September 24, 2001 • VOL. 12 • NO. 18

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Feel the Burn... Slowly
Does 'Super Slow' Training Have a Place in PT?

By Jonathan Bassett

After 35 years in private practice, Gary Lindahl was burned out.

"The tingle I had felt through helping people just wasn't there anymore," Lindahl, PT, told ADVANCE. "I had a thriving practice with several orthopedic and return-to-work contracts, but I was bored. I began searching for better ways to return function to and reduce pain in my clients."

That's when a friend introduced him to SuperSlow® training, a weight-training philosophy founded on long-established principles that's gained recent attention through such television and print vehicles as CNN and Newsweek.

Lindahl traveled to Florida to meet with Ken Hutchins, the founder and developer of SuperSlow and president of the SuperSlow Exercise Guild. Though Lindahl admits that Hutchins wasn't impressed by many of the principles of physical therapy, he welcomed the opportunity to spread the word about SuperSlow to the PT market. Lindahl liked what he heard during the meeting, and thought it might just be the key to reviving his fading interest in his beloved profession. He wanted to learn more, but soon found that certification in the method would require more than just a Saturday afternoon class.

"After reading the manual, which is no small feat, I had to take a three-hour written exam," Lindahl remembered. "After passing that, there was an hour-long oral exam, then four or five hours of technical and practical testing: working with the machinery, learning positioning, alignment, restricting ranges, pinning up machines–all aspects of the method."

Following the achievement of his Level I certification, and after witnessing the remarkable improvement in his patients back home, Lindahl returned to Florida eight months later for his grueling Level II certification.

"I had to shadow this guy for nine days, and he .almost killed me," Lindahl said. A five-hour written exam and more practical testing followed. As a result of this time in what Lindahl fondly calls "boot camp," he achieved Level II, and was appointed Master Exercise Specialist soon after–the only PT in the country to garner that title–allowing him to certify others in the method. Through upcoming papers and talks, he's now ready to bring SuperSlow to the world of PT.

What Is SuperSlow?

At its most basic level, SuperSlow is founded upon the principle that gave rise to its name: weight training repetitions are performed slowly and deliberately, taking a full 10 seconds for the positive motion, 10 seconds for the negative.

Advocates state that what seems to be such a simple change can have far-reaching advantages for those rehabbing an injury or training for general fitness.

"As a physician, I am excited about this approach to care for the back," said family practitioner Gail Dressler, MD, who underwent the SuperSlow regimen with Lindahl to relieve her 30-year history of intermittent low back pain and stiffness. She's since been able to return to martial arts training and other activities without trouble.

"[SuperSlow] works and appears safe when monitored appropriately," Dr. Dressler said. "Additionally, there are other benefits, such as general conditioning and weight control, as well as some emotional stabilization." She now refers patients with back pain to Lindahl's clinic, and finds that they come back not only pain free, but also more motivated to continue exercising.

But there's more to the SuperSlow philosophy than just counting to 10 during a rep. True benefits come from the exceptional, almost excruciating level of intensity that practitioners insist upon during workouts.

On Lindahl's Website, you can read everything about his studio in Fremont, CA, except exactly where it's located. For that, you'll have to call his office manager, who is in a different location, and set up an appointment. Only then will she reveal the site of the unmarked studio entrance.

The reason? Lindahl demands perfect focus during sessions. He allows no walk-ins, which would disturb him and his clients. He plays no music, allows no children, engages in no small talk. All trainers wear ties, there are no mirrors, and 100 percent dedicated professionalism is maintained at all times.

"Anyone can count to 10," Lindahl said. "The professionalism, environment and intensity are what counts. If people can deal with this level of concentration, that's when you'll witness the tremendous increases in strength in a very short time."

Structuring a Program

Lindahl tries SuperSlow with all points of the rehab spectrum: people with Parkinson's disease, MS, disk fusions and osteoporosis can be seen grunting and straining in his studio.

"I don't just work the targeted area," Lindahl explained. "The goal is to incorporate SuperSlow into a general fitness program, and to make people proactive in a fitness program after they leave here." Discharged clients can return to work with Lindahl or another trainer in the evenings to build on their progress.

Lesley Gragg, PT, specializes in treating chronic low back pain with the SuperSlow protocol at BACKmed® Strength Therapy Centers in Lisle, IL. Gragg said she first witnessed the benefits of SuperSlow while in PT school–but not through her teachers.

"My parents were experimenting with the program in their own training, and saw dramatic improvements in their overall fitness," said Gragg, who brought the technique to the attention of fellow students and faculty and even gave a presentation on the technique. To Gragg's dismay, though, it was met with skepticism.

"My peers were uncertain about the functionality of this method of strength training," Gragg said. "I believe strength is strength. If the overall musculature becomes stronger, it is inevitable that activities of daily living will become easier to perform."

In addition, Gragg said her peers questioned the safety of SuperSlow. "Injuries often come from exercising too fast and too explosively," she said. "By removing momentum with SuperSlow, not only is the muscle being worked more continuously, but more importantly, the injury factor is significantly reduced and almost eliminated. I've had no injuries during this training; in fact, I've been able to build up the strength levels of my clients so that they can better avoid injury during activities of daily living."

Another essential aspect of SuperSlow involves not only moving slowly and with control, but reaching complete muscle fatigue. Taking the musculature to a point where it is impossible to complete the last repetition and temporarily holding it will elicit an adaptive response, causing the body to produce more muscle.

