How to Improve Exercise Tolerance and Fatigue

Intro:

Welcome to Dr. Ruscio radio, providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics as well as all of our prior episodes, make sure to subscribe in your podcast player. For weekly updates visit DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking with your doctor. Now let’s head to the show.

DrMichaelRuscio:

Hey everyone. Today I spoke with Dr. Mike T. Nelson. He’s been on the podcast now five or six times, and he is, in my opinion, one of the smartest guys in the space of exercise, exercise science, and translating academic exercise research into application. There was one pearl here that I really want to point you to. The short seems to be that cardiovascular deconditioning is fairly common in our population. This may actually lead people to have a poor ability to recover from exercise, from stress, and it may also lead them to be more sympathetic because their body has to work too hard all the time because they don’t have a low enough resting heart rate. It makes it harder for them to recover because their engine is running just a little bit too high all of the time, because the cardiovascular conditioning at baseline isn’t where it should be.

DrMR:

This is something that I myself noticed. If you remember, I’ve remarked that training with Mike really helped me improve my exercise tolerance. I thought it was predominantly just this gradual “increase the volume over time,” which in part it likely was. One of the things that I didn’t realize was going on behind the scenes, and one of the reasons why sometimes when I’m working with someone I just try to shut my mouth and be a good soldier and follow instructions, is that Mike actually had a plan in place to prevent me from working too hard, which I had a tendency to do and focus me into this lower-level, longer-term cardiovascular base conditioning. It eventually allowed me to work harder, do more, and have better recovery. It was a key reminder that clinicians can’t always explain everything that they’re doing. So it is a valuable reminder that sometimes it’s important to follow the plan.

DrMR:

Even if it doesn’t feel like you’re working hard enough, or a parallel I see in the clinic, doing enough tests, taking enough supplements, doing enough stuff, it’s important and helpful to trust there’s a process that the clinician’s working you through. So in this case, the very valuable insight from Mike that people may be under conditioned from a cardiovascular standpoint, that makes their heart and therefore their system, and therefore their sympathetic system work harder around the clock, making them have more fatigue and more intolerance to exercise and ostensibly other forms of stress. So I hope you will listen to this episode. We are going to attempt to take the test that you can do, either on a rower or just running, to see if you actually have adequate conditioning, and put that into a very easy table where the one or two calculators that you need and the parameters for running this simple at home test are right there for you. I’m also going to be rerunning this test on myself, Dr. Joe, Dr. Rob, Morgan, and if I can cajole her and convince her to do it, Jasmine at the clinic. This is something we’re going to start building into our assessment with patients who have fatigue and this kind of exercise intolerance. So if you’re looking for more of a specific application, we’re going to be building this into what we’re doing at the clinic also, because this is something I definitely noticed a benefit from. I didn’t realize how prevalent this is. So it’s certainly something I want to build into the clinical model over at the Austin Center for Functional Medicine. Alrighty, with that, we will go to the chat with Dr. Mike T. Nelson.

DrMR:

Hey, everyone. Welcome back to another episode of Dr. Ruscio radio. This is Dr. Ruscio back again with Dr. Mike T. Nelson, and we are going to be discussing this topic of how to progress people to tolerating more healthy stressors. That may be exercise, that may be sauna that may be fasting, that may be cold exposure, but Mike is certainly a gentleman who is doing a lot of this with his clients, and today will function kind of as a brain picking to see what he’s learned in advising people on how to really apply these stressors so as to be continually getting stronger and healthier and not burning out. Also, if there is burnout, then perhaps how to troubleshoot that. So Mike, definitely looking forward to picking your brain here today.

DrMikeTNelson:

Awesome. Thank you so much for having me back again.

Measuring Baseline Performance

DrMR:

It’s been many a time now and I’m starting to lose count. One of the many things we have been talking about offline is an indirect result of my own personal experimentation. In thinking about it, there’s a lot of carryover with my questions about how much cold should I be exposing myself to, how much sauna, how much Wim Hof breathing? It got me thinking that we should circle back to a conversation that we had years ago now on how to exercise with adrenal fatigue, even though I think the concept of adrenal fatigue is a little bit faulty. It does represent the scenario of someone who may notice too much activity causes them to crash. So that’s the main concept that I wanted to pick your brain on today, which is how you look at people working with you. I’m assuming coming in with different levels baseline performance or energy, some people might be highly competitive athletes, some people might just be starting. I’m wanting to dive into what the road looks like for people and how you handle that. I know that’s a really broad question, but maybe we can jump in and give people some wisdom and some pearls in terms of how you’ve learned it’s best to apply these stressors over time so as to help people get healthier and not burn them out.

DrMN:

I would say at a high level there’s two things. There’s one, the assessment process. If we’re looking at low tolerance or stressor tolerance, are there some things we could test for in an assessment to give us an idea about where they’re at? Some of those things would be resting heart rate, heart rate variability, which I’m sure we’ll talk about, which is a marker of how much stress is currently on your autonomic nervous system right now, and then even things that people tend to forget, like aerobic performance. As you’ve done the wonderfully fun All-Out Max 2000 meters on the Concept2 rower, super fun times, but that gives us an idea of where the person rates in terms of aerobic capacity. We’ve got a fair amount of normative data there. The fancy term is a VO2max.

DrMN:

If they’re really low compared to a population standard, what I’ve noticed is their ability to absorb or handle other stressors is probably going to be less than ideal. So once we have an assessment done, there’s other things that we can look at too. Then iPhone for training, so we’re actually going to apply more stressors to the system now. I used to have to try to guess and be like, “I don’t know, this many exercises, this many days per week, you know, this time.” Sometimes I was right, sometimes I wasn’t, but in essence it was just in all honesty, really just a guess. What I ended up doing was, “Well, if guess right, we’re good. If I guess wrong, in essence I’ve cost us three, four, five, six weeks of ‘Oops, we got a couple of weeks into it. We just completely torched the person on week three, my bad. Let’s take one or two weeks easy and then let’s start again.’” So what I ended up doing is just starting really, really low in terms of adding additional exercise. So most people, even pretty advanced athletes, will start with one to two sets spread out over what I think is probably going to be a sustainable progress for them over the course of a week. For a lot of people that’s really, really low. They’re like, “Okay, you want me to go to the gym, let’s say four days a week, do some cardio stuff on the other days, and for my gym stuff, you literally want me to put all my clothes on, get in the car, go to the gym and only do two sets of three or four exercises and then come home?”

DrMR:

A little underwhelming.

DrMN:

Yeah, sure. What I realized was with some of the more advanced athletes that in a perfect world, if they could pay me and just take two weeks off, that would probably be better, but no one’s going to do that. So starting lower kind of gives them time to recover from their accumulated levels of fatigue. It also gives them time to get accustomed to different exercises. They’re probably doing things different. That could be a muscle soreness thing, that could be a soft tissue perspective, it can be a motor learning thing, trying to learn new exercises, and just starting with two sets pretty easy. Then I load them with one set each week. So week two will be three sets, and then four sets, and then five sets. I just keep loading them up until they run out of time. Maybe they only have an allocated amount of time to perform training and they just can’t afford any more time and they’ve maxed out their time.

DrMN:

Their HRV goes in the crapper, which tells us that they are super stressed, and they usually send me not so nice emails about how they hate their life and everything feels horrible. At that point we’re like, “Cool, okay. We found your max.” And then now from there, we’ll do a little bit of a taper, a de-load to remove some of the stress, and then we’ll start again. We’ll try to work up to around that load over the next three, four, five, or six weeks. We’ll see if we can go past it in the future and then come back down again. So we’re doing this kind of this wave up and then wave down, wave up and down. That gives me the parameters of what is the bottom end of the wave and what is the top end of the wave instead of feeling like, “Oh yeah, we just smashed someone in week three. That wasn’t so good. Now we have to start over again.”

HRV (Heart Rate Variability) Values

DrMR:

Okay. There’s a couple of questions here that I want to ask, and I’ll try to mute myself so people can’t hear me mouth breathing in the background. So the HRV and resting heart rate, are you looking at certain range of HRV to be acceptable? I know one of the things, at least it’s my understanding, and a lot of that is from what you’ve shared with me, is you’re not necessarily looking for a certain numeric value of HRV, but you’re looking for a relative change. Is that still your thinking or is there a certain range? This is borrowing from the Oura Ring data’s sleep scoring an A sleeper, a B sleeper, a C-grade sleeper. Do you have any more granularity regarding how you’re looking at HRV?

