read. Andy owns and operates Baxter Fitness Solutions in Ashland, Oregon, where for the last 20 years, he has implemented medically-protocoled exercise programs for seniors, focusing primarily on orthopedic and neurologic conditions. Enjoy today's episode.

Dr. Gordon (03:29)

We are lucky enough today to have this icon in our community on whom we've both relied so consistently for exercise wisdom. We've referred patients to him. We've had clients who've reported on the excellence of the training they get at his exercise facility. And any rower in the rogue Valley knows him well as an excellent training of rowing. I'm speaking, of course, about Andy Baxter, And he is really excellent in all those areas. And I'm interested to know. Andy, welcome. Hi. Thank you. We're so glad to have you here.

Andy Baxter (04:10)

The microphone doesn't pick up blushing, but it's in there.

Dr. Gordon (04:15)

Okay. The room is getting warmer. I can tell.

Dr. Lemanne (04:18)

Well, Deborah, you actually work out with Andy, right?

Dr. Gordon (04:21)

I have at times. I'm on a little bit of a hiatus from the rowing club, but yes, I've worked out with him. Did an excellent session with him with the Rowing Club getting ready to train this winter.

Dr. Lemanne (04:33)

For our audience, Deborah Gordon is an outstanding athlete and actually competes in rowing.

Dr. Gordon (04:42)

I will stand on my historic laurels and say that I look forward to some future ones, but thank you for that, Dawn. Andy is... The good point about his working out with the team now is I have inside scuttlebutt from people who are training with him, and people are just delighted over the moon at his insight, carefulness, observance, and sharing the results with everybody. He's great as a coach, so we know all sorts of things that are great about him as a local coach. But there's a lot more to know about what he brings to the table when he's training rowers or athletes in his gym. And there's a lot of that we're we're going to dive into deeply. But Andy, I wonder if you could just first give me some very mundane information about what the initials after your name, M-E-S and P-R-C-S, stand for?

Andy Baxter (05:43)

Absolutely, yes. So M-E-S is Medical Exercise Specialist, and then the other one is Post-Rehabilitation Conditioning Specialist. And so both of those just fall onto that third leg of the physical therapy stool of strength. So if we think of PT as the joint stability, range of motion and strength, then medical exercise is pretty much focusing on the strength component as it relates to medical conditions using exercise as medicine.

Dr. Gordon (06:14)

And so are you speaking about my advanced age as a medical condition?

Andy Baxter (06:20)

Potentially, yeah. Metabolically, probably. Yeah, sure.

Dr. Gordon (06:26)

No, I think that's definitely a consistent observation on people my age. At first, I thought it that we are really metabolically different. But I think of it now as if you're aging, you've got metabolic challenges and you're part of the approach besides my talking to them about their lab values and what they're eating, your approach is essential.

Andy Baxter (06:51)

Yeah. And we seem to drive that point home, and it becomes more prescient as time goes on.

Dr. Gordon (07:04)

I can talk about what happens to your hemoglobin A1c or your fasting insulin with age. What happens from your point of view that make your older clients different from your younger clients? Well, wait, first, I skipped a step. Can you tell us a little bit about this gym that I've referred to a couple of times but haven't really described?

Andy Baxter (07:28)

Sure. So Baxter Fitness Solutions. I've been in business since the '90s. I started down the Bay Area doing post-rehab joint replacement work with Alta Bates Hospital and Herrick Hospital. And at the same time, I owned a gym in Oakland. So it made sense to put that all together and bring those outpatient folks over to our facility. And then the gym ended up morphing itself into more of a medical model. Basically gutted it, took out anything that was contraindicated for those medical exercise protocols, and really just customized it with that in mind. And then the clientele, of course, evolved that way.

Dr. Lemanne (08:15)

So tell us a little bit about who your specific clientele, who they are. Who comes to see you, as opposed to going to the why or something.

Andy Baxter (08:25)

Absolutely. So my whole philosophy started in joint replacement. So it started in the orthopedic realm, which was predominantly knees and hips, but also shoulders and spines. And then it branched out into a lot of the neural components. And then, of course, the- So neural components.

Dr. Lemanne (08:44)

Tell our audience a little bit about what you mean by that.

Andy Baxter (08:46)

Well, stroke and Parkinsonism would be the top two. But then, of course, there's also cognitive decline with age just as an organic process. And then some of the- Wait a minute.

Dr. Lemanne (08:58)

You're saying people go to the for cognitive decline?

Andy Baxter (09:02)

Absolutely. Absolutely, Dawn. How funny you should point that out. Yeah. So what we know now, this is going to get tangential.

Dr. Lemanne (09:15)

I knocked my earphones off.

Andy Baxter (09:17)

But, yeah, so we can definitely talk about neuroplasticity and neurogenesis and what that means relative to exercise and the blood wash of the brain and all that good stuff. But, yeah, so I started in that realm, and that's been my niche. So basically, that hits everybody over the age of, unfortunately, 50 or so.

Dr. Lemanne (09:41)

Do you work with younger clients? I do. Or is it your gym, specifically for people 50 and over?

Andy Baxter (09:47)

The gym is specifically for people over 50. It's physician referral, PT referral, but it's also general membership. But then I personally work with any age group. So if they're working one on one with me, there's no age requirement.

Dr. Lemanne (10:02)

Okay.

Andy Baxter (10:04)

Did I answer your question, Deb?

Dr. Gordon (10:07)

Yeah. So I think just on a very casual level, if people drove by, they'd see this gym that has a small storefront of a name they don't know. But if you walk inside your gym, it looks quite different from the gym at the Y or any of the 24 hour fitness, something like that. The machines, many of them look similar, but a lot of them look different. Different. Yes. And there are a lot of machines.

Andy Baxter (10:32)

Yeah. So our equipment is different. The medical model is at times dramatically different than the commercial gym model. So my involvement in the medical exercise industry over the last 25 years or so has lined me up with a lot of those companies. So CYFIT, Kaiser, my own line, the Powerzone line.

Dr. Gordon (10:55)

Your own line, the machines that you've developed. Yeah. So give us an example of something that I'd walk up and say, oh, this looks like a fill in the blank, but it's actually... And you explain it.

Andy Baxter (11:07)

Yeah. So the CYFIT equipment is medical exercise-grade equipment. And what that means is it actually goes through a certification process, the TUV process in Germany, that allows it to have a medical designation. So you're going to see sci-fit equipment more in hospital clinics and physical therapy clinics than you would see them in gyms. There is some crossover. You will find them in gyms occasionally. But one of the primary differences between SIFID equipment and traditional aerobic equipment is its bi-directional capability. So anytime we can go backward with a predominantly forward movement, we're going to do that. And that has orthopedic implications as well as neurologic implications, because we want what we call reciprocal muscle group balance to support the joint evenly. But we also want to introduce nondominant neuromuscular patterns for the brain.

Dr. Lemanne (11:58)

So I I want to just make sure that our audience understands this. And I was fortunate enough to actually have a tour of your gym yesterday. And the first thing you showed me was it looked like a recumbent bicycle, except you had me go forward and backwards, and there was a lateral motion with the legs as well.

Andy Baxter (12:22)

Yeah. So that's one of my more recent developments, and that's in conjunction with a couple of companies. But we We call that a medialateral trainer. And what does that do?

Dr. Lemanne (12:35)

An ordinary stationary bicycle at the Y doesn't do.

Andy Baxter (12:39)

So glad you asked, Dawn.

Dr. Lemanne (12:42)

I'm going to ask that a lot.