After opening BACKmed, Gragg is now able to include SuperSlow in the program of every patient with back pain who is referred, whether they've just undergone surgery or are looking to avoid it. Patients are typically taken through a 12-week program of 30-minute sessions twice weekly. Following an initial orthopedic evaluation, a lumbar extension machine (LEM) is used for all patients with back conditions. Other exercises might include overhead presses, pull downs, abdominal/spinal flexes, leg presses, and possibly a neck exercise. Breathing during the long reps resembles shallow Lamaze-style breaths.

After completing the program, most .patients choose to continue as fitness clients, paying separately for once-per-week sessions with either Gragg or one of her trainers. But just as in Lindahl's studio, don't expect a session with Gragg to be a relaxed social event.

"These sessions are extremely intense, and require a great deal of concentration and willingness to work hard," she said. "Some of my patients are in their 70s and 80s and had never strength trained; they have not only adapted quickly to this method but also have experienced substantial progress in their overall strength and mobility," Gragg said.

Gragg and Lindahl have enjoyed a steady client base of both physician .referred patients and training clients, and have been fortunate with reimbursement. Gragg leaves billing third party payers up to the patients, but says they are usually successful. Lindahl bills directly, and while this entails a lot of letter writing, insurers have come to like the results he offers.

"They're dealing with a protocol they're not familiar with, but in reality, it's just a different, more intense form of strengthening," said Lindahl, who is enjoying an ever-increasing pool of referring physicians and chiropractors.

What Do Your Colleagues Think?

Reactions from the rehab and training communities to the SuperSlow philosophy remain mixed. Overall, those who haven't heard of it are curious, and those who have like what they've seen.

"I have used this, and it has its place in a program," said Darcy Norman, PT, ATC, CSCS, president and co-founder of Advanced Fitness Inc., Bellevue, WA, which consults athletes of all ranks on functional training and rehabilitation. "You can't deny the testimonials of the people who have used the program and benefited from it."

However, Norman only includes the technique in restricted orthopedic and personal training instances, and as one part of a larger protocol. He never keeps a client on it for longer than eight weeks.

"I use it as one part of a periodized program," Norman said, "based on the needs of the client or patient, which might be to .increase muscle mass or to stress the neurological system for maximum fatigue. I would never use free weights with this method, because posture and compensation patterns can take over to try to stabilize the body, increasing the risk of injury."

Ben Cook, MA, CSCS, CPT, spent eight years as the men's basketball strength coach at the University of North Carolina. Now he works with area athletes of all levels from junior high to professionals at the Carolina Sports Performance Center in Charlotte, NC. While Cook feels the SuperSlow philosophy is little more than a regurgitation of old bodybuilding principles repackaged with slick marketing, he admits that the technique holds some merit, and he will work it in to his programs to "mix it up."

"I have designed 52-week training programs for our athletes," Cook said. "Part of that involves an immediate post-season phase, during which I'm trying to maximize muscle gain to replace what was lost during a rigorous season. Super slow repetitions, 10 seconds up and down, is a great way of taking momentum out of the movement, and placing a tremendous amount of stress on the muscles. As a result, the muscle will have to refortify itself against that stress, packing in more substrate energy, and achieving hypertrophy."

Slow rep speeds are combined with other "shock" strategies such as forced reps, supersets and pre-exhaustion techniques to build muscle. As the season approaches, however, Cook phases these out in favor of movements designed to promote sport-specific power and explosiveness, such as plyometrics.

Dawn Gulick, PhD, PT, ATC, CSCS, assistant professor at Widener University's Physical Therapy Institute, Chester, PA, feels the lack of momentum in completing movements–and the sustained muscular activity associated with it–can be beneficial. However, she cautions that control and stabilization during slow movements are essential, and is concerned that the speed of the movements is not functional.

Norman agreed. "I do not rely on this, because it is not related to what people need for function," he said. "Life is performed in three planes of motion; that is how it should be trained. Using machines takes away the most important aspects of training: coordination, proprioception, balance and stability."

"In our lives, we're raking leaves, picking up groceries, marching up steps," added Cook. "Our training should help us to not just look better, but to be better at the real-life activities we use every day. Doing that means targeting both fast- and slow-twitch muscle fibers."

The SuperSlow manual actually recommends against combining the method with other muscle building techniques, however. "Some trainers have heard fragmented information about SuperSlow and have chosen to mix it in with other exercise programs and protocols they already use. This is a bad idea...the incredible beneficial results that are possible from SuperSlow are significantly truncated if other exertional activities are included," the manual states.

Lindahl doesn't buy this. As devoted as he is to the SuperSlow protocol, even Lindahl doesn't blindly accept all components as gospel, and will tweak the program as he sees fit. One fundamental separation between his practice and the SuperSlow camp lies in the viability of aerobics.

"In the 1980s, I'll be the first to admit that we went too far with aerobics," Lindahl said. "Just look at the pieces of equipment being sold at the time: stair steppers, treadmills, stationery bikes. There was little strengthening equipment, and what we did have was inferior. Strengthening books were all written by bodybuilders. But I don't agree with [Hutchins] that there is no place for cardiopulmonary conditioning in a strengthening program."

Although Lindahl knows he has a long way to go before SuperSlow is accepted as mainstream physical therapy, he is proud of the about-face that PT has undergone in the past 20 years. "As PTs, we used to use modalities and manual techniques as the cornerstone of rehab, and strengthening was a side issue, if it was addressed at all," he said. "Now, most physical therapists realize that high intensity strength training needs to be the core of treatment, and all other aspects must revolve around it."

Oh, and that tingle that Lindahl said he lost? It's back, with a vengeance. Or that could just be soreness from yesterday's gut-busting SuperSlow workout.

SuperSlow is a federally registered trademark of Ken Hutchins. Find out more about SuperSlow training at www.superslow.com. Gary Lindahl's Website is garylindahl-pt.com. BACKmed's Website is www.backmed.com