DrMN:

You can kind of get in a ballpark and say that there are definitely HRV values that are recorded better and worse, or more healthier if we want to use that. It also depends upon what HRV you’re using, what time course. So for example, if we’re looking at Oura, it’s doing something called a time domain analysis. It’s gathering HRV data over the course of sleep. So whenever you’re asleep, and they have little sensors that’ll cross check that, it’s gathering all your heart rate metrics and it’s running one sort of composite HRV score. That’s a little bit different than a system I primarily use. I do use Oura and am using the ithlete system, or a measurement for one single time point first thing in the morning. So most people will get up, they’ll use the bathroom, whatever they need to do, sit down, again most of the time it’s going to be a seated measurement, not lying down, in some rare cases, standing. They’ll rest there, breathe normal for a couple minutes, and then they’ll do the measurement. It take about 55 seconds to get the measurement.

DrMN:

So those scores are going to be a little bit different, even if we equate them to the same time domain, actual “researchy” numbers. On the ithlete scale, they change that to a one to a hundred scale. So I take that time domain number, which is in milliseconds, and they translate it to a one to a hundred scale, just to make it a little bit more user-friendly. So you have different ways of looking at the measurement itself. So on ithlete, if we stay with their one to a hundred scale, since that’s probably more familiar to some people, I’m looking at a score in the 60s, 70s, 80s, somewhere around there. I’ve got clients who are in the 90 and a couple of people have hit a 100, but it’s not a linear progression thing.

DrMN:

So people think, “Oh my gosh, my HRV is only 71, and Bob over here has an HRV of 95. He must be far superior than I am.” Not really. Now if we compared a HRV scores of 41 to 71, that’s a bigger difference. If you’re down in the 40s and even sometimes in the 50s all the time, then I’m starting to wonder. I’m thinking something might be goofy there. If we look at Oura and we use their scale, which is the actual raw data in milliseconds, they do have some clients, and I’ll even hit this where they’re in the teens for HRV routinely, and that seems low. But again, that’s assuming that the measurement is accurate. That could be an anomaly, that could be an outlier or that type of thing. one particular athlete we’ve looked at his on ithlete and this is relatively normal on ithlete. Maybe that’s something from the system itself.

DrMN:

So you can get a rough ballpark of where people are at. A good one to use is also just resting heart rate. You know, for me, for someone who’s training, who’s healthy and doesn’t have any pathologies, any diseases or issues they’re working on, as seated, I like to see their heart rate at least in the 50s. That’s probably lower than general population standards. Some people might even need to go lower than that depending upon what their goals are. So in general, I’m looking at the change in HRV when we start training. So if we start up and we’ve got two sets for this week, we’re going to grab the ithlete data in the morning. If we’re looking at Oura, that’ll automatically be grabbed. Then we add a little bit more, a little bit more, a little bit more.

DrMN:

So by week three, four, five or six, we’ve already got a pretty well established baseline. I’m looking for the seven day rolling average. Is that going up, is it going down, or staying about the same? What you’ll see repeatedly is when you reach that threshold, you’ll see it change relatively fast. So if we’re starting a week where we know we’re really pushing someone hard, it might be pretty good at the beginning of the week. Then by Wednesday or Thursday, it’s already significantly lower than at the start of the week. So I’m looking at that. Also, resting heart rate will tend to go up, so we’ll keep an eye on that. Then in the ithlete app, you can also rate context, which is super important. So you’ll self-report energy, sleep, nutrition, some other metrics, you can put in notes there, and that really helps me then determine what is kind of maybe the underlying factor.

DrMN:

It’s usually simple if we’re just adding load and adding more stress via exercise, especially in the first phase, but it gets more complicated when we’re in a different phase where all of a sudden HRV starts showing us, “Wow, this person is super stressed, but their loading via training isn’t necessarily high.” So then I’m looking at if it’s nutrition, if it’s sleep. Is it psychological? Did they have an argument with their boss at work? All of those things are additional stressors. So having the context at that point is super helpful because the HRV will only tell us the status on your autonomic nervous system. It’ll say, “Okay. You’re more on the parasympathetic rest and recovery side. You’re more on the sympathetic, stressed, fight or flight response side.” It’ll tell us pretty accurately where that’s at. The downside is it won’t tell us what stressor might be the main one, and obviously it can be combinations of them. It could be your four hours of sleep last night. It could be your three Pop-Tart diet, and it could be a whole bunch of things. So looking at those notes in that context gives us the next level down of information of what we can then do for a particular intervention

DrMR:

With the HRV through Oura, what are you finding to be kind of the equivalent of the 60s to 80s normative that you’re seeing with ithlete?

DrMN:

Anecdotally, just from looking at it, I’ve had one of the original Oura rings, the new version, since it first came out and I’ve probably 60 to 70% of my clients have Oura Rings. I would say on that scale I like to see people in the 30s or 40s at the low end to maybe the 70s. I’ve got some clients that are well over a hundred pretty much all the time. They tend to be usually more on the endurance side. Some people are in the 60s, 70s, 80s. It just kind of depends. The other thing to watch out for too is if you’ve got someone who is especially an endurance athlete, the resting heart rate on Oura, like the lowest number that it reports is say 37 or 38 beats per minute. They’re probably not going to see a big change in their Oura HRV unless they go out and have a four night drink bender or something crazy like that.

DrMN:

They have a massive amount of parasympathetic tone at rest because the resting heart rate is so low. The downside of Oura for HRV is that it’s accumulating data when you’re laying down. You could see something called a parasympathetic saturation, which in English just means that your vagal tone, that parasympathetic input is super high, and it’s even higher when you’re laying down because your heart isn’t working that much against gravity. The downside is your other stressors that happen kind of get washed out by this super high parasympathetic tone. That’s one of the reasons for ithlete we measure this particular athlete I work with standing up. So while his HRV score on ithlete looks “worse,” he’s standing, and standing adds a little bit of sympathetic stress, because now your heart has to work even harder against gravity.

DrMN:

That gives you a little bit of that sympathetic tone, so you don’t have this massive parasympathetic input. We can see that changes and stressors from the rest of his life will show up in the measurement. His Oura, unless he goes out and has a couple of beverages or does something pretty crazy, doesn’t really move all that much. So if you have higher-level athletes or you have people with really low resting heart rates, Oura HRV may not be super accurate for that. It doesn’t mean that the measurement is not quite accurate itself. It’s just not as representational of some of their other stressors. Granted, the device is designed mostly for the general population, which I find is going to get you in the ballpark. If you’re really trying to titrate train and some day-to-day stressors you’re playing with, like cold water exposure or other changes, I find having the single point ithlete measurement in the morning is going to be more representative of trying to pull out those scale changes.

DrMR:

Gotcha. With the resting heart rate, are you looking at Oura to be lower because that’s a nighttime and laying down measurement, than the kind of fifties seated measurement that you’re seeing with the ithlete?

DrMN:

Yeah. So in Oura, in general, because it is laying down, I like to see the ideal average heart rate in the 40s. Maybe the low 50s is okay. A lot of it is training also for diminishing returns too. If someone in the general population is resting and their laying down Oura measurement is like 65 all the time, I think that’s probably okay. In my head, I’m thinking, “They probably could do a little bit better with their aerobic base and their cardiovascular training. So let’s run an aerobic test, a VO2max, the 2K or a Cooper run test, and let’s see where they’re at.” In some cases, you will find athletes who are pretty good and the resting heart rate just tends to be a little bit higher. You’ll find athletes whose max heart rate is not exceptionally high, but their output can be really good.

DrMN:

So you’ll find variances in there. My thought process then is “Okay, if that’s a little bit on the higher side, then let’s see where their aerobic capacity is. If that’s not where we want it to be, then let’s train that for a dedicated block.” Most of the time then we’ll see that the resting heart rate goes down. Their HRV generally will trend up. Not everyone, but most people will generally go up. And then that also gives them the capacity to handle additional stressors better. Then we can translate that into handling more volume training, if they’re more focused on speed and power type goals, because you don’t need a shot putter to have to run three miles per se. It’s like the old thing where they had NFL linemen trying to run multiple miles.