Andy Baxter (12:43)

Yeah, these are great questions. Yeah, so most of what you're seeing in gyms is linear, right? And we talked a bit about the kinematic of the hip structure, right? So the hip joint being a ball and socket joint has an internal-external component to it. So that kinematic, while there's flexion and extension, also has to allow for some rotation. So that particular piece is a lateral medial trainer. And what that means is you're getting a lot more side activity in the musculature of the hip. And as we also know from mortality rates and side falls, this is really important because everybody has some degree of lateral instability, and that's not being addressed in all the linear movements that you're doing in a gym, traditionally.

Dr. Lemanne (13:26)

So that's just something baked into human structure?

Andy Baxter (13:29)

That is correct. Yeah.

Dr. Gordon (13:30)

Well, I could imagine that most of our movement is walking forward. And on the rare occasion that you're stepping in my backyard, there's a stone path, and I have to lunge at it in a diagonal way. But that's a very atypical movement, and I really have to pay attention when I'm doing that.

Andy Baxter (13:48)

So that's super interesting. We actually did a study called a Lateral Excursion Study. And in that study, we looked at four different groups of people based on their Their physical makeup. Are they tall and thin? Are they short and heavy? Different body types. And what we know about forward ambulation is that it's predicated by lateral stability. So I call this the sailboat effect. And that is that if you're standing and you want to move forward, when you lift, say, your left foot without right hip stability, you're going to fall sideways to the right. Just like a sailboat with a center dagger. When the wind hits from the side, it propels the boat forward. But it's that center dagger that provides the stability. So same principle.

Dr. Gordon (14:38)

But in a typical... We don't intentionally, except evidently on this unusual bicycle at your gym, we don't typically engage. We don't exercise those lateral movements too much unless we're jumping side to side and playing hopscotch because we're really in second grade.

Andy Baxter (14:56)

That's right. And as we age, This becomes more and more important because we're atrophying. Sarcopenia. We're losing muscle mass as we age. And so then a few things happen, and this is what the study showed, is that we start to develop compensatory mechanisms. One of them is momentum. And momentum can be a very volatile and dangerous place when you don't have the muscular support to back it up.

Dr. Lemanne (15:21)

So by momentum, people go faster to keep going forward? Like riding a bicycle?

Andy Baxter (15:26)

Or they swing their body weight. Yeah, exactly. Like getting out of a chair, swing forward rather than actually using muscles. So that leads into another philosophy of mine, which is what we preach in how we learn and how we train is we have to sequence our learning in pattern before strength, before power.

Dr. Gordon (15:45)

What's the difference between strength and power?

Andy Baxter (15:49)

Great question, Deborah. Let me answer that for you. These are awesome. Sorry, that was way too easy. Yeah. So the difference between strength and power is that strength in a vacuum is pretty useless in the real world, functionally. Strength is usually like a one rep max, what you can push over a fairly short distance at a fairly slow cadence. And power is load times speed. So power is taking the load and accelerating that load. And functionally in our day to day lives, that's way more relevant. To be able to be strong dynamically in the real world is much more applicable. Yeah. And that's where the crossroads of my specialties meet in that on the one side, there's athletic performance. I talk about power a lot, especially as a rower, but just as an athlete in general. And the difference I think we'll get into that later about hypertrophic effect of strength training versus strength training for strength as opposed to muscle size. But yeah, so being powerful and having control of that power through a given range of motion, preferably a functional range of motion, is the gold standard.

Dr. Lemanne (17:05)

So you're looking for those three things. You're looking for a range of motion, you're looking for power, and you're looking for control. Sure. Okay. And you can train for that. Absolutely.

Dr. Gordon (17:16)

And it's incorporating more than just... So I'm two trains of thought are going in my mind. One is that, well, then you have to train for a greater range of motion than just flexing my my arm, extending my arm, flexing my arm, extending my arm. You also have to move things around laterally. But you also talk about closed versus open. Yes. Yeah.

Andy Baxter (17:43)

So that would be The thing about training as we age, I would say that really, I train people, regardless of age, with the basic same progressions, with the caveat that there are going to be certain protocol in place to protect the aging athlete, whether they have specific conditions or just generally speaking. And one of those is that in our facility, we don't do any open chain movement. Can you define? Yeah. Yeah. An open chain movement would be something like a leg extension where your foot is not grounded. So it's a single joint primary rotary movement. So it's just the knee moving when you extend your leg. That's great in a physical therapy setting where you're working with a PT, you're establishing that range of motion, you're establishing joint stability in that range of motion. But once we get into the realm of strength, you can pretty quickly override that joint as you get stronger. So what we want to do is displace that load over multiple joint structures, and that becomes what's called a compound movement. And the foot would be grounded, say in a squat or a leg press, and that makes that chain closed, hence closed chain movement versus open chain movement.

Dr. Gordon (19:00)

So it's multiple joints and it's stabilized versus- Yes, and we're going to recruit more muscle mass.

Andy Baxter (19:08)

And we're also going to recruit it functionally because squatting is something we do every day in some form or another. But unless you're into, I don't know, kicking puppies, the leg extension is not that great functionally in your daily life. And certainly, we don't condone kicking puppies.

Dr. Gordon (19:26)

Glad to hear that. Yes.

Dr. Lemanne (19:29)

So one thing I've What you've been concerned about through my reading is the loss of fast twitch muscle fibers with aging. Is that something that should concern me? And is there something to do about that?

Andy Baxter (19:44)

Yeah, absolutely. And all these questions are, I think, obviously complex in that there's no simple, straight, at least not yet. There's not a simple, straightforward answer. There's all these offshoots. But when it comes to sarcopenia, the loss of muscle mass, can we combat that? Absolutely, and we should. But what I would suggest is that oftentimes, what we're really talking about is not actually strength in the beginning, it's more innervation. And that comes again from this pattern of learning, of creating the patterns, the proper patterns, checking for issues of alignment. And then once that's established, training the pattern properly with sufficient stimulus that we innervate those muscles fully. So oftentimes it's not that a person is weak, it's that they're under innervated.

Dr. Lemanne (20:41)

So it's more of a cognitive neurologic issue?

Andy Baxter (20:44)

That is correct. Say a little bit more about that. Yeah, it's a neuromuscular component in that muscles have innervation ratios and innervation optimization. And so that's simply the message, the motor unit potential of the message from the brain to the muscle. We want to maximize analyze that. And through disuse, that becomes atrophied.

Dr. Gordon (21:04)

So I know in the brain that it's a fairly new thought, maybe 10 years, that older people can actually recruit and build new brain cells. Absolutely. They previously thought they couldn't do that. Correct. But what you're talking about is, so if I'm doing a biceps curl, I don't have as many nerve fibers going to that biceps muscle, likely as I did when I was younger, but I can recruit more nerve growth?

Andy Baxter (21:32)

Yes. And not necessarily because of age in and of itself, it could also be more disuse. Now, does the disuse come from age or societal preconceptions? Then yeah, for sure. But yeah, now we should also identify that different muscles have different innervation ratios. So we have smarter muscles and we have dumb muscles.

Dr. Lemanne (21:54)

Say something about that.

Andy Baxter (21:56)

So, yeah, sure.

Dr. Lemanne (21:57)

Which of my muscles are smart?

Dr. Gordon (21:59)

My muscles are taking that personally.

Andy Baxter (22:03)

I like to focus on the dumb muscles because they have a purpose, and people often misunderstand that. I usually classify dumb muscles as being the calf, forearms, core, traps. That would be my big four. And the reason why they have low innervation ratios is that they're constantly in use at some low amplitude. If they were smart, if they were highly innervated, we would be paralyzed. We would be constantly overworked and underrecovered and catabolic. So by design, those muscles have a low-grade amplitude innervation structure. For instance, we walk, right? Well, if we had really sensitive calves, we would be debilitated, right?

