[42:01:46.747] - Andy Baxter

If you look at the literature on low trauma bone fractures in postmenopausal women, 80% of those recorded fractures are in normal bone and osteopenic bone, meaning only 20% of the recorded fracture has actually occurred in the osteoporotic population.

[42:02:06.287] - Dr. Lemanne

You have found your way to the Lemanne Gordon podcast where Docs Talk Shop. Happy eavesdropping.

[42:02:19.217] – Dr. Lemanne

I'm Dr. Dawn Lemanne

I treat cancer patients.

[42:02:25.117] - Dr. Gordon

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

[42:02:28.917] - Dr. Lemanne

We've been in practice a long time.

[42:02:30.267] - Dr. Gordon

A very long time.

[42:02:32.907] - Dr. Lemanne

We learn so much talking to each other.

[42:02:34.777] - Dr. Gordon

We do. What if we let people listen in? We know that falls are a significant health risk in older with people. Oh, my God. As an aside, a male patient of mine fell recently and broke his hip, and within months, he died. Much more common a complication for men than women, but a real complication with hip fractures. But anyway, to go on. In general, falls in the elderly are the result of slow, weak muscles that can't respond to you being a little bit off balance. And weak, slow muscles go along with weak bones, not what we We want as we age. So walk, run, lift weights, right?

[42:03:22.027] - Dr. Lemanne

Well, in this episode, we have back again Medical Exercise Specialist Andy Baxter. And does he challenge us. He upends everything we thought we knew about bone and muscle health. And one of the biggest myths about osteoporosis, according to this podcast episode, is that osteoporosis is simply about weak bones, and increasing bone density alone is the key to preventing fractures.

[42:03:50.047] - Dr. Gordon

So here are the actual facts. Eighty % of the fractures in postmenopausal women happen in people with normal or only slightly low bone density, not in those with osteoporosis. What? Yeah. This certainly challenges the conventional wisdom that bone density measurements like DEXA scans. This challenges that conventional wisdom that bone density measurements like DEXA scans fully predict fracture risk, because instead, Andy emphasizes that functional strength, muscle power, and the ability to prevent falls are more important for avoiding fractures.

[42:04:33.067] - Dr. Lemanne

Well, the exercise guidelines, they usually recommend walking, and that's great because walking and especially running, right? Those both give you strong muscles.

[42:04:44.737] - Dr. Gordon

Well, not so fast, literally, Andy actually says, because walking and running are mostly skeletal activities, the swing of the walk. You're barely using your muscles at all. What? Yeah, well, that means your walking program that you feel so good about might actually do very little for improving your strength and power, and thereby very little at preventing falls.

[42:05:09.317] - Dr. Lemanne

So if walking isn't the answer, then does that mean that the exercise guidelines put out by the government and official experts aren't reliable?

[42:05:18.607] - Dr. Gordon

Well, just to brighten your day a little bit. Andy tells us that the CDC once had a really great recommendation for osteoporosis treatment, field hockey.

[42:05:30.167] - Dr. Lemanne

I'm not even sure what that is.

[42:05:32.777] - Dr. Gordon

It with rugby is one of the most brutal sports around, and watch it when the Summer Olympics come up again. Okay. So I want to point out that if the standard advice about osteoporosis was true, all you would need to do would be stamp your feet 20 times a day and your bones would be fine. But we know that's not how it works.

[42:05:55.377] - Dr. Lemanne

So what should our listeners do?

[42:05:56.817] - Dr. Gordon

Ha ha, of course. So they're about to hear the specialist Andy, brag about one of his clients, Diane, who's turning 80 in March. And last week, she jumped higher. You know, those box jumps that people do in exercise routines, jumped higher than she has in decades. And so what she does, and what we may all not be doing, is to train using speed coupled with resistance. She trains not just for simple strength, how much can you lift, but for muscular speed and power. That's good news for those of us, Dr. Lemans, I'm looking at you training to stay out of the nursing home.

[42:06:40.927] - Dr. Lemanne

Oh, that's what I'm doing. And we talk about the brain in this episode and how it's our BFF, our best friend forever, right? That's our brain.

[42:06:50.317] - Dr. Gordon

Well, actually, and I know this one personally, if you have arthritis, Andy explains, your brain is set up to sabotage your efforts to stay strong and actually sabotages your efforts to feel better in that joint. So take a bum knee, one that gives out on the stairs or one that hurts when you're going up and down the stairs. It's not your knee giving out. It's your brain shutting down your muscles or telling you, Oh, you better not do that. That's hard on this little joint.

[42:07:26.197] - Dr. Lemanne

Your brain is shutting down your muscles on purpose?

[42:07:29.097] - Dr. Gordon

On purpose. And this is an emerging topic in medicine called neuromediation. Andy reports on this research, how by neglecting neuromediation in your exercise program, you're allowing your arthritis to worsen. So you have to pay attention to this process and circumvent it. I think about brains a lot. And if you think working crossword puzzles is a good option for maintaining overall brain health, we touch on this also, you'll want to hear that part of our discussion.

[42:08:06.077] - Dr. Lemanne

Wait, that's not true?

[42:08:07.107] - Dr. Gordon

Well, pay attention. We'll talk about it. And for those of us using creatine for our brain health, me, by the way, and hopefully all my patients, if you're taking it with your morning coffee, Dr. Le Monde, you might be flushing it right down the drain.

[42:08:23.747] - Dr. Lemanne

There it goes.

[42:08:24.997] - Dr. Gordon

Yeah. Wow.

[42:08:26.417] - Dr. Lemanne

There's so much in this episode. We even touch on why men don't live as long as women and what that has to do with bones, muscles, and the so-called blue zones.

[42:08:37.027] - Dr. Gordon

So buckle up and take notes for this fast and furious roller coaster ride with Andy Baxter on the science of bone and muscle health. Learn why the way that you exercise really matters.

[42:08:51.227] - Dr. Lemanne

Let's get started. Andy, what's going on with you? What are you looking into lately? I hear something about bones.

[42:09:01.097] - Andy Baxter

Oh, yeah. Lots of fun bone stuff because who doesn't want to talk about bones?

[42:09:07.227] - Dr. Lemanne

I like my bones. Yeah.

[42:09:09.917] - Andy Baxter

Healthy bones are important. I thought I'd start. I've got a great story, though. I thought of you guys last week I was training a client, excuse me, and she's been with me for a while. She's a really good athlete, and so I train all levels, ages. And her particular specialty is she's into the Olympic movement. She likes power cleans and snatches and clean and jerk. So movements where you take a load and you accelerate that load. And that's what power is by definition.

[42:09:40.257] - Dr. Lemanne

So the difference between strength is moving something at a slow speed and power is moving it quickly?

[42:09:45.907] - Andy Baxter

Yeah, strength is Usually more of a maximal force at a very even cadence, whereas power is taking a load and accelerating that load, either out of necessity or for the purpose of support performance. So power is load and speed or force and velocity.

[42:10:03.797] - Dr. Lemanne

So power athletes are stronger in general than strength athletes?

[42:10:07.377] - Andy Baxter

No, not necessarily. It's just a different dynamic.

[42:10:11.067] - Dr. Lemanne

All right. Well, you're going to tell us about that and bone health, I'm sure.