DrMN:

It’s just a disaster, but some of those athletes, depending on their goal, need some aerobic capacity to repeat performance. And for people who are not athletes per se or competitive athletes, if they generally report, “I just feel kind of tired all the time,” but their sleep is good, their digestion, everything is good, you can’t really put your finger on anything. They don’t have any frank pathologies, they don’t have any diseases. What I’ve seen is that their aerobic scores are almost always super low. I’ve had a couple where we ran the math and technically their VO2max was negative, which can’t really happen. It just means that they were so low that the equation kind of fell apart at that end. And just getting them into like 50% of the population normative data, which took about six months in a couple of cases, they felt just amazingly better, because our base energy is a robotic based metabolism. It’s how well can we use oxygen and turn it into ATP, which is a cellular currency to run everything on. So if that’s real low, your general health, your energy is going to be low. It’s like if you had an old Yugo that has a three-cylinder engine in it, and you’re trying to race against somebody else, you’re probably just going to get beat. You just don’t have the ability to create any speed, power, or performance.

Types of Cardiovascular Exercise

DrMR:

So are you noticing there is a tendency of people to be a bit underdeveloped from a cardiovascular fitness perspective? I guess that depends on the population of people that you’re working with, but I know in the functional medicine, ancestral and paleo communities, there’s a shying away from more traditional cardiovascular exercise. Not to say that it’s being abandoned completely, it just seems to be hit more through hit training. I mean, the pun there or the redundancy, but established more to these kinds of hit exercises where you’re going from squats to pull-ups and then maybe to pushups back to back. That does seem to elicit a cardiovascular response, but whether or not that’s going to build up someone’s parasympathetic cardiovascular base is unclear. So curious what you’re seeing there.

DrMN:

Yeah, so anything that you’re going to do, if you’re really detrained is going to be a positive. I mean, if you don’t go batshit crazy and you start doing high intensity interval training, you’re probably going to see some benefit from it. There’s several studies showing that. A new study just came out last week showing that one bout of pretty high intensity interval training had substantial benefits in a population that wasn’t super trained. So that was probably lower than what I would’ve thought. I would’ve thought maybe two sessions, maybe three, but they were seeing pretty big changes with just one session.

DrMR:

You mean one session per week over time, or just one session in total?

DrMN:

This is one session per week. So if Monday was your high intensity training day, you just did that Monday and you didn’t repeat that modality again until the following Monday. So pretty low frequency; lower than what I would’ve expected. If you’re doing some type of circuit training, you’re probably gonna get better for that. I’ve done density circuits with some clients. I think there is a benefit to that, but it also depends on what are you trying to do and what are you trying to elicit? So for me, if what I want is more of an aerobic response, which means I want a ton of blood flow to come back to the cardiac system, especially the heart, I want to try to get as much of what’s called diastolic stretching.

DrMN:

If we can push a lot of blood into that chamber, try to get it to become a little bit bigger, and then get that blood back out again. If you think of it from a physiologic standpoint, what’s going on when you’re doing circuit training, you get these benefits that are kind of in between. So if we back up and we go, “Okay, let’s go all the way to the other extreme for the sake of argument, we’re going to do a one rep max squat.” We’ve got a heavy load on our spines, we’re actually loaded. We’re probably holding our breath and creating a lot of tension, both through the muscles, and if we look at the heart and we say, “Okay, under that cycling for a long distance and doing it at a low to moderate intensity, now we’ve got the arms, especially, and the rest of the musculature, other than maybe the legs, they’re not really contracted nearly as much.”

DrMN:

If we look at the heart, the amount of afterload is substantially less. The heart doesn’t need to create this super high pressure in order to get blood flow out, it’s going to be rather easy. We’ve got a ton of muscular movement, a ton of blood that’s being moved around. So we’re probably going to have more blood flow coming back to the heart also, If you look in the literature, this gets kind of messy. You’re looking at what’s called concentric and eccentric hypertrophy development in cardiac tissue. Again, in English, that just means that if I have to make these super high pressures, the body’s going to go, “Okay, I can do that, but I’m going to need to add more muscle to the cardiac system.” And normally if we add more muscle, that’s a good thing, but in the cardiac system, it’s limited because the amount of space that the cardiac tissue can take up once you’re developed is limited by the pericardial sac and where it’s located.

DrMN:

So when the muscle gets bigger, it thickens, but it tends to go into the chamber, meaning that the chamber size that can hold the blood actually becomes less. If we go to the other end of the spectrum, you can have almost the opposite problem, where the heart is almost never really working under high pressures at all. Say in the case of a cyclist, especially moderate intensity, not interval based, that the walls can become a little bit thinner because the heart goes “Ah, screw it. I don’t need all this super high pressure tissue. Never use it, who cares, don’t need it.” So we’re trying to balance these two far ends of the system. What you’ll generally see is if someone is more of a strength and power athlete, and hasn’t done a lot of cardiovascular stuff, they can have a little bit more thickening of the wall. At some point that could become an issue.

DrMN:

You could develop cardiovascular issues because of that. It gets to be a little bit debatable. And again, if you get too far on the right end of the spectrum, that’s probably also going to be an issue. So if I have someone who tends to only do high-intensity interval training, they tend to only lift heavy weights, I do their aerobic system test and it’s really low, and they complain that they can’t handle any more training volume. Great, so I’m going to try to elicit an adaptation that’s closer to the cycling end of the spectrum. So in a perfect world, they would do, 10, 20, 30, 40, or 50 minutes of low-intensity, probably just cycling. I want to get a lot of blood flow. I want to try to develop, with a low level, some of that aerobic capacity.

DrMN:

Now, you can’t do that forever because your body will adapt to it and you won’t see any more changes from it. Can you actually change the cardiac system in someone who is an adult with that work? That’s highly debatable. Some people say yes, but that it may be a year and a half and may be long-term. Other people say, “No, you can’t really change it.” but what I’m looking at as my marker is my aerobic performance. If my aerobic performance is getting better, we can argue all day if that’s muscle extraction of O2, blood flow, blood volume, cardiac changes, who knows? It could be a whole bunch of stuff, but either way I feel better because they’re getting that aerobic adaptation. Now I’m looking at when we add more volume, can they handle more volume? Cool. Can they handle a few more stressors? Most of the time they can.

DrMN:

So we’re always trying to “balance,” the system out for the vast majority of people. I think that the general trend now is like, “Well, let’s just do circuit training.” Okay, you can do that and you’ll get better at circuit training, but you’re doing something that’s already kind of a hybrid of those two. You have some muscle contraction, you have a little bit higher afterload. It’s not crazy high though, so if I’m going to do circuits, I’ll do some stuff from Coach Cal Dietz. I’m going to be relatively low load, kind of contralateral specific stuff to get a different neurologic effect, and they’ll generally breathe only through their nose. I want to get some nice, easy continual work. To me, that’s going to give me this nice hybrid in between of the two. If they have access to a bike, I’ll probably have them do that. The rower maybe gets into some different changes in the vasculature of the legs potentially. And then over time, once we’ve got our aerobic base, now they can handle a little bit more training stress. So now I’m going to probably add in some more complicated stuff. I’ll generally use the rower for that. I might do some intervals. I might do some 20 minute capacity work. I’m gonna start challenging these kind in-between areas also to try to push up their aerobics and just see where they’re at with that.

DrMR:

And so is it fair to say there is a trend toward people having an inadequate cardiovascular base or are we not able to paint with that broad of a brush?

DrMN:

From what I would say, most of the people that I’ve worked with, which is a very biased population, probably 70 to 80% come in with a lower aerobic base than what they think. Now, the caveat is I’m dealing with the population that tends to be already pretty familiar with weight training, tends to like weight training, tends to not like cardiovascular stuff. They’re usually coming in for something very specific. They’re trying to hit a specific goal, performance, body comp, but there’s something going on that they just can’t figure out. So a lot of times it is, “I just can’t seem to recover. Every time I add more volume, I just fall apart within a couple of weeks. I have no idea why.” Or, “I’m trying to add another training day, and I can do it, but then I got to sleep 10 hours a day and really not work much at all.” There’s usually something going on that’s preventing them. And I find with those people, a lot of times it is just a aerobic development. They just don’t have that base to allow them to recover from some of the stressors that they need to apply in order to get to the goal that they want to achieve.