Dr. Gordon (22:53)

Can you go in? What do you mean?

Andy Baxter (22:56)

Well, so a highly innervated muscle, if it's constantly being unstimulated is going to get torn up and need recovery time. So we need the muscle to be dumb so that it's not as sensitive to the input.

Dr. Gordon (23:10)

So it's just going along with the motion without really driving it or forcing it.

Andy Baxter (23:14)

It's firing at a low amplitude, correct?

Dr. Gordon (23:16)

Okay.

Andy Baxter (23:17)

And that's why, and this is a little geekier and down into the weeds, which I'm sure we'll get into more because that's where this is going. But that's why, for instance, the general rule of with dumb muscles is normally you would equate low repetition, high intensity work with strength, and then you would equate moderate intensity, higher repetition with strength, endurance, or hypertrophy. Dumb muscles actually throw that out the window. They combine the two. So with dumb muscles, you tend to go as heavy as you can with much higher repetition, 12 to 15 reps. For just this reason is that they're going to respond to time under tension. And so the longer they're under tension, the more you can maximize that innervation.

Dr. Gordon (24:10)

So if I want to make my calves stronger, I may have to do more standing up on my toes and going back down than if I were trying to make a smarter muscle stronger.

Andy Baxter (24:20)

That's correct. And you have to do it with a much heavier load than just your body weight because it's already fully geared to that.

Dr. Gordon (24:25)

It's already pretty good, though. So the idea of There's a movement now to attach electrodes to the muscles and stimulate them to cause a contraction to cause muscle strengthening.

Dr. Lemanne (24:38)

But it sounds as though that might be counterproductive. In other words, you might, I've seen this, especially with abdominal machines. Trying to strengthen their abdominal muscles this way.

Andy Baxter (24:49)

Yeah, but they're not really trying to strengthen their muscles. They just want to look good in a swimsuit.

Dr. Lemanne (24:54)

Well, they're not engaging this innervation increase that you're talking about here. Is that correct?

Andy Baxter (25:01)

Even if they were, it would be artificial. So what you're not doing is you're not training the brain to train the muscle. And that's the connection you truly need.

Dr. Lemanne (25:09)

That's the connection you need. So putting the brain on the outside on a machine beside your couch, while you exercise your abdominals might not be.

Andy Baxter (25:18)

So remember, the fitness industry is just a giant money-making machine that preys on your ignorance. There's a chapter in my book on that, actually. But yeah, so super fantastic app things for 39.99 a month and payments of four months are not going to help you.

Dr. Gordon (25:38)

So I wonder if I am doing, this is just raising several little spontaneous questions in my mind, so maybe they're quickfire questions. If I'm on doing a machine, do I have to pay attention to what I'm doing or can I watch the video on the front wall and just do it mindlessly?

Andy Baxter (25:56)

That's a good question. It's a valid question. So there are There are instances where having those ranges of motion fixed for you are advantageous, especially in a rehab setting, or if there's some issue where you're going to progress Well, let me back up. So I'll give you an example. An example would be in our strength triad for our post-rehab protocols for hips and knees.

Dr. Lemanne (26:25)

So these are patients who've had hip replacements or knee replacements? Yes.

Andy Baxter (26:29)

So in those protocols, initially, they're on machines with a fixed range of motion and a fixed pattern. So yes, that's mindless. They're just going to do the reps and sets that they're told.

Dr. Gordon (26:42)

They could watch a video?

Andy Baxter (26:43)

As long As long as they stop the required rep range. Yeah. Because the range of motion is fixed and it's being done for them. All they have to do is push and or pull. So the upside to that is that it's much safer if the joint structure is is compromised, and we're trying to build up some joint stability and strength. The downside is you lose that neural component. You lose that kinesthetic awareness of what your body is doing in space and time. So we flip the script. We go to, say, a free weight version of that movement. The upside is the entire body is integrated. Your brain is stimulated. You're moving through space and time in a much more dynamic way. So there's a lot more brain component to that movement. The downside is it's less stable. So you're moving freely in space and time. And so if you're not accustomed to those patterns, then that's a more volatile environment.

Dr. Lemanne (27:39)

Well, Deborah, I'm not sure if this is what you were asking, but my question is, does the concentration on the actual movement during the movement increase the innervation that we're aiming for?

Andy Baxter (27:52)

I believe it does. I've certainly heard that. I couldn't say definitively, but my experience tells me yes.

Dr. Lemanne (28:00)

Okay. Well, tell us a little bit about training for strength versus training for power or training for size. I've heard a lot recently on a lot of longevity health shows and podcasts that we all need to maximize our muscle mass. Yes. And I'm not sure I agree with that. So for instance, whether your overall mass is greater because of muscle or fat, actually, that may decrease life expectancy compared to someone who has less mass overall. Mass is not necessarily all healthy, even if it's muscle. What are your thoughts on that? And what are your thoughts about how to train for muscle mass versus purely strength? And I know there's some overlap. Of course, a stronger muscle is probably going to be bigger, but there's still some difference between aiming for mass for.

Andy Baxter (28:58)

You would I think that the stronger muscle would be bigger, but in fact, that's not always the case. And so there are- Well, a stronger muscle is bigger than a weaker muscle, right? Yes, but a hypertrophic muscle for the sake of hypertrophy isn't necessarily stronger than a muscle that's strained for strength. Yes. Talk about that. And there's obviously the genetic component, right? So we got our nature and nurture. So your genetic predisposition for one or the other is going to weigh heavily. And we can get into about VO₂ max and stuff like that, too. When we talk about improvements in those areas, we're looking at percentages based on the genetic potential that you're born with. Okay.

Dr. Gordon (29:43)

Not just my age.

Andy Baxter (29:44)

Not just your age. No, certainly not. So, yeah, but getting back to muscle mass versus training for strength.

Dr. Lemanne (29:50)

How do those training programs look different? And how are they the same?

Andy Baxter (29:54)

Yeah. Well, so most training programs should have both. They should cycle. And typically when you're developing a training program per cycle, whatever that cycle is, and I'll just give you an example, rowing example, is if we look at a whole year as a cycle, then you're going to have micro cycles and mesocycles within that year period. And then within that period, you're combining your aerobic training, your anaerobic training, your strength training, your power training, your power endurance training. These are all elements within that annual cycle.

Dr. Lemanne (30:28)

Now, is part of the cycle that dedicated to developing mass?

Andy Baxter (30:31)

Yes, absolutely.

Dr. Lemanne (30:32)

And why would that be? What's the benefit of mass?

Andy Baxter (30:35)

So as an athlete, you're going to be in a catabolic state at some point in your training. And that's usually when you get in the racing season. So you're going to start to tear down muscle. So there's always what's called a symmetry hypertrophy phase. And that's usually after the racing season ends. Well, maybe you're going into the winter, you're recovering from injuries, you're redeveloping and reintroducing symmetry to the body. And then you're Building muscle mass in anticipation of carrying some of it down throughout the course of the season. So it has pretty practical effects of you're going to be tearing up some of that muscle in the course of your training.

Dr. Lemanne (31:15)

So someone like me who's not really going to compete and doesn't have a training season but wants to be, I want to live as long as I can and live as well as I can. I don't really have any interest in mass. Should I?

Andy Baxter (31:29)

Yeah. So one of the benefits to having increases in muscle mass in surface area of the actual muscle- Versus strength. Yeah. Okay. Surface area of the actual muscle fiber is that you do get an increase in mitochondrial density, and that has metabolic effects in that your mitochondria, you're using oxygen. So for instance, say a cardiac or a pulmonary patient. Oh, this is a great example. So our medical exercise protocol, say for COPD, very different from the exercise protocol, say, for a cardiac patient. Because the pulmonary limitation, they're not going to benefit as much from pure aerobic training. But what we can do is reduce the aerobic load by increasing muscle mass.