[42:10:15.087] - Andy Baxter

Sure. Well, anyway, so this client, we went through this routine where we were focusing on power-based movements, different types of power, pliometric, power concentric versus eccentric, all these different parameters that you can gain control of how you apply power. And so in this particular workout, she was doing squat presses. She was doing what's called a power press. She was doing medicine ball slams. And lastly, she was doing jumpies.

[42:10:42.087] - Dr. Gordon

And a jumpie-Oh my God.

[42:10:44.167] - Andy Baxter

Yeah, jumpies. Rowers know jumpies well. And so a jumpy is an example of what's called a pliometric activity, where the eccentric phase of the load is accelerated. And what that means basically is if you get into a crouch like a skier, and then you jump as forcefully as you can into the air, Then when you land, you land back in that crouched position. So you do that in succession. It's pretty difficult. So you're using your body mass as the load. Anyway, we get done with this workout and get the elbow bump. Everything's good. She's I'm happy, I'm happy, and she goes to leave and I go to head to my desk, and she turns around, comes back with this big smile on her face, and she says, You know, I can't remember the last time I jumped like that. And so the catch here is that Diane is going to be 80 in March. Very nice.

[42:11:33.557] - Dr. Lemanne

It's hard to jump when you're old.

[42:11:35.247] - Andy Baxter

Yeah, and she does a good job of it. So it's just a little perspective, a little inspirational story there.

[42:11:41.927] - Dr. Lemanne

That's fantastic. No, that's really... That's something that I struggle with. I'm not that old. But I've noticed that as I age, jumping becomes more difficult, and I have to make sure that I get some in in my workouts to keep that going.

[42:11:59.817] - Andy Baxter

Definitely. Relative strength is anything where it's a factor of body weight. So jumping is a really simple way to keep tabs on your relative power, which is how you accelerate your body weight. And as we age, if we're losing muscle mass, then potentially that relative strength is decreasing.

[42:12:18.467] - Dr. Gordon

I have a particular question about jumping, speaking as somebody with pretty well compensated but still persistent arthritis in both knees. Yes. And I have a number of patients who are older and I am for their cognitive ability, wanting to increase their psycho motor speed to increase their processing speed. And I want to tell them to do things quickly, and they and I can't jump.

[42:12:45.027] - Andy Baxter

Right.

[42:12:45.707] - Dr. Gordon

So what What's an alternative movement to jumping that still gets some of that benefit?

[42:12:52.627] - Andy Baxter

Well, that's super important, Deb, because we're getting into contraindications and comorbidities. And that's obviously in the age of population, that's super relevant is what may be good in one modality is not good for you in another. So if you're ostensibly trying to increase bone density, you want some concussive force, but you have arthritic joints, Well, then what's good for the bone density may not be good for the arthritic joint. So the answer is it's going to vary for the individual. And what really matters is to identify those contraindications and comorbidities and then find a lane that's going to work for that person.

[42:13:33.167] - Dr. Gordon

I like that, find a lane.

[42:13:34.997] - Andy Baxter

Yeah. And whether it's a machine or some adaptation, some sling, it just really depends on the individual.

[42:13:42.617] - Dr. Lemanne

Well, you've developed machines to work around all There's a lot of things. Tell us about that. Do you have something for that?

[42:13:49.747] - Andy Baxter

I do. We do a lot of concentric power work. And what that does is it takes away the more volatile, eccentric phase of the movement, which is where most injuries occur. So for instance, jumping with arthritic joints, the risk comes in the turnaround, the amortization, the eccentric phase of going down with the associated momentum that you created in the concentric or drive phase. So what I've done is created equipment that only has load in the concentric phase.

[42:14:21.867] - Dr. Lemanne

So again, for our audience, the concentric is jumping up. Yes. And the eccentric is when you land and you have to reverse the- That's correct. The motions, but you're still using a lot of strength to slow your body down.

[42:14:33.667] - Andy Baxter

That's right. And that's the pliometric component. But yes, so concentric- And that's where the injury happens on the way down.

[42:14:38.367] - Dr. Lemanne

Correct.

[42:14:39.237] - Andy Baxter

And so you can also say more broadly that the concentric phase would be the muscle shortening under a load, and the eccentric phase would be the muscle lengthening under a load. Okay.

[42:14:51.657] - Dr. Lemanne

Deborah, you mentioned, I know this is an aside, but I find it fascinating. Tell us a little bit more about using your body quickly, doing quick motions and cognitive health.

[42:15:04.947] - Dr. Gordon

You're actually prescribing this?

[42:15:07.757] - Dr. Lemanne

Yes.

[42:15:08.427] - Dr. Gordon

So I have an elderly patient who lives in Northeastern, Oregon, and we do these cognitive that have... I shared it with you. I think like 14 different channels that a simple interaction with a computer tests you on, and it tests processing speed, but it also tests psychomotor speed. And particularly with older people, those decline. And I can't just tell them to do crossword puzzles and memorize poetry. They have to do something quickly, and they have to do something ideally mind and body quick. So I have a patient who he's doing actually wonderfully, and he only checks in with me every year or two, and his labs are not worth writing home about. But what he does regularly, besides paint beautiful pictures, is he plays ping-pong.

[42:16:06.907] - Andy Baxter

Great one. Great motor skills.

[42:16:08.467] - Dr. Gordon

It's social, it's coordination, it's hand-eye coordination, and it's quick. So it got me the The idea that I'm going to write to my patient in northeastern Oregon and say, get a ping-pong board and shove it up against one of the walls of your house outside and play ping-pong with yourself. Sure. That would be a good alternative. Pickleball Except for its-Prone for injury. Prone for injury is the current cultural fave that definitely prioritizes the- So people tend to gravitate towards those things.

[42:16:42.457] - Dr. Lemanne

They are enjoyable.

[42:16:43.597] - Andy Baxter

You know who really gravitates towards those are therapeutic surgeons.

[42:16:47.697] - Dr. Gordon

They love that.

[42:16:50.417] - Andy Baxter

So again, we get into looking at the population and making sure that they're actually clear to do that stuff. Do they have functional weaknesses that if they get into positions or put themselves into positions that they can't physically get out of, meaning their reaction, say they're a lateral movement to go get the ball, but then they don't have the strength eccentrically to counter that lateral movement.

[42:17:16.787] - Dr. Gordon

And they just keep going.

[42:17:17.887] - Andy Baxter

That's a fall. Exactly. That becomes a fall. And so what you were talking about, Deb, points to neuroplasticity neurogenesis, which is activating the brain and body in a conversation, that meccano transduction of the cellular conversation between the muscles and the brain. And as you said, crossword puzzles are not going to do it. I had lunch years ago when I was actually working on a chapter for the book. I had lunch Zahkir Ali, and we were talking about brain games.

[42:17:49.937] - Dr. Lemanne

Zahkir Ali, for our listeners, is a local well-respected neurologist.

[42:17:55.487] - Andy Baxter

Yeah, wonderful man. In the rogue Valley here. And so we were talking about brain games. And basically, The gist of that is that if you do practice crossword puzzles, you will get better at crossword puzzles, but that will not translate in the way we want it to translate. So you do have to have that movement component to really get the full effect. And there's blood wash effect, which is getting more vascular blood wash over the brain through activity, not just through thinking about it.

[42:18:24.977] - Dr. Gordon

Which enhances oxygen delivery to the brain, which is one of the deficits in cognitive impairment. Yeah.