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GI Conditions and Cardiovascular Exercise

DrMR:

So one of the questions I’m wondering, specifically more from my vantage point as a clinician who’s seeing patients with IBS, with IBD, with chronic fatigue, with hypothyroidism, some with micro toxicity or mast cell activation, this grab bag of various conditions, but where fatigue is going to be a common symptom. There tends to be this observation where people start shying away from exercise and then reporting that they may take a long time to recover or have a poor ability to kind of get back to exercise. Now, clearly there’s this foundation of, what’s going on underneath the hood that we need to address from a health medical standpoint, but your comments make me wonder if part of this observation where people are having a hard time recovering and they’re down for a few days like you said, is because there’s been this drift of losing their cardiovascular conditioning? That may be exacerbated by the fact that there’s all this messaging that you shouldn’t do prolonged cardiovascular exercise if you have adrenal fatigue. That may have its time and its place and its application. But does this make sense where that may be one of the things that these populations need to work on is gradually improving their cardiovascular base? And that might be one of the causes of the inability to recover from exercise?

DrMN:

Yeah, I would agree. If you imagine the stereotypical client, people that you see, and obviously I’ve worked with some people you’ve referred over to me, once they’re cleared and their digestion’s good, everything’s amazing. They’re like, “I don’t know, Mike, I don’t have anything wrong per se, but my energy level is pretty low.” In the handful of cases I’ve tested them, their aerobic capacity was pretty crappy. But if you think about what went on, they probably lost their ability to do a lot of exercise because of the issues and symptoms and things they’ve got going on. So they weren’t really able to train well. And then normally, like you said, this is exacerbated by people online saying, “Oh, don’t do too much cardiovascular training, that’s horrible. You’re gonna burn yourself out.”

DrMN:

There is some truth to that, but the amount of exercise that most people would need to do to reach what’s called the parasympathetically overreach status, they’re just probably not going to get there. Can it happen? Sure. Is it likely? Pretty unlikely. You can run a simple aerobic test to see where they’re at. If everything is good, all their tests are clear, and you run your aerobic test and they’re at 10% of the population, I would argue that, no matter what, you probably want to get that higher. Now, can I absolutely guarantee that’s going to transfer to having their energy levels come back up? No, but most of the time I find that it does. And even if it doesn’t, then that gives you the ability to rule that out.

DrMN:

So you take someone that say, 50 or 60% of the population standard. They’re aerobic performance is good. They’re not an elite level athlete, they don’t need to get to that level, but it’s good and it’s probably not a limiter. If they still report their energy is low and they feel like dog crap, well, we can probably rule out that it wasn’t that. And so to me, that’s a referral out again to someone such as yourself to be like, “Okay, we did this. We thought it was a aerobic capacity because it was really crappy. They trained and they got to this level. They don’t feel substantially better.” That’s happened a couple of times, but I would say most of the time they tend to feel pretty good. So either way, I think there’s enough data to support doing it as an intervention. The caveat to that is, I like using heart rate variability or some way of monitoring it. Especially when you’re new and you’re really detrained, you can overdo it to start even with long, slow, endurance type stuff.

DrMN:

It’s not likely, but it’s definitely possible. So I worked with a few people after they come into my buddy, Dr. Jeremy Schmoe’s clinic that are post TBI, so traumatic brain injuries, sometimes some POTS, some other issues going on. And while he’s doing the neurologic therapy on their end, in some cases, I’ll start doing some very light cardiovascular training with them. With some of those patients it’s really tricky because they can become symptomatic really fast, but there’s more emerging literature showing that because they’ve been so symptomatic with exercise in the past that they are paradoxic at the same time, very detrained. So they probably need to do something, we just have to be super careful with how much we give them. So watching heart rate during exercise, watching exertion, watching HRV each day to make sure that we give them enough so that they’re starting to adapt positively, but we’re not pushing them right over the edge, because unfortunately they’re kind of riding on the tight rope.

DrMN:

If you’ve got someone who’s a higher-level athlete and doesn’t have any pathologies, has a bigger aerobic base, they’re maybe at 60% of the population and they want to get to 75%. You’ve got a lot of bandwidth there. You can probably screw up a little bit and it’s not going to be a big deal. They can buffer a lot more stress and it’s going to be okay. When you get down on the other end of the spectrum, it gets a little bit trickier because if you add just a little bit too much, you can potentially push them over the edge.

Overtraining and Overreaching

DrMR:

One remark that we had covered on the podcast a while back was, and correct me if anything’s changed here since our last discussion, because this was two, maybe three years ago, more of the high-intensity interval training exercise is likely to cause someone to burn out. It’s kind of that high-intensity exercise with minimal recovery windows that seems to be most prone to causing the crash. Is that still accurate to say?

DrMN:

Yeah, I think so. Right. If we look at the literature, it’s confusing because everybody has their own terminology. So the simple terminology at a high level is overtraining syndrome or someone who’s overreached, if we look at athletes, just because they’ve been most studied in this population. So overtraining syndrome is exceedingly rare, but if you get it and you’re a high-level Olympic athlete, you’re probably screwed. Your career is probably over; you’re probably not even going to the next Olympics. Maybe you can recover if you’ve got time, if you’re really young, but you’re going to be in a world of hurt. You’re probably lying on your couch drooling on yourself for several days to months in a row. Athletes I’ve known who have had this, some of them have reported seven or eight years later that they still don’t feel like they were back to where they were before.

DrMN:

The good part is most people will probably never get to that. Even people training multiple hours per day, for years, very high intensity work. Even among that level of athletes, it’s still very rare. However if you get there, you’re pretty screwed. More common is something called overreaching, which if you use Dr. Bill Kraemer’s definition, you just take two weeks off and maybe the highest exertion thing you do is walk, eat normal, eat your normal nutrition, and if anything, maybe more, making sure you’re not in an energy deficit, sleep, do all the normal things for recovery. If at the end of two weeks, you feel back to “normal,” you in retrospect were probably overreached. So the downside about that is it’s more of a retrospective analysis. What you find is that most people in general will be more overreached. Now you get into the splitting hairs of functional overreaching and non-functional overreaching.

DrMN:

So for a period of time, I may actually want to push you with five sets and fun stuff on the rower, and watch your HRV actually start to go in the hopper. But we’re doing it on purpose for a short period of time, and then after that, we’re going to back off. So that would be considered like a functional overreaching. You’re kind of losing function, but we know what we’re doing. We’re doing this on purpose. So that’s some of the terminology around it. And you can have, as we mentioned, high-level endurance athletes that can be parasympathetically overreached. I’ve seen two athletes where this has happened. One of them actually had HRV as it was going on. We would see her HRV just going down, becoming more sympathetic, more sympathetic, more sympathetic, more sympathetic.

DrMN:

And we started working with her, and literally when we started working with her, all of a sudden her HRV flipped and she became massively parasympathetic, meaning that she was very, very high on an HRV score, which if you’re not knowing the context and didn’t see the lead up, you’re like, “Oh wow, you’re doing amazing. We must’ve done this, all this recovery stuff in here. Great.” And you ask the athlete, “How do you feel?” They’re like, “I feel like dogshit. I can’t even get to the gym to train. I lie on the couch most of the day. I feel like total crap.” So their body is saying, “Hey, you were super stressed. We’re telling you, you’re stressed. We’re cutting your ability to output. We’re cutting your speed. We’re cutting your power. We’re cutting your ability to do volume.” You’re not feeling very good, but if you keep pushing through that, at some point, it’s literally like you flip a switch and it’s like, “We’re going to make you so parasympathetic that we’re literally just going to pull the string out of your back, and you’re not going to be able to do anything because if you keep going, you’re probably going to risk injury or hurt yourself or potentially die.” So those cases are very, very rare, but they can happen.