Dr. Lemanne (32:14)

Interesting.

Andy Baxter (32:15)

Because then we increase their mitochondrial density, thereby lightening the load or maximizing the limited pulmonary output that they have.

Dr. Lemanne (32:23)

So is the increase in muscle mass due to an increase in mitochondrial mass? Is that the mechanism by which Does your muscles get bigger with exercise?

Andy Baxter (32:32)

No, it's the other way around, really. It's the increase in mitochondrial density as a result of the increase in the surface area of the muscle.

Dr. Gordon (32:40)

I would say, though, thinking very literally and from my neurocognitive metabolic trainwrecks sometimes that I have to try and put back together is having larger muscle mass means you have a greater sink for the calories, literally, that you eat, and you're less likely to have higher or more extreme blood sugar excursions. So it's part of the healing of metabolic illness. And also a greater muscle mass, and this is my answer to your question, Dawn, is associated, and so it's more of an observation, and there are theories about why it works, but having a greater muscle mass is associated with sustained good cognitive health over life. And cognitive impairment is more associated with muscle loss or less muscle mass. And it's thought to be pretty linear, but of course- And that's not necessarily related to strength, though. Right. But I'm sure there are outliers, like the Mr. Universe. We're not talking about him. I'm talking about-I mean, they have really short life expectancy.

Dr. Lemanne (33:55)

So many of them die in their 30s, 40s, and 50s. Right.

Dr. Gordon (33:57)

But that might have something to do with other things if they're putting in their system. But within the range of normal active life, part of what I do with my cognitive patients is try and encourage them to do some resistance exercise, not just so they don't fall and break their hip, but it'll have a feedback benefit to their brain. Absolutely.

Andy Baxter (34:21)

And then also in terms, peripherally, of mitigation of inflammatory responses, muscle plays a huge role in that. I don't think So muscle, and I don't think we know the total answer to this, but like with ability to regulate insulin, we know that increases in muscle mass have a dramatic impact on our ability to regulate insulin. And as far as the brain is concerned, muscle is a heat regulator. And so if we think about inflammatory responses in the body, muscle helps us deal with regulating inflammation.

Dr. Lemanne (34:58)

So if If we have two people, and they're both basically healthy, we're not talking about severe metabolic derangements or anything like that, and they're both equally strong and powerful. They can both lift a certain weight at a certain speed, et cetera. You're saying then that the one with more muscle mass is going to be healthier, better off?

Andy Baxter (35:20)

Not necessarily.

Dr. Lemanne (35:21)

With equal strength.

Andy Baxter (35:23)

So many other contributing factors. The first one I would go to is relative strength. So relative strength is strength relative to body weight. So in that case, the person with less muscle mass, if they're equally as strong, they're actually relatively stronger. So that would make the argument for the person with less muscle mass. So from an athletic standpoint, this is really important. Like I always say, we don't build muscles to build big muscles. We build athletes. And if they get muscles as a byproduct of whatever the athletic endeavor they're training for, then so be it. But anything beyond that is usually a waste of energy and weight.

Dr. Gordon (36:04)

That's interesting because I guess I'm usually thinking from the point of view of going from sarcopenia to mediocre to improved muscle mass. But you're talking about potentially, going up beyond that, the actual relative strength being much more important than the building of mass, because whether they're a runner or a rower, they're also moving their weight through space. That's correct.

Andy Baxter (36:27)

Yeah. Having excessive mass can have detrimental effects. If you're a runner, that may not be your best friend because you're going to get that five factor, that orthopedic five factor of every time your heel strikes the ground, take your body weight, multiply it by five, and that's what that joint is feeling. So all of this is relative. There are so many factors involved in those types of statements, but certainly in the aging population, I would say that muscle mass is absolutely good in any capacity because we're combating sarcopenia.

Dr. Gordon (37:02)

Can I dial back to your comment about inflammation? And I'm thinking both in the setting of acute injury or autoimmune disease, where some rheumatoid arthritis. So in the settings where somebody's inflammation might be tuned up higher than they can even really tolerate, are there exercise programs that help somebody with rheumatoid arthritis be able to better move?

Andy Baxter (37:30)

Yeah, there are. And it's really a unique point that you make, because I remember specifically more than 20 years ago, rheumatoid arthritis was completely off limits when it came to exercise prescription. We couldn't touch it with a 10-foot pole, and now we know that's not true. So I treat rheumatoid arthritis in the same way that I would treat MS, actually, in that both have an inflammatory response. And so what you want All you do is be extremely conservative with your progression, and then you base the progression not on the work-When you say conservative with your progression, define that for our audience. So that's the progression of the exercise.

Dr. Lemanne (38:13)

So you make it hard very slowly?

Andy Baxter (38:17)

Very slowly, yeah. So we're going to start by initiating patterns and going through ranges of motion, probably with no load at all. And this includes aerobic activity.

Dr. Lemanne (38:26)

When we say slow, how slow are we talking about? Give an example of where you might start somebody and when you might progress them, how long.

Andy Baxter (38:33)

So in the case of some MS folks, we'll take an extreme. We take our rheumatoid to the extreme. But some folks might do a minute of work, and then they might come back the same day and do another minute. That's how small.

Dr. Lemanne (38:48)

What type of exercise might that be?

Andy Baxter (38:50)

Even a bicycle or a recumbent stepper. Just that little bit of movement. Because what you're doing is you're introducing the pattern, and then you're You're initiating that conversation between the brain and the body. And then there's the potential for inflammation, sometimes not because it's heat-related, sometimes simply because you're throwing something new at the body, and it's integrating the systems of the body to coordinate that movement. And sometimes that learning process alone is taxing enough that that's all you need to begin.

Dr. Lemanne (39:27)

So two minutes a day, separated?

Andy Baxter (39:29)

Sometimes Sometimes one minute a day. Yeah, it can be that slow because the key is you don't want to induce an inflammatory response. You don't want to create an episode.

Dr. Lemanne (39:38)

And when would you increase from there?

Andy Baxter (39:40)

Well, good question.

Dr. Lemanne (39:41)

What signs do you look for?

Andy Baxter (39:42)

Good question. You base that entirely on the patient or the client on how they responded to the previous session.

Dr. Lemanne (39:48)

So they tell you how they feel? Yeah.

Andy Baxter (39:50)

And then if they have some a reaction, then we wait until they're feeling good again, and then we don't progress. We repeat what we did before, but nothing more. And then we don't progress until they can handle the dose that we've given them.

Dr. Gordon (40:04)

That's the caution for people with post-exertional fatigue, fibromyalgia or long COVID. Oh, I pushed it to 15 minutes today, but I didn't feel good. So I'm going to push it to 18 tomorrow. No, go back to what you feel good and do that for a while. Another source of inflammation that I see is people who are markedly overweight, even to the point of morbid obesity. And of course, obesity itself is inflammatory. Our adipocytes secrete inflammatory cytokines. Have you had much experience working with quite obese people in this rehab program?

Andy Baxter (40:48)

I'd say the simple answer is no, and I think that has a lot to do with our little town, in Ashland. We're a pretty healthy town. I would say that Damon, over in our Medford shop, sees a lot more of that. They actually oversee the bariatric post-rehab. So he would be the guy to talk to about that. I don't get much of that anymore.

Dr. Lemanne (41:13)

I'm going to go back to something you said that I found fascinating. My jaw was on the floor and you said you train COPD patients differently than you do cardiac patients. That's correct. Please talk about that.

