In reading and coming across different information and opinions, I find that taking some time to read, think it over, and process the information before conveying my own opinions seems to work best for me, and allows me to be more objective and less emotion-based. That being said, I received an interesting email a few days ago from the American Academy of Manipulative Therapy (AAMT), since I am on their email list and working through their course offerings. The email was a blog post titled "APTA's Vision 2020: Was it abandoned in 2013?" It's a fairly short read and was nice to see someone else connecting the same dots.
If you are not familiar with the original 'Vision 2020' check out the post referenced above. My initial reaction to the new-and-improved updated statement was "Good Lord, how are they going to build public awareness by utilizing a more vague and vanilla vision statement?" The answer it seems, is that they are not. Building public perceptions regarding Physical Therapy - What it is, What we do, Who & What we are capable of treating - seems to very much lay in the lap of each individual Physical Therapist. This is a double-edged sword, and a tangent to the original motivation for this post, so perhaps more on that later!
Anyway, the AAMT email was timely because I had just spent the previous few minutes reading another blog post entitled "Are Physical Therapists Really Frauds?" This was a recent post by Dr. Scotty Butcher, Assistant Professor at the University of Saskatchewan and co-owner of BOSS Strength Institute, and was in response to an article written by Mark Rippetoe a while back. This was good read for me because it brings to light a few problems that exist within both fields of Physical Therapy and Strength & Conditioning. While Rippetoe's article can be viewed as fairly inflammatory and the short-sightedness of some of his thoughts are readily apparent, he does bring out a few good points that the Physical Therapy profession should take note of and take to heart. If you haven't read his original article, it's worth taking a look at.
I also want to clarify that Rip is an expert in his craft, and my intention is not to disagree with or discredit what he is saying. When I say some of his thoughts are short-sighted, I mean that there is no context to some of the statements.
Here's what I don't like about his stance:
Let's start with the car analogy he opens with. Certainly focusing on one part of a car, in his analogy the alternator, without the rest of the car makes that particular piece useless. But on the flip side - you don't tune up a car by simply revving the engine and ramping up the RPM's for a period of time with the breaks on. Saying just load the system and the system will figure it out doesn't always work. It may if your client is an athlete or power-lifter, but odds are that person's system is finding pathways for compensation versus strengthening and engaging the areas of weakness.
His discussion also does not take into account the presence of pain and the neurophysiological changes that have been well documented in the literature. Pain is a game changer. It affects the body's ability to recruit muscles and use motor patterns. It changes the biochemical & hormone profile in the system. If pain is present, simply loading the system and using a "Suck it up Buttercup, You're just weak" attitude won't get it done. This has been well explained in models like the FMS / SFMA where pain is it's own bucket, and is deemed a medical problem warranting medical assessment and treatment.
The other part of the article that is short sighted is the apparent view and assumption that "All PT's are created equal." Despite him giving credit to a "Better than average DPT" who's qouted stating a verbatem comment that I was taught over 10 years ago by a pretty fanstastic PT in the Pilates world, it seems there is this idea that all PT's use tiny correctives with small weights and are heavily based on passive modalities like E-stim, heat, cold, ultrasound, etc. There sad reality is that this is the prevalent view of what PT is and all that it has to offer. And you can thank the 'Big Box,' high volume, insurance-based clinics that accept shitty contracts for $25 per visit and drive volume to make up the difference for this phenomena. The truer reality is that there are quite a number of Physical Therapist who care about what they do, use methods and modalities that are effective and result in actual improvements that push their patients into a post-PT strength & conditioning program.
In his article he asks: "Why do the arbiters of all things exercise – the members of the physical therapy profession – insist that injuries must be rehabbed in a way that's completely different from the way that the uninjured component functions?
Why must they divide the body into its constituent components, figure out a way to make that isolated component function all by itself, and then base their rehabilitation exercises on this faulty analysis?"
I agree with the idea that we should thing systems not individual components, the answer comes in a lot of ways. Let's take low back pain. Is the answer to just teach them how to properly squat and dead lift, just go heavier & heavier, and eventually the person will get strong and the back won't hurt anymore? Eh, Maybe. Or, perhaps you will instead drive that client to get a hip replaced sooner because their back hurts because the hip doesn't move properly. I have seen many clients who's back pain resolved once we teach them how to move from their hips, maintain positioning of lumbar spine and pelvis, intervene with manual therapy focused on the hip, and then once they are pain-free work on loading the system in a way that I think Rip may approve of.