DrMR:

So most people get into trouble by doing things that are a little bit too high on the sympathetic side without an appropriate recovery on the opposite side. So if you’re only sleeping four hours a night, it’s relatively easy to overreach yourself. You probably don’t need a whole lot of work to do that. If your nutrition is good, you’re in a caloric surplus, your breathing’s good, mechanics are good, you’ve got good family structures, social dynamics are fine, you can probably handle a lot of stress.

Tests for Aerobic Base Measurement

DrMR:

Let me, slip in one clarification, because this is interesting, but I think what’s more salient to our audience, where there’s probably not a ton of people who are bridging on overreaching listening or reading this. One burning question I have, because you said something that I think could have a lot of utility for our audience specifically, is exercise intolerance might indicate this kind of deconditioned cardiovascular base. And there’s a test that one could do to figure out if their cardiovascular system is deconditioned. Is this the Cooper’s run test? Is that the one that you’re using for this?

DrMN:

Yeah. So the test is to do an aerobic test to see where you’re at. If you are a runner or you feel capable running, the easiest one to do is the 12 minute Cooper run test. And you can just look up online how to do it. Especially with GPS now it’s pretty easy. You’re going to warm up and then you’re going to run as fast as you possibly can for exactly 12 minutes. Then you’ll record your distance that you went and then you’ll just plug it into an online calculator. It’ll give you an idea of what’s called your VO2max score. The other way you can do it is if you don’t trust yourself to run real fas, you can get on a Concept2 rower and after you warm up, set the distance for 2000 meters and you’re going to row as fast and as hard as you can over that 2000 meters.

DrMN:

Then you’ll just type in Concept2 VO2max calculator and it’ll pull it up. And then you type in the time that it took you to complete that. For the vast majority of people, they’re not going to be an elite level rower. So you put non-elite and then it’ll tell you what your VO2max is. And then below that, it’ll give you a table for normative data. On the rower, you can go one step further and go into the Concept2 logbook, and you can even compare your score against everybody else who has been all over the world and actually logged their 2K scores into the database there. So both of those are probably the ones I use 90% of the time. There’s some other stuff you can look up like the YMCA Step Test and some other things, but those two are probably the most useful and most accurate. If you’re not able to do either one of those, like I said, there’s a step test and there’s some other ones you can look at potentially.

DrMR:

Okay. And you can’t give absolute values because it depends on age and sex, I’m assuming, to give you what the 60 to 70% or higher of the population for the run or for the row is, right?

DrMN:

Right, because the score they’re going to give you there is normalized per kg. So it’s normalized for your body weight. And then it’s also normalized for age, which is useful because you’re then comparing yourself against other people that are similar per se for weight because that’s been accounted for and also for age.

DrMR:

Gotcha. Okay. And what I’ll try to do for our listeners here is kind of cajole Mike afterward to give me a few of these links, and then try to put a little mini table into the post associated with this page where we make it as user-friendly as possible, where you can just kind of look at the table, look at what you did, see the reminder prompts for how to do the test and then know where you click through to enter your data. I guess the one other thing we should probably provide there, Mike, would be how to interpret. Are people looking for a certain score or a threshold to say they’re deconditioned versus their conditioning is adequate?

DrMN:

Yeah. The nice part is on most of those, it’ll say poor, fair, average, good, excellent. So at the top of it, it’ll tell you where you rank. On those scales, at minimum I want to see people at least at around average, if not good to maybe excellent. If you actually go into the data from the Concept2 in the logbook, that gets a little bit trickier because the people who bothered to even log their stuff and do rowing as an exercise, those people are going to be at a higher level already. So that subset of the population there, if you use that as a metric, I got this from my buddy, Dr. Kenneth Jay, I’d like to see people hit at least 50%, right. So compared against another active population, 50% is kind of the mark I would like to see people. And long-term, maybe 75% if you want to get really aggressive with it.

DrMR:

And so you’re saying, when you’re doing the Cooper’s test, that’s a little bit more straightforward. You’re looking for a minimum of being average or better yet to be at a good score, but for the Concept2, since it’s more of a select population, you have to look to be at the 50th percentile or higher, or what specifically are people looking for when they look it up?

DrMN:

So there’s two ways to look at it. I can do a 2K or I can do a Cooper run test. And that will tell me my VO2max. That’ll tell me my aerobic capacity for lack of a better word. The VO2max has pretty good normative data, and the ability for the equations to get you in the ballpark are pretty good. So on those, I like to see people hit at least average to good, maybe even excellent, because the population data that they’re giving you there is literally population data. So it’s everyone, everybody else, just general population data. If you want to go the next step down, and you’re like, “Okay, so compared against everybody else, I’m good to average. But what about if I wanted to compare myself against people who already are doing some exercise?” Because usually what you’ll find is most people are like, “Okay, I was good there, but what would be the next thing I could rate myself against?” So if you go into the Concept2 logbook, this is people now who are taking the time and effort to actually log what they’re doing on the rower. So you have a biased population that’s already physically active, so their minimums are going to be higher than just compared to general population data.

DrMR:

Is there also good general population data for the rower? Or are you saying Cooper’s has that data, but with the rower it’s no matter what data you’re looking at, it’s a little bit more niche?

DrMN:

Nope, it’s with both. So we’ve got really good normative data on VO2max, and then there’s two ways you can get to VO2max. If you don’t like running, you can do it on a rower and that will be your score via the equation, and this is just done via the website. Or if you like running, you can do it as a Cooper run test. And on both of those, the first thing that you’ll see is just the general population data. So on there, I like to see people be at least good to average, probably even closer to the excellent area. If you’re already doing pretty good on that and you like rowing, you can then go into the Concept2 site and that has data from everyone who’s already doing rowing. So that data there is going to be comparing yourself against people who are already relatively physically active. Because the next question, if someone does a 2K, they’re like, “Well, what’s a good score for my 2K?” And going into the Concept2 database will give you a better idea of how you rank against other people doing that modality.

Cardiovascular Exercise Recommendations

DrMR:

Okay. Well, great. I think this could be a good exercise for people to go through, especially for someone who is struggling with fatigue or exercise intolerance. If you’re coming back below average, then I guess the next step would be cardio training. But Mike, to fully put you on the hook here, in case you do a good or a bad job, is there a general recommendation for loading themselves to improve their cardiovascular perspective or performance over time? I know it’s probably hard to answer because I’m asking for a blanket recommendation, but any recommendations for people there to get onboarded?

DrMN:

The easiest thing to do is just start with whatever modality you can handle. So if you like running, do running. If you like biking, do biking. If you like rowing do rowing. I think biking is probably underrated. If somebody said, “Hey, what modalities should I do? I can do all of them, and I want pure more aerobic development,” I’m probably going to have them do biking. And with that, you can use the Phil Maffetone equation, which is 180 minus your age. So if you’re 40, say 180 minus 40 would be 140. You can use that as a rough guide to your maximum heart rate for it to still be lower to moderate intensity work. So if I’m 40 years old, 180 minus 40 is 140 beats per minute. If I go out and I start doing stuff and I’m pegging 155, 160, and I’m staying there for several minutes, no matter what that is, it’s probably not low to moderate intensity anymore.

DrMN:

Another marker I’ll use is can you breathe in and out through your nose only? That’s going to limit your upper end also. I like people to start lower and just get in the habit of doing it. So for awhile I was doing this with myself before I had a bike. I would just get up and do six minutes nasal breathing on the rower six days a week. I just started there for quite a while. Previous to that, I even started just doing four minutes. So do whatever you can. I would rather people get in the habit of doing it for a lower duration, but higher frequency, especially if they’re more on the detrained side, than feeling like they need to go out for one to two hours on a Saturday, because it’s way too easy for them to overextend themselves.

DrMN:

Even if they can handle running, their joints, their ligaments, everything else is probably not quite prepared for that pounding. So I like having people start at even just a couple minutes. If you’ve got a stationary bike at home or bike you can ride around the neighborhood, just get on each morning and do two to five minutes. Do that maybe Monday through Friday. Once that feels pretty good, then you just add a couple minutes to it. If you don’t have any limits on that, you can start at maybe 10 to 20 minutes a day, but I would really highly encourage people to start much lower than they think, because the question they get, which is a solid question, is what is the ideal amount for the best physiologic change? I haven’t seen a lot of really good literature on this, but if you pushed me hard, I would say you’re probably looking at accumulating two to three hours per week for a six to eight, maybe 12 week block.