Andy Baxter (41:23)

Yeah. So that's a unique setting. So let me frame that for you. So if we So we used to do the postcardiac rehab for Asante, and that was pretty straightforward. We made some changes. I made some changes in conjunction with the doctors there, where we did away with heart rate monitors because the typical Haskell-Fox model, the 220 minus age, is nonsense. Wait a minute.

Dr. Lemanne (41:52)

So I used that this morning for my workout. Yeah. Calculated, I can never really quite believe I'm as as I am and my heart rate should be so low. Right. So I should stop doing that? Or only if I'm a heart patient.

Andy Baxter (42:07)

Yeah. So let me give you an example. So let's take four people. Let's say those four people are all 60 years old. And one person is a woman, and she's 5'4 and 180 pounds. And the other person is a woman.

Dr. Lemanne (42:22)

Okay, so average height and a little bit heavy.

Andy Baxter (42:25)

Yeah. And then the other person is tall and athletic. And then the other person is a man, and he's tall and extremely frail with some comorbidities. Another person is grossly overweight. All four of those people are 60 years old. So the Haskell-Fox bottle would say, Okay, if we take 220 and subtract 60, all four of those people are going to have the same training heart rate. And that's absolutely not true. Sure. Okay. So we have to take into consideration the body types, the comorbidities, and then the contraindications. What meds are they on? So this was the rub in the post-cardiac was that what if somebody's on a beta blocker? Well, that 220 minus age is out the window because maybe it's being artificially sealing. So what we did is went to the RPE scale. So the rate of perceived exertion scale, scale of 1 to 10, and this is again, specifically cardiac patients, but we use this all the time in our program. And if we use the RPE scale where the patient gets to police their own intensity. They're not looking for a number or an equation. They're just going to go, hey, on a scale of 1 to 10, if 10 is the hardest thing I've ever done and one is sitting on the couch doing nothing, this activity should feel like a three to a four.

Andy Baxter (43:43)

So they get to police themselves. They get to moderate that intensity based on that three to four out of 10 scale.

Dr. Lemanne (43:50)

So in your book, you talk about being able to sing your favorite song. Yeah, sure. What's your favorite song, Deborah?

Dr. Gordon (43:58)

Ten years ago on a warm dark... Anyway, Cold Dark Night. Okay.

Andy Baxter (44:05)

So let me continue on that. So there's the aerobic component for the cardiac patient. But then when we get to the COPD patient, we have a really unique circumstance there where the pulmonary output is limited. So we look at the systems in the body, and then we've got the pump, and we've got the engine, and then we've got the tires, right? So all the different components of the car- Wait a minute.

Dr. Lemanne (44:29)

The What pump I've got, what's the engine?

Andy Baxter (44:31)

Well, so you could say the body and the tires or the skeleton and the muscles. Yeah, I got that.

Dr. Lemanne (44:36)

And I got the pump as a heart, but what's the engine? Is that the mitochondria?

Andy Baxter (44:42)

It's everything together.

Dr. Lemanne (44:43)

Everything in between those.

Andy Baxter (44:45)

But the problem with the COPD patient is that the limited pulmonary output, which I guess maybe we would call the gas, is so you're getting limited pulmonary output to the muscles.

Dr. Lemanne (45:00)

Okay.

Andy Baxter (45:00)

And in COPD, aerobic conditioning is not going to improve that pulmonary output. That volume is capped. Correct. It's not going to increase. So what we want to do is reverse how we think about the improvement. We can increase the volume, but we can decrease the load. And the way we decrease the load is by increasing muscle mass, thereby increasing mitochondrial density. So there's more uptake for the limited oxygen that we have.

Dr. Lemanne (45:32)

Okay.

Dr. Gordon (45:33)

And so from the outside, the COPD patient, if they stay at their RPE of three... No, P. Perceived? What is it?

Andy Baxter (45:41)

Yeah, rate of perceived exertion.

Dr. Gordon (45:43)

Rate of Perceived Exertion. Rate of Perceived Exertion. As long as they stay at that, somebody from the outside could say, wow, but he's doing that a lot faster than he did a month ago. But really, it wouldn't have been by improving his lung health. It would be by improving the function of the little muscles that do it. So they do it requiring less bolus delivery of oxygen.

Dr. Lemanne (46:06)

Now, which muscles? All the muscles? The respiratory muscles? Which muscles?

Andy Baxter (46:09)

Oh, no, the working muscles.

Dr. Lemanne (46:11)

The working muscles, so the arms and the legs. Yeah. Okay. All right.

Andy Baxter (46:15)

So that's the COPD thing. Now, the other thing is- So if you have two people side by side in the gym, what is the cardiac patient going to be doing on your machines or weights compared to what the COPD patient is going to be doing?

Dr. Lemanne (46:33)

How do their workouts look different?

Andy Baxter (46:34)

They're going to look different in that the COPD patient is going to put the primary emphasis on strength training initially because they can tolerate higher intensities in very short doses before the aerobic requirement takes over. The opposite is going to be true with our cardiac patient. They're going to try to increase their aerobic base in a low level, 3-4 out of 10 way so that they can broaden the base, more highly innervate the muscles to use the oxygen, but without stressing the aerobic system. So they're going to get their adaptation through increasing the volume of the work, not the intensity of the work. The COPD patient is going to increase the intensity of the work, not the volume. It's a complete opposite. And one is strength-related, the other is aerobic-related.

Dr. Lemanne (47:21)

Very interesting. So does creatine, the supplement, help those COPD patients then?

Andy Baxter (47:27)

I don't have an answer to that because I've never really I thought about it in that way.

Dr. Lemanne (47:32)

I would think it would because that first anaerobic burst there.

Andy Baxter (47:39)

Yeah, that first burst, that first 30 seconds or so.

Dr. Gordon (47:41)

And also, and because I was going to say, throw a third person to the gym, which is the sarcopenic patient, which is, unfortunately, way too many of us.

Andy Baxter (47:52)

And that's the hypertrophic component. So they're going to benefit from more hypertrophy-based training.

Dr. Lemanne (47:56)

And how is their workout going to differ from those first two, the cardiac and the COPD patients?

Andy Baxter (48:01)

So they're going to have more of the higher volume strength training, the higher rep.

Dr. Lemanne (48:04)

Higher reps? Okay. All right.

Andy Baxter (48:08)

Oh, and then we could talk about eccentric versus concentric.

Dr. Lemanne (48:11)

Please, yes. So I have been told that eccentric training increases strength more quickly, but it causes more damage in the meantime. That's correct.

Andy Baxter (48:19)

So you have a rest indicator. Yeah. So eccentric training, certainly, that's where hypertrophy is king. You're going to get more muscle mass through your eccentric training. So you can You can change the ratios of concentric to eccentric. You can change the quality of the work without having to increase the load by manipulating the eccentric concentric. I did a little offshoot, but we have a piece, a multi-planar resistance device that I developed for spine patients. And with that device, we were dealing with patients that can't handle big loads or even small loads. So what we had to do is figure out a way to increase the quality of the work without overloading their spine. And we worked with another company called Computer Sports Medicine and created a little box that has a feather on it so you can track the movement of the patient. So we take a movement and instead of doing, say, a two-second concentric and a two-second eccentric, we created a specific protocol. It was a four-second concentric and a seven-second eccentric, and then a one-second rest, which It's called the amortization phase. And so your total time for one repetition was twelve seconds.

Andy Baxter (49:36)

So you can get a huge quality improvement in the work without overloading the compromised patient.

Dr. Lemanne (49:43)

Because you're going in two different directions?