[42:18:32.037] - Andy Baxter

Yeah, all good stuff. Movement is good.

[42:18:35.317] - Dr. Gordon

Yeah. You talk way more like a neuroscientist than I do. I don't even think I could repeat those sentences you said, but they made a lot of sense. Yeah.

[42:18:42.847] - Dr. Lemanne

Well, tell us more about your recent excursions into bone health. Yes, Yeah.

[42:18:46.557] - Andy Baxter

So this is... Excuse me. This is wonderfully complex and confusing. And if it leaves you feeling exasperated and downtrodden, then we've done our work here. So what I did was this all started years ago. I was speaking at a conference on frailty and aging, and one of the other guest speakers was a specialist on osteoporosis. So I went to her talk. It was very good. And she pointed out that if what we think we know about osteoporosis was true, then all we would have to do is stamp our feet in place 20 times a day and we'd be fine. And as we know- To stimulate the bones. To stimulate bone density. And as we know, that doesn't necessarily work. There actually is no cure for osteoporosis. And if somebody says they have a cure for osteoporosis, they're trying to sell you something that's probably not going to work. So So I did a-When you say cure for osteoporosis, do you mean there's no way to reverse bone loss once it's occurred? That is correct.

[42:19:54.007] - Dr. Gordon

Yeah. I would disagree with that, but that's how I'm interested to hear what you have to say.

[42:19:57.897] - Andy Baxter

Yeah. And so a big part of what makes this all so confusing is really diving into the definitions of what is an improvement in bone density. What are we identifying? What part of the bone is actually improving or slowing the decline of that density? Is it trabecular bone? Is it cortical bone, cortical bone being the outside smooth portion of the bone, trabecular bone being the inside spongy part of the bone, which is-With the marrow for our listeners.

[42:20:26.697] - Dr. Lemanne

So the innermost part is the marrow.

[42:20:29.027] - Andy Baxter

Yeah. And since that's the part we're really trying to strengthen in terms of osteoporosis by definition-The trabecular, the middle part. Correct, the trabecular. We get into, and I'll just jump into this part, the testing. And what the meta-analysis of, in this case, 44 of those studies shows is that DEXA scans are not very accurate at measuring trabecular density. So the measuring-What do DEXA scans measure then? Well, they do a good job of measuring cortical bone density, which is the outside bone. And the interpretation of those readings are also come into play. So how it gets interpreted can vary. It can even vary from one test to the with the same practitioner. So there's variability there that raises questions as to the accuracy of the testing. So if we go with some just basic numbers here, and those basic numbers would be in women ages 60 to 69, you're going to see roughly six-tenths of 1% bone loss per year. And then as you get into that 70 to 79 carat category, you're up to about 1. 1%, and then that doubles in the 80 to 89 category at 2. 2 %. So What we want to do is figure out how can we slow that decline and what works and what doesn't work.

[42:21:57.157] - Andy Baxter

There are so many different modalities. There's weight-bearing activity, there's There's competitive light aerobic activity, there's strenuous strength movement, there's whole body vibration, there's isometrics, all these different ways. And the question is, which one works? And the answer is, well, some Some of them maybe. And that's the definitive summation of all these studies is that some stuff works for some people and some stuff doesn't. And so what the recommendation is based on these studies is that a multi-component offense is much more effective if we want to get the best outcomes per individual is to shotgun it.

[42:22:41.907] - Dr. Lemanne

So do as many of those activities as you can get in.

[42:22:45.907] - Andy Baxter

Yeah. And And then the other thing I'll add to that because it's on topic is that if you look at the literature on low trauma bone fractures in postmenopausal women, 80% of those recorded fractures are in normal bone and osteopenic bone, meaning only 20% of the recorded fracture has actually occurred in the osteoporotic population.

[42:23:10.417] - Dr. Gordon

Oh, that is very interesting.

[42:23:11.837] - Andy Baxter

That's very interesting. It's very interesting.

[42:23:13.087] - Dr. Lemanne

Do you have any ideas about why that is so?

[42:23:15.917] - Andy Baxter

Yes. So So one is that, and this one is a bummer, but one goes back to the DEXA scan thing, which is actually maybe that the readings are inaccurate to begin with. So that undermines all of this stuff. But the other is simply that the chances of getting a fracture from a fall are there for everybody. And what's truly important is not necessarily increasing bone density. It's just being functionally strong so you don't fall in the first place. Okay. And since we know that we can't really do a one size fits all, and we haven't even talked about comorbidities yet, right? So we get into aging population and you can't just say, hey, you should go out and play volleyball because that will increase your bone density. Disregard the fact that you're 79 and you're overweight and you're arthritic. So clearly, you can't prescribe one thing for every body. The other thing that I'll add, and this one's very eye-opening, goes back to this conference because then I was doing some research back then, and at the time, the CDC had recommended for exercise modalities for osteoporosis. Are you ready for it? Field hockey. Oh, Yeah.

[42:24:33.027] - Andy Baxter

So everybody get out there, join a field hockey team, and all your bone density worries will be left behind.

[42:24:39.777] - Dr. Gordon

Yeah, with you.

[42:24:41.407] - Andy Baxter

Yeah, right. And so why is that? And so now we get into some So some anthropological research here because the reason for that is that the foundational work done on bone density was performed in teens and 20-year-olds. So they were looking at female athletes, predominantly soccer players, volleyball players, and field hockey players, because they do a lot of quick directional changes, a lot of pounding, a lot of concussive effect. And they saw- And the field hockey players had more bone density than the soccer. That was the one, yeah. The field hockey players, and soccer was a close second, yes. And so this is also interesting because now there's research that shows that what you did in your teens and 20s has a huge impact on your ability to sustain bone mass as you age, even if you're inactive in your middle years.

[42:25:37.637] - Dr. Lemanne

That's really interesting.

[42:25:38.847] - Andy Baxter

So you were a college athlete, and then you got into life, and that didn't involve athletics, and now you're postmenopausal and you're exhibiting osteopenia, well, if you start exercising, you're going to see much more market improvement than the non-athlete from their 20s and teens.

[42:25:54.867] - Dr. Lemanne

So there's some foundation that remains. Yes, correct. You can rebuild upon. Correct.

[42:25:59.677] - Andy Baxter

So it's like, pick your parents, go back to your young self and exercise more, and that'll save you down the road.

[42:26:06.647] - Dr. Lemanne

Very interesting. So, yes, if there are any young people listening, pay attention.

[42:26:12.627] - Dr. Gordon

So the little bit devil's advocate thing I would put in Well, there's two. One's a question. I understand that some DEXA facilities can actually test, do a TBS test, and get a trabecular bone score. Yeah. Have you seen that Is that helpful?

[42:26:32.627] - Andy Baxter

So, yeah, there are other more advanced versions that are clearly better. It's just the baseline DEXA scan that you can go get a test and then your doctor can prescribe, going back and get a second test. The run-of-the-mill DEXA scan is not that.

[42:26:49.577] - Dr. Gordon

It's just if they can add this other one on, it would help it a little bit. Yeah.

[42:26:52.927] - Andy Baxter

And there are some other imaging modalities that are far more accurate.