DrMN:

People will hear that and they’re like, “Oh my God, that means I have to do an hour on Monday and an hour on Thursday. Well, you can just work up to doing 20 minutes, five or six days a week. In six days a week at 20 minutes, you’re already at 120 minutes or two hours. So I’d rather have people start lower and slowly increase the time per day. And I’m a bigger fan of frequency. There’s not a lot of literature to support that as getting a better physiologic response, I’ve just seen that it works better anecdotally. And then it’s much less likely you’re going to overextend yourself, because what happens is people are like, “Oh, I heard this weirdo. He says you’re supposed to do two hours a week. And I went hardcore on Monday and just nasal breathed and I forced my way through a run, and then I felt like crap for four days, and I didn’t do anything again.” People just tend to overshoot because it is lower intensity stuff. So you can kind of push yourself through it per se, but that’s actually not what I want. I want people to have it still feel relatively easy and then come back and do it again the next day. Cool. Then you got that down. Okay. Now add a little bit more time. Once you start getting to the point where you can do 20, 30, 40 minutes at once, maybe you can bump up the intensity a little bit. But I’m a much bigger fan of getting up to a longer duration with a higher frequency for a set period of time, maybe an eight to 12 week block. See where you’re at then, and then figure out what to do next.

DrMR:

And you were saying the target, again being careful that it may not be the best fit for everyone, was it one to two hours or was it more like two hours where you’d like people to optimally work up to over time?

DrMN:

If you pushed me, I think the accumulation of time within the two to three hours per week is good. The caveat I would add is that I would make that an aerobic development block, meaning that your number one goal during that period of time, let’s say eight weeks, is to increase the bottom end of your aerobic capacity. So your other lifting will be more minimal. You can definitely still lift, but you have to watch your recovery ability. At the end of that, you can run your aerobic test again and see if you’ve gotten better. What I see as a general trend is people hear, “Oh, I heard, so-and-so say two to three hours of zone two aerobic work is best.” And they just do that the rest of their life. And it’s like, “Well, maybe. I don’t think that’s going to be a bad thing.” But you know, at some point your time may be better off invested in something else.

DrMN:

So I’d rather see people pick a priority, do that for a set period of time, reassess and see where you’re at. At some point, if you keep reassessing with low to moderate intensity stuff, your VO2max is not going to improve. So at that point I would rather see people transition into some type of interval training, some type of aerobic capacity training, something that’s a little bit higher intensity because again, our main output is looking at what is our VO2max, that aerobic number. I have some people that do very little low-intensity aerobic stuff, but their VO2max is within 80% of the population. It’s pretty high. They’re pretty active. They walk a lot, they move a lot. So for them it’s probably not a huge benefit to do another three hours of low-intensity work unless we’re really trying to push recovery. But for someone who is very much on the detrained side, I think you can get a lot of benefit from it, just getting the lower intensity accumulation of time.

Real-World Training Example

DrMR:

I’m not sure if you recall the details from when we started working together, but I remember going through that protocol. I remember it not feeling super challenging, but I’m assuming my cardiovascular base wasn’t quite where it should have been and rightfully so. I had kind of drifted away from cardio training, because once I graduated out of college cross, I would still do some, but I kind of slowly drifted over time toward more sprinting, weight training, hit training. My cardiovascular training definitely got better over time, but that was the first step. So I guess, do you recall any details from my case just to give people an example of how this looks in the real world, other than it was a train wreck and you were scared for me?

DrMN:

It was a disaster, your pancreas was going to fly right out of your body, you know, just total disaster. No. I mean, if I remember right, I can pull up the numbers, but your aerobic numbers weren’t too bad, but they weren’t as high as what I would expect for someone with your activity level. So that’s the other part people have to look at too. I want to say you were, maybe on the Concept2, right around 40%. I’d have to double check. So if someone is very active like yourself, they have a fair amount of muscle mass, everything is good, but they’re reporting, “My energy feels a little bit low. I just can’t really seem to get to the next level,” for someone like that, if we use the 2K, and we use the Concept2 as the marker, within the Concept2 data I’d want them to be hitting at least 50% of the population within that athletic group, maybe even higher.

DrMN:

If we look at what you were doing, it was a fair amount of higher intensity stuff. So if the higher intensity stuff had been working, then we would have expected your aerobic score relatively to your performance to be higher. And it wasn’t. And what we did, if you remember the hell week of testing, we tested everything on that entire spectrum. We went from a hundred meter all out, just max wattage, 30 seconds all out, 60 seconds all out, 180 seconds all out, 2K, which is around seven to eight minutes for someone in your case, 20 minute capacity test also. And the 20 minute capacity test was one of the lower ones along with the 2K. So the speed and the power ran was not too bad. The lactaid stuff was okay, but the ability to keep doing work was lower.

DrMN:

So that also tells me that if those numbers are lower, relatively speaking, let’s kind of work more on those. So if you remember, the first thing we transitioned into was a little bit of 2K work and a lot of 5K, 20 minute capacity type stuff. So once we established more of the low end, the aerobic base for eight to 12 weeks, now we’re going to up the intensity a little bit, but we’re not going to have you do 500 meter repeats. We’re going to have you go for maybe 20 minutes. Because the duration is longer, your output is obviously going to be less. No one really rows a 5K at the speed they do a 2K if it’s the same person. So by making the duration longer, but it’s still shorter than some of the work you had done before, that’s just the way of the intensity. And then that is more specific work to what you were kind of missing on that spectrum.

Patience with Training

DrMR:

And I did notice, and I’ve reported on the podcast before, that I was amazed that my ability to do more exercise over time increased as I just kept at it and was consistent and slowly ramped up the intensity. But, you know, to your point, Mike, and I think this is a good reminder for people that a good clinician will make things look easy. You know, there were times when I was just kind of going through it and it felt like I could push harder or we could do more, or for patients, I could take more supplements or we could do more stuff, but you know, it ended up getting me to the point I wanted to be. It didn’t feel, and I thought it was going to be like this thrashing where, “Oh my God, I’m working with Mike Nelson. This is going to be intense, and it’s going to be all this craziness, dripping sweat and blood every day.” It wasn’t. That at times did feel underwhelming, but three to five months later, I was doing a full workout and then saying, “Hey, you know what? I think I’m just gonna do another 10 minutes of rowing after I did a 20 minute capacity run.” So, on the user end, things definitely got there. That’s a good reminder for me, and I think for patients, to give your clinician some time, because some of these things may take a little while to fully turn, and don’t jump ship too prematurely. Sometimes things may not seem exotic or very difficult, but there’s a lot of analysis typically going on behind the scenes. So in this case, Mike was seeing a clear pattern where the cardiovascular system was underdeveloped and the solution to that wasn’t more hit training, like “Oh, it’s really tough, and you’re going to be breathing really hard and sweating profusely,” because that’s what I was doing too much at the beginning. So I actually never realized all those things tied together in that way. So nice work.

DrMN:

Part of it is based on the client’s personality too. So when we did a harder 20 minute capacity test, I could tell you, “Okay, you’re going to go relatively hard on this,” but in my head, I’m like, “I know it’s 20 minutes and I know what the wattage is going to be. And I know what the distance and everything else is going to be.” That’s way different than, “Okay, let’s go hard for 30 seconds.” To the user though, however, you’re like, “Wow, that’s 20 minutes. That was was hard.” And it is, but because it’s 20 minutes, not 30 seconds, by that definition, your output is going to be less, which is what I wanted, because you were missing the lower end of the spectrum. So in your case, you needed someone to kind of trick you into doing things that were kind of hard because you expect it to be hard, but were the things that you needed to work on.