Andy Baxter (49:45)

Because you're slowing down.

Dr. Lemanne (49:47)

Because you're going slow?

Andy Baxter (49:48)

Yeah, correct.

Dr. Gordon (49:49)

Okay. Thinking about all these muscles working, and you mentioned at some point that you do a lot of work, say in the racing season, and you break muscles down and things like that, and it reminded me of an exercise caution that I think has gone in and out and in and out of favor. And what's your stance on what's your opinion about stretching?

Andy Baxter (50:12)

That gets back to functional application. And so I'm a firm believer in not actually using the word flexibility in my vernacular. What I prefer to use is functional range of motion because flexibility, I think oftentimes implies We realize that more is better and more is not necessarily better, especially as we're aging. We want to be functional, and we want to be as strong as possible through that functional range of motion. But oftentimes, at least in my experience, is that people that do a lot of stretching type activities as they age and don't focus on the muscular component, develop joint laxity and joint instability.

Dr. Lemanne (50:56)

You come down This is Ashland.

Dr. Gordon (51:00)

I know.

Dr. Lemanne (51:01)

You come down pretty hard on yoga.

Dr. Gordon (51:03)

I must say my- It was really fascinating.

Dr. Lemanne (51:05)

Give us a little information about how you came to that position. You see a lot of yoga injuries, apparently.

Andy Baxter (51:13)

I certainly have. Yeah, but I've seen injuries from all kinds of modalities of exercise. And then there are other exercises that are not- What kinds of injuries do you see in yoga?

Dr. Lemanne (51:23)

How could you hurt yourself in yoga?

Andy Baxter (51:25)

Oh, back injuries, hip injuries, knee injuries, for sure.

Dr. Lemanne (51:29)

And this is from pushing the joint too far and getting that laxity that you're speaking of? Correct. And is that fixable? Once a tendon is a little bit lax, can it be tightened up again?

Andy Baxter (51:41)

Yeah. A simple answer is yes. To a point. And And past that point, no.

Dr. Gordon (51:47)

But you can work on the muscles around it to cushion its failure at a certain point. I must say one of my good buddies, a local chiropractor, you guys could have a whole night's rant about yoga injuries they've seen. Yeah.

Andy Baxter (52:02)

So I'll tell you the genesis behind that chapter, and I wish I could give you the exact name, but I don't remember. It was an article, and I think it was in the Times, but it might have been the Post. It was one of the New York papers, and it was written by a yogi who was also an orthopedic surgeon. And he wrote a whole piece on why yoga was bad. And he was a yogi and an orthopedic surgeon. So it was very telling. And it just rings true to what I've experienced. And it's a cautionary chapter. I'm not trying to trash anybody. I'm just trying to bring light to that.

Dr. Gordon (52:43)

And there's certainly are really great... So my presumption is that there are some great yoga- Absolutely. Exercises to fall back on. One of the ones I give myself instruction to do is to do at least a minute of planks every day. Even if it's a day I'm not exercising at all.

Dr. Lemanne (53:02)

Is that a yoga exercise?

Dr. Gordon (53:04)

I think of a plank as a yoga exercise, going in and out of downward dog or upward dog.

Dr. Lemanne (53:08)

Oh, I see. That's how you get into plank. Okay.

Dr. Gordon (53:10)

Yeah. So I think sustained exercises But yeah, the over stretches, the overly flexible person. But sometimes stretching feels good. Am I injuring myself if I'm dropping my heels off a set of stairs to stretch my calves?

Andy Baxter (53:32)

That's a great question because that particular example does sometimes get people in trouble, especially as we age. A PT is often referred to that as Weekend Warrior Syndrome. People tend to get pretty tight Achilles tendons. So keeping flexibility of that tendon structure is super important because if you go out and play in a softball game some weekend-Or a pickleball. Or a pickleball, your chances of having an Achilles avulsion go way up. So hence the weekend warrior syndrome.

Dr. Lemanne (54:05)

Well, as we age and people tend to want to get to 100 now, and there are a lot of efforts to describe a path toward that. What are your thoughts on how we measure how well we're doing over the decades? And how do you help people determine how well they're doing, what they should be next?

Andy Baxter (54:30)

Gosh, there are so many. Deb, did you want to jump in there?

Dr. Gordon (54:32)

No, I was thinking, great. I can't wait to hear what you say because some common podcasts that we listen to focus a lot on what is your VO2 max number? And I think, well, this is a whole different system. Yeah, what's his answer?

Andy Baxter (54:46)

So the other day, and just so you guys know, I don't have to go far to come up with these examples because they happen every day. And that's the wonderful part about my job. I get inspired every day by my clients and what they tell me from what they've applied in the real world from their training. But the other day, a lady was traveling and she was on the flight. She had her carry-on bag. And as she opened the overhead bin, the husband and wife were standing behind her and the husband reached in and said, Here, let me help you with that. And she looked at him with disgust and then hoisted her case up and slammed it into the bin. And the wife goes, Damn, So I would say that's a good functional measurement of quality of life and functional health.

Dr. Gordon (55:39)

It's a good reason to fly at least once a year to make sure you've still got those muscles.

Dr. Lemanne (55:44)

A little push Jerk, isn't that?

Andy Baxter (55:45)

Yeah, it's a good push press. Yeah, for sure. So, yeah, there's so many different markers. I mean, of course, the A1C and all the medical stuff and the hard numbers. But I see more the real world What is the practical application of can someone do that? Can someone get their groceries up as a flight of stairs? Can they get off a toilet seat? Can they get out of their car on their own? All these little things that maybe before they came to us, they couldn't do. And so they have these markers. They don't even know it until it happens. And then they realize, oh, wait a minute. I couldn't do that before. My quality of life is improving.

Dr. Lemanne (56:25)

Tell us a little bit about VO2 max then. Is that something we should pay attention to, not pay attention to? Look at relatively? Are we getting better? What are your thoughts on that? Is it useful?

Andy Baxter (56:36)

Yeah, I think the key word there is the relative part. And so what I would say is that what I was always taught in college and then after college as an athlete, which I think bears out in the science as well, is that most of that stuff is congenital. I mean, it's genetic, right? So the nature-nurture argument there is definitely leaning in in favor of the nature side of the equation.

Dr. Lemanne (57:02)

So VO₂ max, your capacity to develop a high or low VO₂ max is set.

Andy Baxter (57:08)

Yeah.

Dr. Lemanne (57:09)

But you have some control over whether you can reach your own.

Andy Baxter (57:11)

Correct. So that goes back to the relative thing. So if we look at, here's just a really simple example. But if we say that 70% of your VO₂ max potential is genetic, then that leaves 30% that you can work with. Now, if we want to say generally that you can see improvements as high as 20 % improvement, what you're really talking about is 20 % of that 30 %, not the whole 100. So that's really 6 %. Or is that right? Did I say that right? Something like that. Something like that. Yeah, so that's about 6 %. So just so we're all apples to apples, I think that's the true measurement. Then things get a little trickier if you're an athlete, because if you're an athlete, then that improvement is going to be much smaller. If someone's completely deconditioned, they're going to see more improvement than the athlete is going to see, because that's already been maximized. And usually the athlete, their genetic potential is already higher. So it's not 70, it's more like 85 or 90.

Dr. Lemanne (58:10)

They're preselected. Yeah, correct.

Dr. Gordon (58:12)

Even in the people who are athletes, and so they're not in your... Well, I guess even sure athletes injure themselves. But I'm thinking either athletes or people who have a exercise habit either have a week where they're not feeling so well or a period of time where they're working more hours or their sleep is poor. So people have to, I imagine, do their own ratcheting back and not try and just my score on this erg machine has been a minute and a half for the last six months, and I'm not going to let it be less today. I don't care how badly I slept last night. So people have to self-regulate, too, right?