[42:26:57.537] - Dr. Gordon

Yeah, the REMs. But you quoted some bone loss statistics, and I would just say pertinent to comparing athletes to my age demographic, all of us are continually demineralizing and remineralizing bones. And both of those rates are somewhat age Predictable, but they're both modifiable. And you have a realm that I'm dying to hear more about how you do that with people. And I've been encouraged recently by the work of a chiropractor, Dr. Keith McCormick, who's pointed out that there are blood tests that measure your demineralizing and remineralizing rate and a host of, obviously exercise, but the diet supplement lifestyle features that can affect your demineralizing and remineralizing rates.

[42:27:52.357] - Andy Baxter

Yeah. So we didn't even get into diet and pharmacological interventions. And I mean, again, more and more variables that need to be addressed and honored, for sure.

[42:28:01.187] - Dr. Gordon

But I'm curious about the different... I tell people, if you want to increase your remineralization rate, you put on a weighted vest and go uphill if you don't have access to a gym. But the lucky people who have access to a gym, what are they doing?

[42:28:16.737] - Andy Baxter

Yeah, so good question. And it goes back to the shotgun approach, the multi-component approach, because there are so many different ways to try to attack that or approach that. One of the things that I've always been a fan of in our programming from the very beginning is when we look at protocols for medical exercise, we want to accommodate and eliminate all contraindications. One of those would be if I'm dealing in a population that has osteoporosis, osteopenia, chances are pretty good I'm going to be in that same pool. We're going to have a lot of osteoarthritic conditions. And so what something like concussive axial loads, which is top end loads with concussion, like a heel strike jumping, as we said.

[42:29:09.887] - Dr. Lemanne

We're not talking about brain concussions.

[42:29:11.937] - Andy Baxter

We're talking about jumping. Concussive force. So the heel strike on the ground, punching a heavy bag when the hand hits the bag, that concussion. I guess the receiver of that could also have a concussion. That's a different story. There you go. But so the thing is, is that in that same pool of people, because of those osteoarthritic conditions, we're not going to want to do that as much because what may be good in theory for the bone density is not going to be so good for those arthritic joints. So instead, if you imagine your femur as like a twig, and you were going to grab that twig on both ends and then like a wishbone, you were going to bend it. Will those lateral forces on the bone stimulate the bone density without the concussive axial load. So something like a leg press or a squat will generate stresses on the bone, but in an orthopedically safe way. So that's one example of how to accommodate other comorbidities and still be able to stimulate the bone.

[42:30:15.437] - Dr. Gordon

And the thing I I like about both those activities that you talk about is I think an underdeveloped muscle group as we age is all those around our hip joint. When people say the word hip, I always have to rule out, okay, you don't mean your hip joint. You don't have actually arthritis in your hip joint. But all the muscle complexity around it. I thought I had great glutes until I went to a physical therapist who gave me some advice for my knees and raised her eyebrows and giggled at me. No, you do not have great glutes. I don't care if you've been rowing for 10 years. I wasn't getting properly coached, evidently rowing.

[42:30:56.807] - Andy Baxter

So that's a really good point. And we talk mechanically. This is just an interesting factoid, but to your point, and that is that if you're walking and say you have a healthy meniscus in your knee, when your heel hits the ground, you would think that the meniscus would be the first line of defense for the shock absorption of that joint, when in fact, it's not. It's your glute. So that glute firing is your first line of shock absorption, even before the meniscus gets to do its job.

[42:31:23.587] - Dr. Gordon

Which protects the meniscus from over. Yes.

[42:31:26.917] - Andy Baxter

So glute strength is essential. The foundation of all the strength work that I do for the last 30 years with the population that I serve, I can say with confidence, is based in deadlift because we want that co-contraction of the ham string-glute complex to assist what our quads are doing, which in turn protects your back. So the more glute ham string interface we get, then the less stress we put on the spine.

[42:31:55.807] - Dr. Lemanne

I remember coming and seeing you, Andy, about 10 years ago for a hip injury, Deborah. And here we are. You had me do an interesting deadlift where my hands were far apart on the bar. Do you remember that? Am I remembering this correctly?

[42:32:15.927] - Andy Baxter

Yeah, it could be some form of... Were we keeping our legs straight or were we bending them?

[42:32:20.957] - Dr. Lemanne

We were bending them and doing a deadlift with bent to straight knee.

[42:32:27.817] - Andy Baxter

Yeah. So that's just going to give you- It was very tough on the glutes.

[42:32:30.687] - Dr. Lemanne

I mean, more so than a regular deadlift.

[42:32:32.947] - Andy Baxter

And what that's doing is just buying you a little more range of motion. So by getting a wider grip, we're going to clear the bar off the ground further. So you can go deeper. You just got me down lower then. Yeah, correct. You just get deeper in the movement. Okay.

[42:32:45.187] - Dr. Lemanne

It's tricky. Okay. I tricked you there. That was very helpful.

[42:32:48.127] - Dr. Gordon

And then in the deadlift, you can do a mini version of what a younger person or less painful person could do in their jump. And you did this when you coached our rowing team when I was at one of your winter sessions. If you do a different speed lifting the bar and putting it down. Sure.

[42:33:07.007] - Andy Baxter

Yeah, you can change the cadence, the tempo. We do a lot of that. I did a lot of that in spine rehab and knee and hip rehab as it relates to controlling the concentric phase versus the eccentric phase versus what's called the amortization phase. And what we agreed upon in the programming was a four second concentric with a seven second eccentric. So very Flow. In a spinal rehab population, this is super important because it allows us to work at a much higher quality of work or intensity of work at a much lighter weight, simply by controlling the tempo.

[42:33:46.817] - Dr. Lemanne

Very interesting.

[42:33:47.077] - Dr. Gordon

It reduces the investment you need to make in a set of weights for your home gym. Sure. If you have that option to change the...

[42:33:55.357] - Andy Baxter

Slow it down a bit.

[42:33:56.257] - Dr. Gordon

The pressure of it. Yeah.

[42:33:57.767] - Dr. Lemanne

Well, if a person has no limitations, if everything's present and working well, is there one of those list of six or seven different approaches that works best for improving bone density and bone health?

[42:34:11.507] - Andy Baxter

Well, so I would say yes, maybe. Yeah, I think that's And that's how we can get into that a little bit is some of these... We talk about if you look at an MRI, if you read a lot of MRIs, you know what words to look for, because there's a specific language in MRIs, things like acute, general, mild. You look for these keywords that are telling you what they're trying to say, and they're very specific. Well, It's mild, it sounds general, but it actually means something very specific when you're interpreting an MRI. Well, it's similar in a lot of white papers, is you want to see things like definitive and conclusive. And let me just read this for you. This is I'm just going to underline. This is all within one paragraph. I underlined these statements, and this is as it relates to exercise in osteoporosis. So in one paragraph, I underlined the words possibly, appear to be, may have, suggested to be, support the possibility, the possibility. I think that was it. So that was all in one paragraph, right? So there's not a lot of... So to answer your question is sure, maybe.

[42:35:36.807] - Dr. Lemanne

And then it probably sounds like the usual academic trepidation. At the end, it probably says, and more research is needed.

[42:35:42.717] - Andy Baxter

Absolutely. Yeah, there's a follow-up paragraph.

[42:35:45.817] - Dr. Lemanne

Every paper is the proper ending of every academic paper.