DrMN:

That’s why I got into nasal breathing. If you can do 20 minutes on a rower and nasal breathe, you’re probably not going to hit your all time max, but it’s going to feel fricking horrible. And to people who are programmed that exercise is effort-based, they like that because it feels hard, but I like it because it’s still accomplishes my objective of getting in some good quality work, but let’s not frigging redline you every day, because I want you to come back in and do more work the next day and the next day. If I let someone just redline themselves, they’ll do great for a week or two, then they blow up and need two weeks off. So I was trying to find that fine line of wanting them to get a similar sensation so they stay on board, they stay motivated, they believe they’re going in the right direction, while making sure that the physical thing that we’re having them do is actually getting them to the result that they want. Because that’s the thing that matters.

Proper Intensity of Training

DrMR:

Sure. It’s a great point. That gives me a follow-up question. I’m really asking for myself because I like to kind of redline on every day if I can. I’ve definitely noticed my ability to tolerate that has increased pretty notably, but there’s also a threshold. How do you find most people are able to program on a weekly basis once they’ve gotten their conditioning fairly sorted out, they’ve rectified any imbalances? Like my cardiovascular base was inadequate. That’s now fixed. Asking for the people who have the predilection that I do to kind of redline six days a week or so, is that ever sustainable, or do people need to oscillate into these lower-intensity bouts, let’s say a few times per week, to keep them from overreaching?

DrMN:

I find that most people, if you go hard, the next day in general would be less. So there’s two things. So if you’re the type of person who wants to go hard often, then the skill set you need to work on is transitions. How hard can I go to get to what is close to a peak, and then how fast can I literally relax and get back down to a relaxed state before I have to go again? So that could be, let’s say doing a bench press, doing a three rep max. Okay. It’s go time. All right. Great. I got my three rep max. Awesome. Now I’ve got maybe three minutes to rest before I do it again. How parasympathetic can I get in those three minutes and then be ready to go again? Maximal sympathetic again, within two to three minutes?

DrMN:

How high can I get to the peak? How fast can I get to recovery? How high can I get to the peak the next time? Because the thing that people think they need to do is “During this three minute period, I have to stay amped up because I’ve got this next three rep max coming up.” I find that type of person just burns up way faster. If you watch professional athletes, they make hard things look easy. If you watch an NFL receiver, you see them go hard for a play and then just kind of jogged back and start again. They’re able to transition very fast. Same with an Olympic weightlifter. I love the old Russian films. This huge guy walks out on stage like he’s going to take a nap, touches the bar and his eyeballs get huge and sets a world record. And then he lumbers off stage, I guess, to go take a nap again.

DrMN:

Very, very good at, “I’m going to be as relaxed as possible until I need to be at sympathetic as entirely possible, accomplish the task. Great. Now I’m back to being parasympathetic again,” the transition between those two. So once you have that skillset, that’ll be a huge difference in terms of ability to perform and recover within time. That goes back to what was one of the main things that dictates how fast you can become parasympathetic is your heart rate recovery, which is dictated primarily by parasympathetic tone, which is upregulated when you’re doing aerobic type training. It’s that aerobic system, after you’ve done say a heavy lift, that’s going to get you back to baseline faster. So if you have someone who is not as well conditioned, their aerobic base isn’t as high, they stay in that elevated heart rate for a longer period of time.

DrMN:

And they’re literally outputting more stress for probably not the same output. And then long-term you’re looking at psychologically, can you take someone and have them be more performance outcome based and less “How did it feel?” Because CrossFit is a great example. Not to rip on them, but I think CrossFit has done an amazing job with the coaches and everything else, and the progression they’ve had in the last five to eight years, but it’s an example most people are familiar with, or they know people who are doing CrossFit. They will tend to brag about how hard their training was and less about what they actually did. “Oh my God, that MetCon just beat the shit out of us today. It was amazing. I loved it.” And on one hand, I’m like, “That’s cool that they’re doing the hard things and looking forward to it,” which is awesome.

DrMN:

The hard part is you need to modulate that and you need to look at your performance, because if that goes completely unchecked, you have someone who is all a hundred percent effort-based and their performance is degrading. And that’s when you see people burn out and get injured. So if you keep an eye on performance, then that’ll give you a metric as if you’re going in the right direction or not. That could be just simply adding another rep to what you were doing. It could be adding weight. It could be doing the same amount of work in less time. It could be just adding a little bit more time to training. It doesn’t have to be anything super fancy. But if your progression over time, week to week, not always day-to-day, is getting better, and your cost is not accelerating, meaning your HRV is not showing that you’re super sympathetic all the time, you’re probably going in a more sustainable route. If I start seeing those get kind of screwed, like, “Maybe for a week, we’ll let performance drop a little bit and HRV get more sympathetic. Next week’s an easy week. I’m not worried about it.” But if those start diverging, where performance now seems to be trending down, HRV is the same and you’re becoming more sympathetic, then that’s making me nervous because no matter how hard you try, you’re going to end up with the perception of everything feeling harder, but literally getting less out of it than before. I think that’s the main trap people run into is that, “I went to the gym, especially with interval training. It was really hard. Great. And I’ve been doing this hard thing for like six weeks in a row and all of a sudden I’m not getting better, but it still feels really hard. I can’t figure it out.”

DrMR:

I’m currently struggling with that myself.

DrMN:

And it’s because the brain literally gets rewired to the reward being the effort. And by all means, you definitely have to put in effort. You have to. But it would be like someone going to work and being like, “Alright, boss, eight to five workday. How thrashed can I be at like 5:05 PM tonight? That’s my goal.” That doesn’t make a lot of sense. Ideally you’d want to be like, “Okay, how much can I get done, make my boss happy. And then I feel pretty good. I’m going to go train at the gym afterwards.” It should be performance-based first, then cost after that.

Tolerance for Additional Stressors

DrMR:

Yep. Love it. And I’m on the same page and also understanding how people can fall into the addiction to hard work. That does have its role, but that’s should also be in relation to goal achievement and progressive improvement in performance so as not to be imbalanced in how you load an individual. One big question, I’m wondering about, the other item I wanted to pick your brain on was how to improve tolerance to other stressors like sauna therapy or cold exposure. And it sounds like one of the ways to do that is make sure someone has, if they’re insufficient, a developed cardiovascular base, because it’ll help them have more of a parasympathetic undertone and help them recover more quickly. Is that fair to say? Are you seeing that in people, in terms of allowing them to tolerate more of those healthy ancestral-like stressors?

DrMN:

That’s generally what I see. If someone’s stronger, has a bigger aerobic base, they’re just a lot harder to kill overall.

DrMR:

That’s well said.

DrMN:

I think there’s a bunch of cross adaptations that we don’t understand yet. So if we take with the exercise example, I want to get better at deadlifts. You should probably deadlift, right? Do you want to get better at said thing, then do the specific thing. But at some point you can only do so much of that. I’m going to deadlift five days a week doing the exact same thing. But maybe if I did a squat or I did a kettlebell swing, or I do hip thrust, whatever. I got better at something that wasn’t a deadlift, but I didn’t do the deadlift. So it’s, what’s called positive transfer. And if you look in physiology, it’s labeled across adaptation.

DrMN:

So they did this really cool study where they exposed people to cold water immersion for just literally one session. And then afterwards they took the group that they exposed to cold water immersion and the group that they did not, the control group, and they exposed both groups to hypoxia, or low levels of oxygen, and they looked at the response. So obviously low levels of oxygen is going to be a stressor. What they saw was the group that had the previous cold water immersion for only one session did much better under the hypoxic condition, even though when they did the cold water immersion, oxygen levels were exactly the same. It turns out the underlying mechanisms are similar or at least have some transfer. No one’s entirely sure yet. So I think if you’re looking at other things to target, once you’re aerobic base is good, your training is good, your nutrition and lifestyle generally is pretty good, what would be the next level of things to make you more robust?

DrMN:

I would target what I call the homeostatic regulators, temperatures being a big one. Humans are homeotherms. We like hanging out at the same temperature, but we can expose ourselves to cold water and we can expose ourselves to heat via sauna. pH would be the other one. So a highly acidic environment would be like your high interval training that would fit into that, or doing specific breathing, either breath holds or a Wim Hof super ventilation method. Blood glucose and fuels would be the other one. The last one would be oxygen and carbon dioxide regulation. So I think if you’re targeting those areas and you’re getting better at, let’s say cold water immersion, there’s probably something else that you’re getting better at that I don’t think we’ve even tested or understand yet. I think if you start targeting those areas, you’re going to have a fair amount of cross adaptation, just like the aerobic work helps with many other things.