Andy Baxter (58:54)

We are our own worst enemy. Absolutely. A hundred percent. I think as a culture Sure, we tend to overtrain, for sure. I was just thinking about this the other day in my own training is that in my practice, I used to define all my training by the day. So it would be labeled Monday, Tuesday, Wednesday, Thursday, whatever. And I realized that that's not healthy because then you get anchored to this notion that on that day you have to be doing this. And that doesn't accommodate for injury or tired or sickness or you didn't get enough food or whatever the case may be. So what I did was I switched instead to numbering them. So now those workouts are by number instead of by day. And that way I just postpone it until I'm ready, and then I just follow the sequence.

Dr. Gordon (59:48)

So I might have a week or so where I'm really busy, and it'd be better to do a little something, though, wouldn't it, on a regular basis, even if I can't do my 30 minute workout?

Andy Baxter (01:00:00)

Yeah, a little something is always good. Even for metabolic turnover, always good. But physiologically, the general understanding is that you can go as much as two weeks with nothing, and you're not really going to lose anything.

Dr. Gordon (01:00:14)

Even So, aha. Isn't it true that an older person loses fitness more rapidly than a younger person?

Andy Baxter (01:00:21)

Yeah, probably true. So it's all scalable, right?

Dr. Lemanne (01:00:25)

So we're not talking bedrest, but just skipping the gym for a couple of weeks.

Andy Baxter (01:00:28)

Is that true? Well, basically for people's mental health, if they get really stressed out about the fact that maybe they're going to be traveling for a week and they're worried, I just tell them not to worry about it because they're not going to lose anything inside that week. There's the physiological component, but it's also the mental component because people tend to beat themselves up over this. And then oftentimes, say you are overtrained or you're sick or you're not recovering fully, you're going to be way better off resting than pushing through it, right? And you'll come back stronger for it.

Dr. Gordon (01:01:03)

Although sometimes I must say making myself get up and go for a five or 10 minute walk makes me less tired. And then there's other times I don't succeed in making myself do that.

Andy Baxter (01:01:13)

And that would have regenerative effect anyway. I mean, that's not the exercise I'm talking. Certainly, just getting blood flow is always a good idea.

Dr. Gordon (01:01:22)

Always a good idea. We like that blood flow. Yeah.

Dr. Lemanne (01:01:26)

Well, now, you talk about in your book, in chapter 22, you talk about A client for whom your program didn't work, and her name was Terry.

Andy Baxter (01:01:34)

Right.

Dr. Lemanne (01:01:35)

And I found that really interesting. And the reason that you- I did, too. The reason that you came up with after with Terry, looking into things, was because of some of the medications that she was on for the very things that the exercise was supposed to help. So she was on a beta blocker for a heart issue. She was on a statin for, apparently, some heart issue as well. And she was on a diabetes drug called Pioglidosone, which isn't used so much anymore.

Dr. Gordon (01:02:07)

I've never even heard of it.

Dr. Lemanne (01:02:08)

Yeah, it's not used so much anymore. That class of medications has gone away as a major source of treatment for diabetics because we have these new drugs, the GLP-1 receptor agonist, which I'd love to talk about if we have time today. But tell us a little bit about Terry and how that can derail people and what you did for her. You did get her fixed up, Yeah.

Andy Baxter (01:02:30)

Yeah. So something that in this case was overlooked would be classified as comorbidities and contraindications, right? So we had done everything that we would normally do in her case to help her out. She was brilliant and steadfast and very consistent in her training. So she did all the right things. And at the end of that period of time, I think it was a year, she did not see improvement. And we were-Oh, that's brutal. It was brutal. We were dumbfounded and embarrassed and angry and all those things. It was like, why is this not working? And so in desperation, I started thinking outside of the box and I thought, maybe we should do an inventory, a pharmacological inventory of all the meds you're taking. So we did. And her doctor was, unfortunately, not helpful in this. And this gets to the real-That's old fashioned now, isn't it? Yes. Yeah. And that was part of the problem was he wasn't doing the homework to look for those contraindications of the meds. And so these meds were canceling each other out in very, very bad ways. And So once we figured that out, she got rid of that doctor, went to a new doctor, went through the meds more thoroughly, figured out what she needed and what she didn't need, looked into some more dietary intervention as well.

Dr. Lemanne (01:03:59)

You said You said in your book that she went on a paleo-style diet and fixed up food allergy situations that she had. And she switched doctors and apparently stopped taking those medications, the statin, the beta-blocker, and the old-fashioned diabetes medication.

Dr. Gordon (01:04:20)

Have either of you ever taken a beta-blocker? Yes, it's brutal. It is brutal. And I said, poom, three days.

Dr. Lemanne (01:04:29)

Yeah, exactly. That's how long I last with it.

Andy Baxter (01:04:32)

Our experience has been that it's the dosage. They just don't get it right. And so it's not enough to just go, okay, you're this age, you're this body weight. I'm going to give you this dosage. You need to actually test that and see if it works for you. And then take that information back to the doctor and go, yeah, based on these numbers and how I'm feeling, this isn't working for me and see if they'll change the dosage.

Dr. Gordon (01:04:57)

And I think having a doctor who understands the different... Beta blocker is a huge category, and the cheap and easy ones, and the ones they are historically most used to prescribing, are the ones that greatest impair your ability to sleep, walk uphill, have sexual energy, have mental energy. I mean, they are the most disabling where some of the newer ones, not so bad.

Andy Baxter (01:05:24)

And this goes back to why we use the RPE scale, because if we weren't doing that, people would get into trouble if they're on blockers.

Dr. Gordon (01:05:32)

Right.

Dr. Lemanne (01:05:33)

What do you think about the new drugs? The GLP-1 receptor agonist, Ozempic, Mounjaro. Yeah. So in my book, we talk about the magic pill.

Andy Baxter (01:05:44)

Of which there is none. There is no magic pill. So I don't have a strong opinion on this other than my experience, which is if it sounds too good to be true, it probably is.

Dr. Lemanne (01:05:56)

Have you seen people who are exercising while on these medications patients? Does it seem to interfere or help them?

Andy Baxter (01:06:03)

I don't have any experience with that. Okay.

Dr. Gordon (01:06:05)

There was a study, I think, published just really recently showing how much exercise, specifically resistance, exercise combated the sarcopenia associated with those drugs. So I think you should get a flashing neon sign at your light, a light on your window saying, diabetic drug takers, welcome here. Sure. Because I think if you can get somebody exercising more and combat the sarcopenia that does go with those muscles, with those medications, because they just stop eating everything. Right.

Andy Baxter (01:06:47)

Well, I think, Deb, this is in your wheelhouse more. But when we look at metabolic turnover versus metabolic deficit, we know So that metabolic turnover is much more healthy for all systems in terms of perfusion, in terms of exchange of nutrients and expression of toxins.

Dr. Lemanne (01:07:11)

Define what turnover versus...

Andy Baxter (01:07:13)

Yeah. So If we... Deb, do you want to take this one? No.

Dr. Gordon (01:07:17)

I'm curious how you explain it. I'll learn something from you.

Andy Baxter (01:07:21)

Well, my basic, the way I like to put it is that, let's say we've got a person and their caloric intake is 2,000 calories, and they want to lose weight. So a standardized reduction would be, okay, let's drop your intake by 500 calories per day. So there's one person, okay? So they're on a 500-calorie reduction. But if we took another person and said, rather than decreasing your caloric intake, we're going to increase your caloric output. So what that does is rather than having a restriction, we're going to provide more turnover between the intake and the output.

