Here’s What You Need To Know…
1. Fluffy functional training with little scientific or anecdotal backing has a limited role in a physical therapists patient care, but seems to be the most popular use of “therapeutic exercise” prescription in the industry.
2. Thinking that principles of strength and conditioning no not apply to the rehabilitation setting is foolish. Physical therapists should start studying the foundations of strength and how to properly implement these strategies if they want to see marked and sustainable results for their patients.
3. While making up theoretical functional training exercises with no rhyme, reason or rationale is inherently easier for physical therapists than emphasizing foundational movement patterns and strengthening them, the lack of long term carry over into function speaks for itself.
4. Physical therapists need to be better than the theraband, better than 3 sets of 10 for every exercise a patient completes, and absolutely better than our low level industry standard. It’s time the profession of physical therapy starts learning from the strength coaches and personal trainers.
Why Physical Therapists Suck at Prescribing Exercise
Exercise sequencing is something that absolutely dominates the strength and conditioning world. Strength and conditioning professionals constantly think over their programming. Am I working for strength? Am I working for hypertrophy? Am I working for power? What is my daily and weekly volume? How should I structure to optimize rest and allow for maximal muscle recruitment and stimulation for my desired outcomes?
Are their programming ideas and methods always the best? Is anyone’s actually the best? Probably not, but there is still plenty of research to be done to help us redefine what is the best, and no, it’s not functional training just in case you were wondering. Additionally, what the best is will vary from individual to individual and be based on desired goals. Never less, I have a lot of respect for the detailed thought that good strength and conditioning coaches put into trying to achieve optimal programming for themselves and their clients.
On the other hand, working in the physical therapy world for the last few years has shown me how little thought A LOT, but not all, physical therapists put into programming their rehab exercises. I see so many therapists that don’t seem to care what exercise their patient starts on, the sequence of subsequent exercises, have a goal with exercise dosing, or even at what point they do manual if it’s a part of the treatment program.
Do physical therapists patients tend to get better? Sure they do, but quite a lot of conditions get better over time without any sort of intervention at all. We should be striving to get people better faster, and even improve their function to a higher level than it was before they came to see us.
Just so you know this, the picture below is what pops up into google when you type in “strength training in physical therapy” for images. This is just downright disgraceful for physical therapists. Let’s work on changing that people, shall we?
For some reason we, as physical therapists, seem to get into the mentality that rehab and strength and conditioning are mutually exclusive. We forget that muscles are muscles and they respond to stress. We forget that there are certain principles that work more effectively for specific outcomes like strength, endurance, and skill refinement. I personally even remember one of my clinical instructor laughing at and demeaning my background and credential as a Certified Strength and Conditioning Specialist (CSCS). He made sure to let me know it wasn’t going to do anything for me in my practice and that principles don’t apply to people in rehab.
Well Dr. CI, PT, DPT, OCS; after a couple years of growth and practice I couldn’t disagree more. Sequencing of exercise and treatment interventions can have a huge impact in physical therapy. Purposeful selection of exercise type, volume, and intensity can also be extremely valuable components of a well-designed rehab program. In this particular post, I want to spend time focusing just on exercise sequence so it doesn’t turn into a 20,000 word beat down to read.
Many people would argue that these principles only matter and are applicable in your athletic population. I however, strongly disagree. I’d like to go step by step through a couple of real life outpatient orthopedic cases to demonstrate how you can and take your treatment effectiveness and critical thinking to the next level.
Case #1 The Geriatric Lower Back Pain Patient
In front of you sits a 70 year old sweet little lady with non-specific back pain, decreased balance, difficultly arising from low surfaces, and a history of falls. How are we going to use strength and conditioning principles and strategic exercise sequencing with her?
Well for starters, we have excellent research that repetitively shows cardiovascular exercise often has very positive effects for pain inhibition and increased pain pressure thresholds. However, it should be noted that most often at least 10 mins at 50% VO2 max is necessary to stimulate analgesia. This is why I try to get almost every single patient of mine on a walking/cardio home exercise regimen if possible.