[42:35:49.317] - Andy Baxter

And in fact, it goes even further. More street research is needed in these specific places, and then it lists them. Yeah. Fair enough. But I think the multi-component approach to answer your question more specifically is a little bit have some power, have some strength, have some load bearing. If you have healthy joints, a little bit of concussion is a good thing. Stimulate those bones. Also, when you do concussive movements, you're also stimulating connective tissue, and that's important, too.

[42:36:18.097] - Dr. Lemanne

So in the real world then, for someone like me who's aging, what does that look like? So do I do all of those things every workout three to five times per week, or do I specialize As in one for a week or two and then move on? How does this look?

[42:36:36.107] - Andy Baxter

So programming, again, I wish I could give you a better answer, but it really does depend on the individual. It depends on the volume of the work, because if somebody is only training twice a week, then that's not going to work for them. If you're training twice a week, you're probably going to want to include a little bit of everything in each workout. If you're working out five days a week, thoughtfully and intelligently, then we would probably split that up. Maybe we'll have a strength day, we'll have a power day, we'll have a plio day and then an aerobic day.

[42:37:05.667] - Dr. Lemanne

So power and plio, you separate those then?

[42:37:08.007] - Andy Baxter

You can. You can put them together. The adaptations are different. So plio sessions- Can you tell me a little bit?

[42:37:16.767] - Dr. Lemanne

I don't have a clear difference in my mind between those two. Okay.

[42:37:20.907] - Andy Baxter

Yeah. So I was really fortunate many, many years ago to do an internship with a guy named Don Chou. And Don Chou is considered the founding father of pliometrics. And Dawn He's probably retired by now, but he was at Stanford, and he had a clinic down in Hayward as well. And basically, a pliometric is anything where you're creating extra load in the eccentric phase that you have to counter or bounce back from, literally bounce back from. Imagine you're standing on a milk crate, and I say milk crate because it just gives you that image. And so you're standing on that milk crate and you step off into space, and then you hit the ground and you drop into a squat, and then you come out of that squat and jump as high as you can. So that's a classic example of a pliometric activity, because when you step off of that crate, the acceleration of your body mass when you hit the ground, it is greater than the load if you were just standing still and you dropped into a squat. So you're creating this extra load through gravity, and that creates the pliometric force that you then have to counter by turning around, that's the amortization and driving out of it, and that's the concentric.

[42:38:35.617] - Dr. Lemanne

Got it. Okay, that's a great example.

[42:38:37.307] - Andy Baxter

Whereas power is just the concentric component.

[42:38:41.147] - Dr. Lemanne

Give me an example of a power exercise.

[42:38:42.577] - Andy Baxter

Power would be- Similar to this. A clean is a good one where If you take a weight from the ground like a deadlift, but instead of just the deadlift, you continue to pull all the way up to your shoulders and then catch it there. Well, typically you want a weight that's heavy enough that you couldn't control that movement. It would be too heavy. Maybe you could accomplish the deadlift component the first third, but the second and third thirds would require some acceleration, some momentum to complete the movement. Okay. And so load and speed equals power.

[42:39:14.227] - Dr. Lemanne

Excellent. Thank you.

[42:39:15.247] - Andy Baxter

Yeah.

[42:39:17.347] - Dr. Gordon

One of the questions that is attributed to vain women over time is that, I don't want to work out because I don't want to get big muscles. From my point of view, first of all, I think they're very attractive up to a certain point, certainly. But there are correlations that I'm curious to have you comment on, correlations between increasing muscle mass and longevity, correlations between increased muscle mass and cognitive ability. And I guess I want to say, actually, I should preface these by saying, does one of those power versus plio moves build muscle mass more than the other? And then the comment about longevity and cognition.

[42:40:08.767] - Andy Baxter

Yeah. Okay. That's a lot. Yeah. The floor is yours. Let's start with the hypertrophic effect of movements. And so hypertrophy and muscles. Traditionally, we tend to think that the eccentric phase of the movement produces more muscle gain. There are plenty of studies that suggests that that increase is far less than we previously thought. And then, of course, there's the genetic predisposition for muscle mass based on body type. Again, that's also questioned, but some people grow muscle better than others. And some people People are much stronger and leaner than others, meaning their relative strength is higher. Their strength relative to body weight is higher. And in athletes, that's usually a good thing because we don't want to be carrying around extra weight, which goes to your point of longevity. Now, here's an interesting thing, and this is current. So there, as you may know, and your viewers may or may not know, for the 2028 Olympics, they are shortening the Olympic distance for the rowing venue. So what has always been known to be 2000 meters is now going to be 1,500 meters. So the question posed to some of the best ex-fiz guys in the business is, how does that physiologically affect the selection process?

[42:41:28.027] - Andy Baxter

How do we train? And so if we say that a 2,000 meter course is roughly 80 % aerobic and 20 % anaerobic, a 1,500 meter course is going to be 70 % aerobic, 30 %. 1k, 60, 40. So as the distance gets shorter, the anaerobic or power component gets much greater. That leads to how do we utilize VO2 max? And the answer there gets to your question about muscle mass and longevity, and I would say, versus muscle mass and performance. Because those can be two separate things. So we were talking about the idea of muscle mass and longevity. Yes. Well, so I thought of you when I was reading this piece because Because VO₂ max is dependent on muscle mass for performance.

[42:42:22.887] - Dr. Gordon

Can you define VO₂ max? And I know there's a way I can just test it on my erg at home.

[42:42:29.007] - Andy Baxter

Yeah. And the test that you do on your erg at home is based entirely on data collected by Fritz Hègermann, who is our Olympic ex-fiz guy and amazing guy who I worked with for years before he passed away. And so, yeah, so VO₂ max is the total capacity of the lungs, right? So the liters of oxygen output. But here's the key for performance is that that doesn't amount to much if you can't receive that oxygen. And how do we receive oxygen? We receive it through the mitochondria on the surface of the muscle. Ergo, the more muscle mass you have, the better you're able to take up that oxygen. So when we get into power and rowing, this shorter course is going to favor bigger, more muscular athletes because they're going to turn over that oxygen better at higher intensities than more aerobic athletes, which are going to be actually slider, but they're going to burn that O2 over a longer distance at a lower intensity. So it varies. It's on a scale. That was the thing I was going to mention to you.

[42:43:34.557] - Dr. Lemanne

Talk a little bit more about longevity. I know, Deborah, you had a question about cognition.

[42:43:40.857] - Dr. Gordon

But we can stick with longevity. So it's been my impression from what I've read, and I'm always encouraging people to try and build their muscle mass, is that it's going to lengthen their life as well as enhance their brain and their attractiveness, I think. But anyway, what about muscle mass and longevity to start with?

[42:44:03.037] - Andy Baxter

Well, so in my limited experience of what I do, because I've got my lane and it's a narrow lane, but I would say- Dense.

[42:44:14.077] - Dr. Gordon

Narrow but dense.

[42:44:14.897] - Andy Baxter

Yes, narrow but dense. Yeah.

[42:44:16.547] - Dr. Lemanne

A lot of traffic in your lane.

[42:44:18.387] - Andy Baxter

A lot of traffic. Exactly. And the potholes everywhere, guys. It's just... Yeah. But I would also add to that the metabolic effect, right? So the muscle mass has a profound metabolic effect across so many different areas within our body, some of which we may not even really know that well, and getting back to the brain. So muscles have an ability to reduce inflammation. They regulate insulin very well, which is an inflammatory response as well. So there's a lot going on there. But in my lane, what I would say that I have confidence in saying is we're going to preserve and improve quality of life through functional capacity. So if I've got more muscle, if I've got good, usable, strong functional muscle, then I'm going to have a better life because I can do the stuff I want to do, because I can avoid those falls and the fractures that come with them.