Dr. Lemanne (01:08:00)

So they're going to use up the calories rather than not eat them. Exactly.

Andy Baxter (01:08:03)

And that's just a healthier state to be in for all systems.

Dr. Gordon (01:08:07)

For all systems. And the hidden truth in that caloric restriction that so many people don't know is they say, well, I'm doing my same amount of exercise, but your resting caloric expenditure goes down when you restrict your normal caloric intake. Resting metabolic rate goes down. But your active metabolic rate is something you have obvious control over.

Andy Baxter (01:08:33)

Yeah. Yeah. And we can expand on that into body composition as well, which is metabolically, we want metabolically active tissues because all systems benefit from that. And that's why scales are evil. And there's a chapter on that, on why scales are evil.

Dr. Gordon (01:08:48)

So I think we're going to wrap up here because otherwise we're going to just have to start chapter two and sign up for another session here in the studio. But you enjoyed a particular machine Jean, when you toured his facility yesterday, something about it. Just your description of it sounded intriguing to me. The shuttle balance can...

Dr. Lemanne (01:09:09)

Oh, yes. That was exciting.

Dr. Gordon (01:09:12)

In what way?

Dr. Lemanne (01:09:14)

It was like going to an amusement park. It was really fun. And it was this device. It's a platform that hangs from four chains on a frame, and you can hang onto the frame when you get onto this platform, but it moves. It's like a swing with four chains, but very close to the floor. And Andy had me balance on it, and he told me that it was developed by NASA and Boeing engineers, I believe. Is that correct?

Andy Baxter (01:09:40)

Well, it was developed by a couple of guys up in Bellingham that were working on a project for NASA. Okay. But I developed that specific protocol.

Dr. Lemanne (01:09:50)

Oh, you developed it? Okay.

Andy Baxter (01:09:51)

The protocol, not the machine. Oh, okay. And there's a gazillion ways to use it.

Dr. Lemanne (01:09:55)

But the protocol was so fascinating, Andy. You're going to tell us about this. You had me stand on there and then you had me move 45 degrees in different angles. You had me first get my balance and then move and move my head, move my gaze.

Dr. Gordon (01:10:09)

I hope somebody videoed this.

Andy Baxter (01:10:11)

It's when I start throwing fruit, that gets really, really dynamic.

Dr. Lemanne (01:10:17)

Yeah, I felt my brain wake up.

Andy Baxter (01:10:19)

Yeah. So basically what we're doing there. So getting back to the very first question about what the gym does is we have five major components to our system. We have an aerobic component. We have a We have a strength component. We have a vestibular component, which is the board that you're talking about. We have a motor skills component, and we have a power component. So five components total. So this is the vestibular component. And vestibular reflexes are basically three categories. We have our ocular, our colic, and orthopedic. So ocular is what your eyes are doing. Colic is how you level your chin. And then orthopedic is whatever baggage you bring with you into your world as it stands right now. So if you were car accident in 1982, whatever compensatory mechanisms you've developed over your lifetime to deal with that injury that you may have occurred or incurred, that's your orthopedic baggage. And so your orthopedic reflexes to maintain balance, we need to accommodate for that.

Dr. Gordon (01:11:18)

How you hold your chin? Yes. So somebody who walks around with their chin in the air has a different vestibular challenge. Absolutely. Steadiness.

Andy Baxter (01:11:27)

Absolutely.

Dr. Gordon (01:11:28)

Resisting dizziness challenge.

Andy Baxter (01:11:30)

If you remember Bill Bradley, who had Parkinson's, who was the basketball player/politician. He was the guy who came up with the idea for low light gaze, where you refocus your gaze further out ahead because people with Parkinson's tend to look straight down. And so it's the same thing as we want to get your chin level because it sets everything else up for success rather than... The old saying is wherever your head goes, your spine will follow. So we We don't want to be looking down. We want to be looking up and out. And that all goes to that postural awareness. So your colic vestibular reflex is that your body wants to maintain a level chin. So we need to help facilitate that any way we can.

Dr. Gordon (01:12:14)

And challenge it, it sounds like on this swinging platform. Sure.

Andy Baxter (01:12:18)

Yeah.

Dr. Gordon (01:12:19)

Okay.

Dr. Lemanne (01:12:19)

That was really exciting. Very exciting.

Dr. Gordon (01:12:22)

Well, I'm dying to see it in motion.

Dr. Lemanne (01:12:25)

It's called the shuttle. Apparently, it knocked the shuttle off its This orbital path.

Andy Baxter (01:12:31)

Yeah, the original... So this is one piece. The original piece that they were working on was called the shuttle, and they developed it for NASA, and they tested this thing to the bitter end, they thought they'd worked all the bugs out. They even had a little holding placard for it inside the shuttle, and then they approved it. They green lighted it. They went into space. The astronauts were there. They took the shuttle down off the rack. They put it on the floor. First guy stepped on it, and it threw the shuttle off orbit. And so they scrapped the program.

Dr. Gordon (01:13:01)

Wow, that's incredible.

Andy Baxter (01:13:04)

It's a crazy story, but yeah, they're good guys. It's a cool piece.

Dr. Gordon (01:13:08)

I look forward to seeing it. I want to wrap up a little bit. If people are interested in learning more about what you're doing and they're local, they are in luck because you have gyms in both Ashland and Medford. Correct. Do you work with people remotely at all?

Andy Baxter (01:13:27)

I don't. No, not enough in the day.

Dr. Gordon (01:13:30)

Yeah. Well, thankfully, you're not sacrificing us to serve your greater public. But I would like to give a shout out for your book, which is a good, quick read, both entertaining and enlightening, called The Exercise Prescription by Andy Baxter. And we had a fun little conversation about the picture on the front. So don't associate that with him. No, it's not me. Either the gym or the personnel. But your picture is on the back, though.

Dr. Lemanne (01:13:59)

Yeah. And you're in a helmet.

Dr. Gordon (01:14:02)

Yeah. That must be a... I was trying to wear a helmet to go out on the water and row?

Andy Baxter (01:14:07)

No, that's for rafting. I had a second career as a paddler, so I was on the US team for rafting.

Dr. Gordon (01:14:14)

Yeah, that took me a back, too, this morning. I thought, what? That's quite an ocean squal you must have been rowing through.

Andy Baxter (01:14:20)

Well, there's full contact rowing, which is a whole another animal. But yeah, I'm kidding.

Dr. Gordon (01:14:25)

Okay, good. Well, thank you so much for spending time with us today and stirring a bunch of more questions and determination in my mind. Dawn, do you have anything else to add?

Dr. Lemanne (01:14:37)

No, except thank you, Andy, for taking such good care of the cancer patients that I sent you and who sing your praises and come in pretty buff after 6-12 months. It's hard to recognize them.

Andy Baxter (01:14:52)

And healthier and happier.

Dr. Lemanne (01:14:53)

And so much healthier and happier.

Andy Baxter (01:14:54)

And thank you both for allowing me to be part of your crew. This is wonderful.

Dr. Gordon (01:14:59)

You have been listening to the Le Monde Gordon podcast, where Docs Talk shop.

Dr. Lemanne (01:15:07)

For podcast transcripts, episode notes and links, and more, please visit the podcast website at docstalkshop.

Dr. Gordon (01:15:16)

Com. Happy eavesdropping.

Dr. Lemanne (01:15:27)

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Dr. Gordon (01:15:44)

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Dr. Lemanne (01:15:56)

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Dr. Gordon (01:16:10)

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Dr. Lemanne (01:16:17)

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Dr. Gordon (01:16:34)

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