Some people would say that if you start most patients in your physical therapy clinic on a piece of cardio equipment you are just running a mill. I call total BS on this. Even if all you are doing is warming up, you are going to help tissue extensibility and the subsequent metabolic processes of exercise. Sure, if you have people barely peddling along with no resistance on the bike then you probably aren’t getting much done.
My rule is that people have to start sweating and be huffing a little before they can be done warming up and get into exercise. I’ll argue all day long that 8-15 mins on the bike is a hell of a lot more beneficial than walking straight in to lay on a hot pack while doing transversus abdominis hollowing for 10 minutes. Heat doesn’t even penetrate deeper than about a 2cm tissue depth anyway. I’m glad you just increased blood flow to the skin and subcutaneous tissues, but exercise is going to increase blood flow to a greater degree than any modality you can employ (fancy manual techniques included).
We know that 70 year old Mrs. Jones here has a history of falls and lower extremity weakness due to her reported poor ability to sit to stand. Recent research has shown that as individuals age they dramatically lose their ability to produce power and also that increasing power may be an effective method to aid in decreasing falls. Don’t believe me here’s five references for starters (ref, ref, ref, ref, ref, ref).
Strength and conditioning (can be found in the NSCAs Guide to program design) principles traditionally state that power exercises should be performed first/early in a workout because they are explosive and draining. Power has a time component to it. Essentially, how fast you can move the most amount of weight. Obviously when an individual falls the quicker and more strongly they can generate a compensatory righting reaction/catch themselves the less likelihood they have of going down. Ergo, increase power to decrease risk of falls. Common ways I work on power production are explosive sit to stands from a challenging height, explosive step ups, sport cord resisted fast paced walking, and even shuttle jumps with partial body weight.
After power exercises we may work more on strength with deadlifts and teaching a hip hinge, reverse slide lunges with hand held assist, Swiss ball wall squats for quad focus, weighted bridges, heel raises, Swiss ball hamstring curls, tall step ups, etc.
Next, you could work on mobility and movement exploration activities to decrease fear of spinal movement and improve mobility. Cat-camels, prayer stretches, prone on elbows, segmental spinal flexion activities, side glides, self thoracic extension mobilizations over a foam roller, trunk rotations, etc.
Finally, you could end by focusing on reactive postural control with perturbations or narrow base of support ball tossing activities. Doing this at the end of treatment may mimic fatigue states in which the patient has been ambulating in the community and is that a higher risk of falls. Conversely, if the patient had no focal weakness you would start and focus the bulk of your session on varying challenging balance tasks as this will have greater carry over because it is skill focused practice.
Case #2 Middle Aged Chronic Shoulder Pain Patient
A second example to demonstrate thoughtful exercise sequencing can be demonstrated in Larry. Larry is a 52 year old male with right sided sub-acromial pain that started roughly a month ago while playing tennis. Upon examination you notice that Larry is mildly weak and painful in all planes of shoulder movement but most notably external rotation. You assume he has posterior cuff dysfunction based on your exam and consequently altered control and RTC recruitment due to pain (ref, ref). Additionally, he has limited thoracic spine extension as well as mild glenohumeral internal rotation deficit (GIRD) likely due to his long history of overhead activities in tennis.
I’m a big believer in performing your manual techniques early on in treatments sessions to allow for decreased threat perception and subsequently pain to allow for improved completion of more active strategies like exercise. Matthew Danzinger has written an outstanding article called manual therapies make space that explains this in more depth. This is an excellent post that I strongly recommend checking out.
Since Larry has an acutely painful shoulder, ideally you want to decrease guarding first. We know that tendinitis/osis issues tend to feel better when they’re warmed up, so you start Larry for 8-15 mins on the elliptical to get a slight sweat and gentle non painful or threatening cyclic shoulder movement. To further decrease his pain you strategically decide to perform manual therapy interventions first. You apply gentle soft tissue work to the posterior cuff, PROM with a posterior humeral glide, supine thoracic HVLAT to upper and mid thoracic levels, rhythmic stabilization drills at varying shoulder elevations as well as in quadruped to improve RTC firing. Next, you follow this with strong gripping to further enhance recruitment of the RTC in a non-painful manner.
