How To Be A Strength-Focused Physical Therapist
“Hi, I’m Scotty and I’m a Physical Therapist.” It wasn’t that long ago that this confession would have been my caveat emptor prior to engaging in conversations about physical therapy and strength training.
There has been both much criticism and much support for the idea of physical therapists as the go-to practitioners for exercise prescription in health and rehabilitation. Honestly, many of the criticisms of physical therapy have been well earned by well-intended therapists who do their best to prescribe exercise rehabilitation while respecting some sort of perception of client fragility.
However, in my role as a researcher/educator, and co-owner of a strength and conditioning facility, I’ve recently seen a shift in this profession. No longer are we willing to accept the status quo of two pound dumbbells and red thera-band isolation exercises as our flagship methods of training. Our profession is slowly, but surely, evolving to incorporate quality strength and conditioning principles into our day to day practice and is now recognizing the value of loading-related adaptations – with outstanding results.
As an educator, though, I get frequent questions from students and new clinicians about how to make this shift, when many others in the industry are either resistant, unaware, or unwilling to do so. So, I reached out across Canada and the United States to several of my physical therapy colleagues who have demonstrated great success in paving the road to strength, to give you their insights on some key issues in making this transition.
So you want to be a hybrid physical therapist strength coach? With a sprinkling of my perspective as well, here is your how-to guide, direct from some of the industry’s elite.
What is your perspective with incorporating strength training into your physical therapy practice? Why do you practice the way you do?
For many, the answer is simple. Hybrid practitioner Dr. Jarod Hall thinks people try to make this concept too hard or foreign to PT at times. “I’m really not doing anything ground breaking in the clinic,” he says. “I just make sure to look at my patient through a lens of challenging their tissues to adapt.”
Owner of Shane Physiotherapy, Jason Shane concurs; “strength training falls under the category of building up tissue tolerance. Most injuries happen because clients’ tissue tolerance is less than the demand they are putting on said tissue. Through strength training we are able to build up their tissue tolerance to allow them to perform their activities of choice.”
Strength and conditinoing expert Dr. John Rusin reiterates this; “While passive treatments can be advantageous for getting people out of pain, especially in the early stages of recovery, our job is to prevent injuries as rehab practitioners, and the only way to do that to the best of our abilities is to load sound foundational movement patterns, period.”
This concept doesn’t just apply to injury prevention and sports, however. New Doctor of Physical Therapy (DPT) graduate, Dr. Michael Mash, had great success with incorporating strength principles into all of his clinical rotations. “My patients on the Level-1 Trauma unit were doing bodyweight squats at bedside. Those at the nursing home were doing squats in their walkers, and I was progressively loading people with free-weights at my outpatient rotations,” says Dr. Mash.
In order to do this, owner of The Lifter’s Clinic, Mario Novo suggests that we need “a foundation of sound strength and conditioning programing” to inspire clients to reveal the resilient and confident person they are. Have a look HERE at my Strength Rebels approach to adding the strength foundation to acute/long term care settings.
Senior’s health and prevention advocate, Christina Nowak, PhD(c), works with the 50+ demographic. Through her blended therapy/strength coaching practice, STAVE Off, she is a firm believer in the use of exercise, and especially strength training, for the master’s age category. “I feel like it is often under-dosed and under focused on in practice today,” she preaches. “I started practicing this way because I saw a huge amount of success with giving people an exercise program over any manual therapy particularly in my demographic. It is also the most highly validated method that physical therapists have in their tool belt so it seems just wrong not to emphasize it.”
Is strength training different than ‘muscle strengthening activities’ often written in the Therapeutic Exercise prescriptions and texts?
“I don’t see a difference between strength training and therapeutic exercise other than semantics. On a regular basis I give the same exercise, though perhaps lighter to start, to my rehab patients as I would give to the athletes I work with,” says Shane.
Mash agrees, “Strength training is a muscle strengthening activity and vice versa. However, these terms do have a stigma attached to them. Me personally, I prefer to use the phrase “strength training” as it implies a long-term, goal-driven ideology.”
Nowak does make somewhat of a distinction and believes that therapeutic exercises have a place. “I use them as accessory movements to some of my core movement patterns like squatting to get up from a chair or the burpee to be able to get up off the floor.”
Hall again believes that therapists should keep it simple. “If you apply an intervention with the focus of increasing strength and overloading tissues to adapt it is strength training. It’s that simple. Making tissues stronger in a programmed manner is strength training. It may look different for each patient and everyone won’t be using a barbell all the time. Using compound movements that don’t focus on a single muscle are usually better choices, but there can be a place for isolated single joint strengthening as well.”
As a general rule, how and when do you initiate the process of strength training in your clients?
With resounding exclamation, our panel agrees, “ASAP!”
Novo believes strength is started on day one with the removal of pain inhibiting factors through the tailored pain science education and treatment. He uses a varied approach of manual therapy modalities “to decrease the threat perception of the patient in order to modulate the perception and inhibition of muscle recruitment. This recruitment can then be explored through PNF patterns, and isometric based contractions.” Once the individual expresses full ROM and tolerance to end-range loading or functional end range loading, he will often progress into the realm of tissue specific strength which “will begin with establishing their individual tolerance to progressive loads.”
The approach I advocate and promote is similar to Mash’s: “Day one on evaluation,” he says. “If it is a lower quarter injury, I assess the squat and hip hinge pattern. If it is an upper quarter injury, I assess the overhead press pattern. Depending on what I see, I begin loading these patterns with either barbells or dumbbells as quickly as possible as long as they are not painful and there are no contraindications.”