[42:45:20.657] - Dr. Gordon

On a very practical level, it's logically inarguable. Yeah.

[42:45:26.057] - Dr. Lemanne

Oh, and that gets to- Well, I'm going to play devil's advocate here. Sure. So you know who has more muscle and doesn't live as long as males?

[42:45:33.627] - Andy Baxter

Because they're dumb.

[42:45:35.407] - Dr. Lemanne

Oh, okay.

[42:45:36.487] - Andy Baxter

Yeah. Well, I'm glad we figured that one out. Let's move on. And one of the things that I've noticed about, and this This is a little bit far off and way out of everyone's lane, but I'll throw it out there just to see what you think.

[42:45:54.477] - Dr. Lemanne

Deborah and I, you and I have talked about this a little bit, and that's my theory that the blue zones, the people in the blue zones, perhaps it's what they eat and everything, but one of the things that's very consistent with them is that they're short. These are small people, the Okinawans, the South Americans, the people in various Mediterranean And in Australia, islands, typically women in the high 4 feet, low 5 foot, and the men just a couple inches taller than that. And longevity seems to favor the shorter, smaller, less muscular less mass body type. And again, there's the male/female dichotomy. And I wonder if that's also literally due to size. And how does that fit in with the muscle And is it really muscle size and the amount of muscle, or is it muscle health that we're really looking for?

[42:46:54.427] - Andy Baxter

Well, I can't speak to some of that because it's above my pay grade, but I can speak to the idea of the quality of muscle mass, because one of the things we're looking at a lot is volume for volume's sake is not that great. Potentially, you have to utilize it in a way that's more functional. But let me get to the meat and potatoes. And that is muscle density produces what we want without any negative effects of carrying a lot of extra mass, which can be stressful. So we want our muscles to be contributing to our metabolic health and our mechanical health as well. So there are plenty of people out there with big muscles that are not very strong. And there are plenty of people out there that are thin and wiry that are very strong. And that goes back to- And who's healthier then? Well, I think that comparing the two, I would probably say that the thinner, more densely muscled person is healthier, is certainly functionally more capable.

[42:48:01.437] - Dr. Lemanne

So the person with big muscles, maybe the components in the muscle or not is ideal?

[42:48:06.507] - Andy Baxter

Yeah, you're filling space and you're creating mass that you're putting stresses on the skeleton that as you age, maybe not such a great thing unless they're contributing. And that gets back to this point of relative strength. In case in point, I'll use a rowing example. If I put, say, a middle distance runner in a boat, and he's fairly strong, but then I put a football lineman in a boat next to him, the lineman is much stronger than that middle distance runner. But who's the faster rower? Well, the middle distance runner is going to be faster because his relative strength, meaning strength relative to body weight, is much higher. So that's the example. You have to be able to produce power commensurate to body mass.

[42:48:47.497] - Dr. Gordon

I have a prejudiced about middle, and maybe it's really more about long distance runners. Some of them are the puniest looking people, not the ones you see competing at an Olympic level, but you just look at some of the people going for long runs up in our heels, and some of them are so skinny and puny. I want to give them a steak.

[42:49:09.047] - Andy Baxter

Yeah, I agree.

[42:49:10.097] - Dr. Gordon

Is that a misapprehension on my part? I love getting in arguments on Twitter where they're talking about what's the best all-around exercise. And I say rowing, hands down, hands down, and not long distance running. Yeah.

[42:49:24.857] - Andy Baxter

So running, and from the perspective of the aging body, running has some shortcomings. And I'm sure there will be people that disagree or want to fight this. But the fact of the matter is that running and walking are mostly skeletal activities. There's very little muscular involvement. And part of the mechanical reason for that is simply the limitation of range of motion. So the movement of running from flexion to extension of the hip and knee and ankle can't be compared, say, to something like rowing or even cycling, for that matter, where you're taking a joint structure through a functional, say, 90, 95 degree range of motion or even higher. So you're not recruiting a lot of muscle mass.

[42:50:06.597] - Dr. Gordon

There was a tension a few years ago, I think because of some Tour de France injuries, that cyclists actually have a surprisingly higher than expected rate of osteoporosis. Correct.

[42:50:19.297] - Andy Baxter

Yeah, that was a big one. And that goes to the non-concussive, non-load-bearing activities.

[42:50:27.117] - Dr. Gordon

You can cycle forever, but you're not confronting that stress of stepping off a milk crate.

[42:50:34.377] - Andy Baxter

Yeah, exactly. And same with swimming. And same with, in fact, rowing. They put swimming, rowing, and cycling in the same group. Yeah.

[42:50:44.337] - Dr. Gordon

Don't all rowers lift weights, Andy. Don't They should.

[42:50:47.617] - Andy Baxter

Yeah, the good ones do, Deborah. The good ones do. Yeah. I did want to get to this other study, which I think is very interesting and very relevant, very relevant to the population we serve. And that is on the topic of neural mediation.

[42:51:03.237] - Dr. Lemanne

Oh, yes. Yes.

[42:51:04.477] - Andy Baxter

Tell us about that. Yeah. So neural mediation is a really interesting thing. And in the psychological world, this is known as the pain, fear, avoidance model. And simply put, if something hurts, We catastrophize that thing. We make it bigger than it probably is, and then we avoid it at all costs. So the pain, fear, avoidance?

[42:51:27.287] - Dr. Lemanne

Yes.

[42:51:28.327] - Andy Baxter

Okay. And that's the model. And this can be an emotional thing or it can be a physical thing. And in the physical world, we call that neuromediation. So I'll give you an example. This is a really common one. You've probably heard this one before. Your patient comes in and says, I don't know what happened. I was walking down the stairs and my knee just gave out. I hear that a lot.

[42:51:48.587] - Dr. Lemanne

I hear that a lot. I hear that. Yeah.

[42:51:50.317] - Andy Baxter

So why is that? Well, that's the process of neuromediation. If you have an arthritic knee or say you've got a patellar femoral syndrome, some anitis, some inflammatory thing going on that causes pain, then your brain is smarter than you are. And it says, well, I don't want to do that because it hurts. So the brain will de-innervate the muscles and basically shut them down so that you don't have to go through that painful range of motion. So So walking downstairs is typically painful for people that have arthritic knees if they're not doing it right or accommodating thoughtfully how to do it right. So what happens is the brain just shuts down those muscles. You go to take a step and there's no muscle to support the joint, and down you go like a sack of potatoes. So that's called neuromediation. Now, here's the problem, and this is where it gets really interesting. It's a new study out that is now saying that this is what's referred to is a maladaptive pain response. And simply put, your brain is shutting down muscles to avoid a painful range of motion, where what it should be doing is pushing through that pain, building up the muscular support for the joint, and ultimately relieving the pain.