DrMN:

I think that those things will then help make you more robust in ways we don’t quite understand. So for cold water, there’s some interesting stuff on glucose. So I’ve done this, I don’t remember if you’ve done this or not too, but resting blood glucose is like 85. I want to say I did four minutes at 42 degrees. I got out, pricked my finger again, and just four minutes later, it was 56. I’ve done this a couple of times. So for whatever reason, cold water seems to do interesting stuff with blood glucose. It does interesting stuff with beige fat tissue, kind of making it more like brown adipose tissue with all the mitochondria. I think that we’ll find the cold water immersion and sauna also have a lot more metabolic effects that we’ve kind of underestimated. In untrained individuals, sauna exposure is almost equivalent to low-level cardiovascular training. Blood volume, expansion, heat shock, protein regulation, a bunch of other stuff.

DrMN:

So if we go back even further, all those things are things ancestrally we kind of had to regulate. And we’re now running the experiment of what happens when we don’t really regulate these things. We hang out in temperature-controlled places all the time. People run from one temp-controlled place to the next temp-controlled place. Blood glucose doesn’t really vary all that much. So we’re kind of running the experiment where we’ve removed these stressors and it’s probably not going to be a good outcome. I don’t know how bad or what’s going to happen, but it’ll be interesting to see.

RuscioResources:

Hi everyone. This is Dr. Ruscio. In case you need help, I wanted to quickly make you aware of what resources are available to you. If you go to drruscio.com/Resources, you will see a few links you can click through for more. Firstly, there is the clinic, which I’m immensely proud of. The fact that we deliver, cost-effective, simple, but highly efficacious, functional medicine. There’s also my book, Healthy Gut, Healthy You, which has been proven to allow those who’ve been unable to improve their health, even after seeing numerous doctors, to be able to help them finally feel better. There’s also our store where there’s a number of products like our Elemental Heal line, our probiotic line, and other gut supportive and health-supportive supplements. We now offer health coaching. So if you’ve read the book or listened to a podcast like this one, or are reading about a product and you need some help with how or when to use, or how to integrate with diet, we now offer health coaching to help you along your way. And then finally, if you are a clinician, there is our clinicians’ newsletter, the Future of Functional Medicine Review. I’m very proud to say, we’ve now had doctors who’ve read that newsletter, find challenging cases in their practices, apply what we teach in the newsletter and be able to help these patients who were otherwise considered challenging cases. Everything for these resources can be accessed through drruscio.com/Resources. Alrighty, back to the show.

DrMR:

Tying into the ancestral plausibility of cardiovascular training, I know oftentimes it’s criticized, “Oh, did you ever see a caveman jogging through the bush?” But in thinking on this just now, hunter gatherers likely did a very high amount of low-level activity, namely walking and foraging. So perhaps that’s part of the reason why the cardiovascular base condition that we’re describing here is important, because people likely have more of an episodic high-intensity, meaning go to the gym and work hard for 20, 40, 60 minutes. But they’re devoid of that walking constantly through the day or constant movement, constant foraging, shelter procurement and things like that. It seems pretty plausible to me, but I’m wondering how that strikes you?

DrMN:

I would agree with that. There’s very interesting data on the Hadza that looks like they move around probably a fair amount. Now, granted, they’re probably in a low-energy availability and they’re constantly looking for food and hunting and hitting the ground for tubers and stuff like that. So I think having more low-level of movement is going to be beneficial. I agree with you a hundred percent that even people who train, it’s like, “Okay, I’ve got a desk job. I get up, I go to my desk job, I sit on my butt all day. Maybe I run to the bathroom a couple of times, I parked next to the building. Time for exercise and go beat the crap out of myself for 60 minutes of this super high heart rate, circuit training, whatever I call it, super high intensity training.”

DrMN:

Then they come home and just sit on the couch and watch Netflix for three hours and sleep six hours. So I think that there’s benefit to that. That’s better than not exercising for sure. But if we look at your overall movement during the day, it’s very, very minimal. So I think getting some movement, going for a walk, low-intensity stuff is underrated, although it’s starting to become a little bit more popular. The main research look for that is going to be Pontzer. He’s published a lot of research looking at the Hadza and just looking at general movement. Unfortunately, what we find is that more is good up until a point. If you’re one of the nutbags who is trying to get 15,000 to 20,000 steps a day, you’re probably on that high end of the spectrum where going to 25,000 is not going to make any damn difference, even if you had the time to do it. But if you go from 3,000 to even 6,000 steps a day, you’re probably going to see a lot of benefit with that.

Episode Wrap-Up

DrMR:

Well, Mike, I feel like we could talk for another hour here, but I want to be respectful of your time. I know you have a few different courses and you also offer one-on-one training, which is how I got Humpty Dumpty put partially back together. Can you tell people more about where they can connect with you?

DrMN:

Sure, the best place is through the newsletter. So you’ll be able to get a hold of me there just by hitting reply. The main thing I have right now is the flex diet certification. So if you go to flexdiet.com, that’s eating interventions geared mostly towards nutrition and recovery for body composition and health and performance.

DrMN:

There’ll be a way to get on the wait list there, that’ll put you on the daily newsletter through which most of the information goes out. Just hit reply and we’ll send you a free gift. And once the physiologic flexibility, cert is open, that’s more looking at the homeostatic regulators, cold heat, pH, et cetera, you’ll be notified through there. And if they’re interested in one-on-one training, they can just hit reply there and we’ll go from there.

DrMR:

Awesome. Well guys, as you can tell, I highly recommend Mike’s work so much to the point where I’ve trained with him myself. I definitely want to encourage you to check out the work that he’s doing. And Mike, thanks again for taking some time to speak with us.

DrMN:

Thank you so much for having me and let me yammer on again on the show. Really appreciate it.

DrMR:

Always a good time. Thank you again.

Outro:

Thank you. Thank you for listening to Dr. Ruscio radio today. Check us out on iTunes and leave a review. Visit DrRuscio.com to ask a question for an upcoming podcast, post comments for today’s show and sign up to receive weekly updates. That’s D R R U S C I O.com.

 

Are people tending to be underdeveloped from a cardiovascular (CV) fitness perspective? 

• Trend is CV fitness is underdeveloped
• Circuit training helpful, but may not fully hit CV conditioning endpoint
• HIIT more likely to lead to burnout or overreaching
• Exercise intolerance might indicate cardio deconditioning. Testing can answer the question.
    ○ Test for aerobic capacity:
    ○ 12 min Cooper Run test
          • Warm up, run as fast as possible for 12 mins exactly
                ○ Online calculator
                ○ Look to score – looking for minimum at ‘average or good’
          • Or concept 2 rower, 2,000 meter, asap for 2K
                ○ Then concept 2 VO2 calc – type in time – not elite
                ○ Look to score – looking for minimum at ‘average or good’

1st assessment 

• HRV (heart rate variability) and resting heart rate
    ○ HRV: Oura: teens low, average 30/40s-70s.
          • Less accurate b/c your laying down
    ○ Ithlete: 1-100; 60s-80s
          • Not a linear relationship…
          • Oura sleep score, not sure difference between C sleep and B+ sleep made big difference
    ○ RHR:
          • Seated, 50s
          • Oura: 40s/low 50s
• Tracking HRV over time,
    ○ When does HRV start to tank? 7 day rolling average, will drop when overloaded.
• Aerobic performance, VO2 max

Push until feels overloaded

• Wave up/down.  More with weights. 

Building exercise tolerance with fatigue, observations

• Improve CV base

• Do whatever form you like; run, row, bike
• Heart Rate of: 180-age for target heart rate 
• Breathing through nose only 
• Duration of whatever you tolerate, aim for lower duration but done more days per week.  
• Attempt to slowly work up to 2-3 hours total per week.  Over an 8-12 week period, and then change training. 

Building tolerance to other ‘ancestral stressors’ (fasting, sauna, cold)

• Lifestyle, sleep
• Cardio/parasympathetic conditioning

• Intestinal Support Formula by Functional Medicine Formulations
• Dr. Ruscio Resources