Now Larry can perform resisted external rotation, modified push-ups, protracted wall slides, and resisted scaption without pain in order to load the tendons to stimulate healing as well as generate improvements in strength. Had you jumped straight into these exercises it may have been painful for Larry, and you wouldn’t have gotten nearly as far as fast.
At this point, Larry’s shoulder is good and warm and a cross body stretch to target the posterior shoulder capsule/soft tissue structures and aid in the improvement of his GIRD may be an effective choice. Side note- I personally do not like the sleeper stretch at all. It directly mimics the Hawkins-Kennedy test position which is one of the most sensitive special tests for shoulder pain provocation we have. Why do we want to make this an exercise? Getting back on track, you may decide to follow up with thoracic rotation and extension drills to improve his movement patterns in his overhead tennis swings.
As time progresses and Larry’s shoulder becomes less acutely painful, you decrease the amount of repetitions and increase the weight to further stimulate strength gains in the target tissues. Twenty five reps for repeated rotator cuff activation becomes 10 to 15 reps for strength gains, and modified push-ups become good form full push-ups, overhead presses, and bear crawls.
Putting The Strength Back Into Physical Therapy Programming
I know you’re thinking; “this sounds great and you make some good points, but sometimes in a busy clinic this just isn’t feasible Jarod”. I agree it can be difficult, but I’m going to offer some ways to help you manage this.
- Try to do multi-joint exercises, and do them first.
- Have patients warm up. Physical therapists need to realize that the therapeutic process can sometimes be hard work. It shouldn’t be a day at the spa with steam towels, hot packs, e-stim, and magic sound wands.
- Build your flow sheet in the order you want to do exercises. I use an EMR system that allows me to constantly reorder the flow of exercises. I’ve trained my techs to help me order my flow sheet at we work with patients.
- Use a lot less 3 sets of 10 in which all 30 reps can be done in one set, and use a lot more 3 sets until muscle burn/fatigue.
- Train your patients to help let you know when they do hit their target rep count and their muscle no longer feels tired with it. For example, when I have a patient with shoulder pain and RTC weakness I may ask them to do seated external rotation with elbow propped on their knee to get the shoulder at 90 degrees flexion but still supply some degree of outside support with the knee. They are midway through their rehab and we have started focusing more on strength. They started with a 3lb dumbbell hitting fatigue at 15 reps. I let them know as soon as they can do 15 reps and it feels like they could easily do 5 more to let me know because it’s time to move up in weight. Make the clinic environment one of constant progression and overload and help your patients to understand how important those principles are to their recovery.
- Try to do manual first if it’s in the patient’s treatment program.
- Don’t make them do the same exercises in clinic that they are doing at home except for checking their form and determining if progressions need to be made. This will give you more time to work on progression in clinic.
- Instead of writing continue plan of care at the end of your note maybe try jotting down what specific exercises or domains (strength, power, control, etc) you want to focus on next treatment as a reminder.
Time For Physical Therapists To Start Respecting Strength
I hope you can see how important critical thinking and clinical decision making can be in building the program you prescribe to your patients. Remember that exercise is medicine, and it’s the dose and timing makes the medicine effective. You have powerful prescriptive authority, and it’s your job to determine what the effective dose it.
About The Author
Dr. Jarod Hall, PT, DPT, CSCS is a physical therapist in Fort Worth, TX. His clinical focus is orthopedics with an emphasis on spinal manipulation, therapeutic neuroscience education, dry needling, and purposeful selection and implementation of the foundational principles of exercise the management of both chronic pain and athletic injuries. Dr. Hall is also an adjunct assistant faculty at the UNTHSC DPT program lecturing and instructing in the assessment and treatment of orthopedic injuries, pain sciences, and manual therapy. Dr. Hall regularly presents continuing education at the state and national level for practicing physical therapists. Additionally, Dr. Hall is an internationally recognized blogger, whose work has focused on how to succeed in the clinical environment as a new grad, debunking common exercise and rehab myths, manual therapy, and pain science.