[42:53:04.167] - Andy Baxter

Now, I've known this for 20 years, and we've practiced this for 30 years. And so the physical therapy community knows this is true. That's why we have this term neuromediation. But we don't We don't understand why. Why would the brain do that to us? And the maladaptive pain response is the answer. And so the example given is if you roll your ankle and sprain your ankle, that's an acute injury. It's very painful. It's very specific. Neuromediation is a protective mechanism for your brain to help that injury heal itself, shuts everything down so you can't walk on it. That's a short term fix. Arthritis is a chronic chronic long term condition, and therein lies the problem. So the pain response is meant to be a short term pain response, not a long term pain response. And if we listen to that pain, the message that our brain is telling us, we actually make it worse because we'll avoid it. And so what the new recommendations are based on this information is reinforcing that we have to strength train through arthritic conditions of the hip and knee and recognize the pain, certainly, but also recognize what it is and And that if we train through it safely, of course, with the proper protocols, we're going to alleviate the pain by regaining the functional support for that joint.

[42:54:27.047] - Dr. Gordon

Wow. Speaking my language, Andy.

[42:54:30.047] - Andy Baxter

Super exciting stuff.

[42:54:31.087] - Dr. Gordon

Super exciting stuff. It reminds me of a conversation I had with a colleague, Dr. Link from Missouri. Actually, I'd have to... I should get in touch with him again. Get him on the podcast. And we were talking about working through the pain of arthritic knees, and I was saying how I like to hike up in the hills, and I often feel better afterwards, but sometimes it hurts to do it. And I have evolved in the time since I've talked to him, that believing that the hiking is good for me if I do it wisely, speaking to what you just said, and it's okay if I medicate away that instinctive pain response that will say, Don't go down this hill or don't take such good steps, even Even if you are doing it carefully. Yes. And so a little bit of medication, I believe my knees have gotten progressively stronger and less sensitive, less painful doing things that hurt me a few years ago, even though the conventional orthopedist advice is, don't do stuff that hurts your knees.

[42:55:36.397] - Andy Baxter

And I would add to that, that going back to the glute talk, is to have the strength component to strengthen the glutes, hamstrings, quads, all of those things to support those knees so that you can continue to hike in the hills.

[42:55:48.187] - Dr. Gordon

I'm heading for my deadlift apparatus this afternoon. There you go. Thanks. With some good coaching from you last year that's definitely helped. Right on.

[42:55:56.527] - Dr. Lemanne

Well, that's a really interesting point, Deborah and Andy, I'd like to hear more from both of you about medicating before a workout to enhance the quality of the workout?

[42:56:07.347] - Andy Baxter

Is that a thing? It depends. My experience, certainly, I wouldn't go in. I would turf that to Deb.

[42:56:18.767] - Dr. Gordon

Right. So I would not take an anti-inflammatory before I was going up in the hills unless it was my last choice. And I'm going about to say... So what's not controversial is taking a Tylenol before you go because Tylenol dims the brain's perception of pain, but it doesn't interrupt the natural inflammatory process, which I think within reason is helping my knees be stronger. A little bit of arachidonic acid starting a little bit of inflammation and recycling it.

[42:56:51.257] - Dr. Lemanne

How interesting. I think that's really interesting. And of course, getting that exercise in is so important for overall health and in my field for cancer prevention. There is a little warning, though, recently about acetaminophen and its carcinogenic capacities. So in Britain, especially, there have been some studies looking at increased risks of cancer with daily acetaminophen use. So you really want to watch the amounts, I think.

[42:57:19.437] - Dr. Gordon

Yes. No, I just do it for hiking. When I'm rowing or when I'm lifting weights, I'm using feedback that's painful as comments on technique. But When I'm going up and down a hilly surface, it's inevitable that it's going to hurt if I'm not a little bit careful and maybe Medicaid a little bit. But no, I wouldn't take either one of those before I headed out either on the to the gym. I think I could hurt myself. I'm curious, just as a really, really tiny aside, what's the dose of Tylenol that seems to be hazardous?

[42:57:57.627] - Dr. Lemanne

I'd have to look it up. I recall, I don't recall the exact dose right now, but it was more like the study was stressing frequency of use, daily use.

[42:58:08.017] - Dr. Gordon

But I think there's a measurable increase in the risk of cancer. Okay, we're going to try- We'll have a podcast on that. We'll have a podcast on that and look at it because over-the-counter pain medication is... Well, I think pain medication in and of itself is a complex topic that we've, as a medical profession, have swung wildly to various extremes, and it's hard to find the sweet middle. From when pain medicines were first encapsulated into pills and we use them freely, and then we use them too freely, and then we were cautioned as doctors not to ever hand them out to anybody.

[42:58:52.207] - Dr. Lemanne

And there are a lot of political overtones to that, too. They're really complicated. They're above my pay grade. Yeah.

[42:58:59.967] - Dr. Gordon

But I think the recruiting, if that maladaptive pain response triggered my glutes saying, Hey, this is my turn to take over for the knee, which is not doing a very good job right now, that would be a really smart adaptive pain response.

[42:59:17.237] - Andy Baxter

Yeah. So to throw my hat in the ring on this topic, cortisone comes to mind. And I'm nine times out of 10, I'm not a fan. And because getting away from arthritic pain, getting into more acute and severe pain, say shoulder injuries or a meniscus pain, for instance. So what we would call a real pain that's trying to tell you something is severely wrong, cortisone will mask that. And then you're going to end up doing more damage while under the influence of cortisone so that four to six weeks later, when you come out of it, you're actually in worse shape. So historically, cortisone, I think, was invented in the '40s, and originally, it was as an anti-inflammatory for diagnosis. And now, of course, it's being thrown out as treatment, which I think is irresponsible.

[43:00:06.817] - Dr. Gordon

So some of the other cortisone injections in the knee are handed out in first-line treatment, but there are now alternatives using platelet-rich plasma, stem cells, and rooster comb cartilage. Oh, yeah. All of which seem to me they'd be quite a bit safer than cortisone, which also they're not so systemic as cortisone is. I remember in my training, they'd say, Don't worry about putting cortisone in somebody's shoulder because it doesn't go systemic. And it didn't take but one patient to learn that That is ridiculous.

[43:00:48.787] - Dr. Lemanne

I want to go back to bone health, and I have a specific question that I think a lot of people will have, and that's, how well do the United States guidelines, which is, I believe it's 150 minutes of moderate pace walking. I think that's three miles per hour per week.

[43:01:10.847] - Andy Baxter

Yeah.

[43:01:11.487] - Dr. Lemanne

Does that improve bone health?

[43:01:13.137] - Andy Baxter

Great question. Is that enough? Well, The answer is yes, no, maybe. So again, it comes to this issue of what works for one person may not work for the other. And the general guidelines on walking activities is, again, a general form of exercise, I think, speaking systemically, is that it's just basically good for you. So specific to bone health, conclusively, you just can't say, but it probably couldn't hurt for bone It could hurt if you're atrophied and have arthritic joints. Walking may not be the best thing for you. So again, it just goes back to we have all of this partial information, and some of this stuff might work for some folks, and some might not for others.

[43:02:03.187] - Dr. Lemanne

If the DEXA scan isn't a perfect way to assess bone density and bone health, are there better tests?

[43:02:11.767] - Andy Baxter

There are. I don't have the names of them, but there are some specifically cited testing protocols using different types of densitromathy other than the DEXA.

[43:02:25.017] - Dr. Gordon

There's something called a REMs test, which is in general thought to be more sensitive than a DEXA, but of interest. I had somebody who broke a bunch of bones recently, and their REMs test was fine. And their bone density on their DEXA was terrible, which correlated with the number of injuries she got in her accident. But I had a woman in this week who has one of the worst bone density scores I've ever seen on her wrist. And she said, Well, why didn't I break it when my legs went out from under me and I landed on that wrist a couple of weeks ago? To your point, if it's not a perfect test.