Nowak asserts that you shouldn’t let your clients fool you. “There is SO much potential in our clients and we need to overcome any fear or engrained belief, such as “oh I’m x age I can’t do it.” This is the biggest barrier to starting strength training with my clients. The earlier I break through the better and strength training can become more of a staple in my programming.”
What’s more important: reps/sets/load or movement quality?
Unanimously, our panel answered “both”.
Dr. Rusin believes that “movement quality is more important to develop, but once that is mastered and ingrained, loading up and challenging the system from multiple different training stimuli is quite important.” This is echoed by Shane, who states, “I would much rather have a client perform 5 reps of 1 set with good movement quality than multiple sets of 10 plus reps with poor technique.”
Having said this, however, Hall cautions that we really have a tough time defining movement quality, and injury prediction is pretty dismal at this point. “There are countless anatomic difference between individuals that will influence how we each move,” he says, “and we each may be suited to excel at different movement patterns based on these simple variations. Not to mention visual detection of variations in positions as simple as pelvic tilt have shown to be quite unreliable.
Quality movement is movement that is pain free and gets the job done for the patient. I think there are more and less efficient movements for specific tasks, but really like to put a lot of emphasis on a variety of movement as well as novelty instead of “quality”.” The difference comes when the movement becomes more loaded. In this case, it is more important to follow closely to “neutral zones” in positioning, but this decision takes more clinical judgement and experience, not to mention some trial and error. Hall also believes that “being able to recognize when you’ve chosen wrong and make adjustments determines a good clinician and coach.”
How do you “sell” your approach? How do you convince clients (and colleagues) that lifting heavy (properly) is good for them? In short…… “how do we change a paradigm?”
Without a doubt, our panel believed this was the most important question for new strength therapists to address. While each of them had some excellent suggestions (which I highly suggest you read in the full transcript linked at the start of this article), the biggest advice was to “live the lifestyle”.
Therapy and your treatment methods are all about your philosophy. As Rusin so simply put it, “the sell is in the results.” Mash adds that you say something like, “You think you have trouble now picking up your kids/toys/boxes off the ground? Wait till you can deadlift 135 lbs. off the ground pain free. Suddenly picking things up off the ground become MUCH easier.”
Novo suggests you first win the patient over and not to worry about your colleagues at first. “Educate with imagery and use your body as a demonstration (this is why you need to train yourself and others first),” he emphasizes. “Provide examples that are simple and to the point. Practice the movement with them, film them, show them the differences, talk about their successful points and allow them to state the obvious flaws, provide them a frame work for the one movement to be practiced in their home program.”
So, how do we change a paradigm? We live it. We lift. We encourage our colleagues to lift. We prescribe lifting-based therapeutic movements. We make strength relevant to your, your clients’, and your colleague’s lives.
Any final advice to rehab pros or coaches who aspire to run the hybrid model?
Shane summarizes many of the answers nicely, “Number one, go lift some weights, regularly!”
Perhaps even hire a strength coach or personal trainer to start if the weight room is new to you. It’s an old phrase but one should practice what they preach.” Nowak, Mash, and Rusin all emphasize that you need to coach people with movement to develop that skill. Novo adds that you need to develop the confidence to take the risk to try this approach out. The sooner you hit the weights yourself, the sooner this will come.
Hall suggests that you get started on social media and never stop learning. Plug into a network of like-minded therapists (the author and contributors to this article would be a great start!) and bounce ideas around. I can personally attest to the power of social media networking. The path I am currently on with my research, practice, and teaching has been driven and fueled by the support I’ve received from these folk. Don’t underestimate it.
Importantly, Dr. John Rusin provides one of the biggest pieces of advice. “Follow your passion, cut out a path, and know it’s going to be a damn hard one to do what you truly think is the right thing for your clients and patients.”
Finally, my advice to you is to remember that treatment philosophy is a choice. Remember that you’re not alone and just because these methods may not have been taught in PT school, doesn’t mean they’re not tried and true. Last, remember that there is power in strength – if you lift, you’ve felt it. You know it in your soul. And that is the most important point. Believe in yourself, and your clients will too. Happy lifting, my fellow therapist and coaches!
For those interested, the unedited transcript of the interviews can be found in the form below:
About The Author
Dr. Scotty Butcher, BScPT, PhD, ACSM-RCEP is an Associate Professor in Physical Therapy at the University of Saskatchewan, co-founder of Strength Rebels, and consultant at Synergy Strength and Conditioning in Saskatoon, SK, Canada. Formerly certified as a CSCS and currently training as a powerlifter and part time CrossFitter, he has a passion for strength training and translates this to promoting quality exercise training and rehabilitation practices for clinicians and students. His focus in research, teaching, and clinical work is on the hybrid rehabilitation/strength training approach, and shares his views through blogging and vlogging. Connect with Scotty on Twitter, Facebook, and YouTube.
Michael Mash, DPT, CSCS, FMSC
Owner, Barbell Rehab
Twitter: Barbell Rehab
Mario G. Novo, DPT
Owner, Lifter’s Clinic
Facebook: The Lifters Clinic
Christina Nowak MScPT, CSCS, PhD(c)
Co-Owner, STAVE OFF
Twitter: Christina Nowak
Jason Shane MPT, B.A., FDN, IMS
Owner, Shane Physiotherapy
Facebook: Shane Physiotherapy
Jarod Hall, DPT, CSCS
Facebook: Jarod Hall
Dr. John S. Rusin, PT, DPT, CSCS, ART, FMS1-2, YBT, SFMA, FDN