[43:03:10.297] - Andy Baxter

Yeah.

[43:03:13.797] - Dr. Gordon

But I'll look up what I'm just referring to this REMs test because she got it in Bend. So it's available regionally, at least, and I'll make a comment on that.

[43:03:25.987] - Andy Baxter

Yeah, I actually did find a couple of things here. There's a quantitative peripheral computed tomography, MRI, magnetic resonance imaging, and then hip structural analysis using DEXA, but that's a different set of measurements.

[43:03:44.597] - Dr. Lemanne

Okay, thank you. Well, are there any other things that you'd like to tell our listeners about bone health and what you do and what you recommend?

[43:03:55.897] - Andy Baxter

I recommend everything a little bit, and it might possibly work.

[43:04:02.567] - Dr. Lemanne

What about diet?

[43:04:04.117] - Andy Baxter

Oh, absolutely. Yes, we didn't even get to that.

[43:04:06.107] - Dr. Lemanne

What about diet? That does play a role, of course. It does. Tell us a little bit about your thoughts on that.

[43:04:11.677] - Andy Baxter

Well, it's hugely important how our gut operates. So gut health is massively important because we not only have the biological value of the fuels that we take in, but we also have the question of bioavailability. So it's not just to eat the right stuff, it's how we're taking it up.

[43:04:29.637] - Dr. Lemanne

Whether it actually gets from the gut into the bloodstream?

[43:04:31.727] - Andy Baxter

Exactly. So gut health is massively important. I know that's Deb's wheelhouse for sure. So, yeah, no, it's massively important. Like I say, there's so many variables that just confound this topic, and that's one of the big ones.

[43:04:45.547] - Dr. Gordon

Yeah. I've been on a role recently learning more and more about my favorite supplement, creatine. And the importance of increasing your muscle, and particularly increasing your creatine at my cohort's age more than... Yes, my daughter can take those things, but it's all way more important. She can increase her protein and she can take creatine. But if you're in my cohort, you should be taking creatine, monohydrate, and eating more protein than your doctor normally tells you to.

[43:05:21.187] - Andy Baxter

Absolutely. And I can jump in on that. There's some really great new stuff out that is looking into brain health and creatine as well.

[43:05:29.137] - Dr. Gordon

Yes, and cardiovascular health. Absolutely.

[43:05:32.117] - Andy Baxter

So here's an interesting one I'll throw out, and I'll just quote Darren Candow. And Darren's a researcher in Canada. He's considered one of the foremost experts on creatine. And his new guidelines, he suggests a point 0. 1 gram per kilogram of body weight, which is about double what the North American suggestion is. Very interesting stuff.

[43:05:57.297] - Dr. Lemanne

So that would be 0.

[43:06:00.627] - Andy Baxter

1 grams per kilogram? Per kilo.

[43:06:02.387] - Dr. Lemanne

So it would be seven grams for a 70 kilogram person?

[43:06:04.597] - Dr. Gordon

Correct. Instead of five grams.

[43:06:06.847] - Andy Baxter

So the three to five grams. And even the five grams, according to Dr. Candow, is really three, because we go back to the issue of bioavailability. Ability. You've got about a two gram wiggle room there.

[43:06:20.127] - Dr. Gordon

I definitely want that link to share it with our listeners, and I want it for myself. I double up on my creatine, particularly one of the things I tell people that they can rely on it for in a slightly increased amount is if I had a really bad night of sleep last night, which I did, I take double the amount of creatine in the morning, which gets me up to 10 grams, which probably gets me at five grams or something.

[43:06:46.747] - Andy Baxter

I split it. I do five in the morning and five at night, and that just works well.

[43:06:52.957] - Dr. Gordon

That's really... That seems like a wise thing in terms of body utilization. It's reported that a couple of percentage points of people react badly to creatine in the afternoon in terms of it interfering with their sleep. And who knows what that's about?

[43:07:08.837] - Andy Baxter

I will add one other thing that Dr. Candow points out, and that is coffee. Coffee cancels creatine. So his recommendation that if you're a coffee drinker, wait at least one hour between the creatine ingestion and the intake of caffeine.

[43:07:24.037] - Dr. Gordon

Oh, my goodness. That is changing my world.

[43:07:27.497] - Andy Baxter

Otherwise, according to Dr. Candow, you're peeing that stuff out.

[43:07:31.917] - Dr. Gordon

Okay. Excuse me, I have to run to my creatine supply right now.

[43:07:38.987] - Andy Baxter

Good information, though.

[43:07:40.807] - Dr. Gordon

Really good information. Andy, I hope you're going to share with us links that we can share with our listeners to some of the references you cited. They're brilliant. I will. And thank you, as always.

[43:07:52.297] - Dr. Lemanne

Before we go, will you tell us where our listeners can find you, your web presence, and tell us the name of your book?

[43:08:00.517] - Andy Baxter

I have zero web presence. I can't find myself online. I'm under the radar. I do have a couple of books.

[43:08:10.017] - Dr. Lemanne

You actually do have a website. I was on it last night. It looks very nice, and I think the inside of your Ashland facility looks quite amazing. Oh, thank you. These days.

[43:08:17.777] - Andy Baxter

It is on there, and there are a lot of nice testimonials. Yeah, the gym- Very happy clients. Thank you.

[43:08:26.497] - Dr. Lemanne

It's called baxterfitness. Com.

[43:08:29.787] - Andy Baxter

Yeah. So Baxter Fitness Solutions. So the website is- Baxter Fitless Solutions?

[43:08:35.127] - Dr. Lemanne

Okay. Tell us. Tell me.

[43:08:36.457] - Andy Baxter

Yeah. Bfitsolutions. Com. So just B-F-I-T-Solutions. Com. Excellent. And I do have a couple of books that I've got the exercise prescription. And then I have a rowing book called Racing Yesterday.

[43:08:49.637] - Dr. Gordon

And I think given your body comp, you should try out for the next Olympics. Thank you.

[43:08:55.997] - Andy Baxter

Yeah. When I saw that shortening the distance, I thought, okay, I should take another shot at it.

[43:09:01.367] - Dr. Gordon

Go call your rowing partner and get back in the boat. Yeah. Thank you so much, Andy. Thanks, guys.

[43:09:07.947] - Andy Baxter

That was fun.

[43:09:08.277] - Dr. Lemanne

Thank you, Andy Baxter.

[43:09:10.017] - Dr. Gordon

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

[43:09:17.997] - Dr. Lemanne

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

[43:09:26.747] - Dr. Gordon

Com.

[43:09:27.177] - Dr. Lemanne

Happy eavesdropping. Everything presented in this podcast is for educational and informational purposes only and should not be construed as medical advice. No doctor-patient relationship is established or implied. If you have a health or a medical concern, see a qualified professional promptly.

[43:09:54.227] - Dr. Gordon

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[43:10:06.317] - Dr. Lemanne

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[43:10:20.757] - Dr. Gordon

Again, if you have any medical concerns, see your own provider or another qualified health professional promptly.

[43:10:27.607] - Dr. Lemanne

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[43:10:46.337] - Dr. Gordon

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