But here's the thing -- If we don't break down those pieces, we don't ever see where the dysfunction lies. If you don't know what's at fault, how are you going to intervene? I think there is danger in saying "Just get strong" at all cost without first going through the steps necessary to allow getting strong to happen in a way that won't be detrimental to the system. Perhaps I am being short sighted in assuming Rippetoe isn't evaluating in this way, but based on his original article, I feel that's a fair trade off.
Here's what I do like, and clearly you will see that, in as much as my initial tone seems down on Rip's article, there is more that I like than that I dislike:
The article brings to light a large disparity that exists between what physiologically & functionally makes sense, and what is sometimes done in the clinic. Too often PT, from an exercise standpoint, is very rudimentary and basic. I had a conversation a while back where the comment was made that "Corrective exercise should be must that -- corrective. It should make the desired change quickly, and we should be then moving on accordingly." This makes total sense to me. If you are doing the same corrective exercises with the intention of rehabbing an issue, I would venture to say you're either not hitting the root cause of the issue, or you are not progressing to the next phase of what is needed for long lasting change to take place. This does not apply to correctives that are used within a dynamic warm up, or as a maintenance/recovery program to keep your body tuned up, as I believe this is a different intention.
Traditionally PT never gets to the heavy lifting. Too often we see Outpatient physical therapy clinics who do not have a dumbbell over 12#. They have no cable columns. They have no barbells or kettlebells. They don't do body weight training beyond supine bridging, prone extension, quadruped, or the occasional front or side plank on a plinth...yet they advertise and promote specialties in Sports Medicine. How do the athletes get back to playing and ready to take on the stresses of their sport given all they have had is manual therapy, heat/ice, E-stim, and a few basic theraband exercises?
The answer too often is -- They Don't.
Not that they don't return to sport, they just usually see a personal trainer or strength coach who works to make up the difference. Why is this? Well, physical therapy is too often controlled by the insurance carrier. If the athlete has full range of motion, is mostly pain-free, and is deemed to have "good 5/5 strength" by means of crappy break testing, then they are discharged. At that point the physical therapist's hands are tied and the patient is discharged. Being in a non-traditional setting, this is not the norm for out athletes. We are able to intervene to get them out of pain, work to improve the things that require improvement -- soft tissue mobility, joint mobility, neuromuscular control, etc. and the work on reloading the system through strength training. Or, in cases where they have Strength & Conditioning and Skills Coaches, we can work with those professionals in a team approach to fill in the gaps.
I also do like the awareness brought to the idea that muscles work in systems and subsystems, not just in individual isolation. The rotator cuff and hip rotators do much more than rotate the shoulder and hip. How often are you training the stabilizing functions of these muscles as opposed to just concentrically & eccentrically loading them?
Last bit -- I believe that pointing out problems without proposing solutions is really just complaining. Rather than just pointing out the issues seen within the physical therapy profession, it would have been nice to see some suggestions beyond garbage advise like "Think twice before you listen to a physical therapist or rely on his weenie "corrective" exercises" or "You know how to get strong, so stop taking the easy way out and justifying it with big words and questionable science." I'd rather build bridges between professions than walls, but I'm sure that kind of thing doesn't get as may Facebook likes or T-Nation Article views. Inflammatory titles and bold claims get readers and keep attention. Hopefully if you're still here by now, I've managed to do a bit of both. My suggestion is two-fold:
1) Physical Therapists need to get better at strength training and building true strength versus just neuromuscular adaptations. This is certainly limited by time frames and insurance restrictions, which leads to the next point,
2) The Physical Therapy profession at large needs to do a better job of breaking insurance carrier control over care, and improve the public awareness about what we do and how well we often can do it -- provided of course, that it is being done well, and too often it's not.
3) The Personal Training and Strength & Conditioning world needs to be able to identify quality Physical Therapists and other medical professionals who speak their language to build working relationships with. There certainly is a ton of benefit that can be gained by both partied and their clients when the two disciplines work together
In summary, the Physical Therapy profession is in an interesting place, at least in the arenas of Outpatient Orthopedics and Sports Medicine, which is where much of this conversation applies. As health insurance costs rise, patient's out of pocket responsibilities rise, the pressure will be put on the Physical Therapist to be able to make effective, lasting change quickly. The consumer will demand it, and the system is rapidly evolving.
A recent systematic review by Ojha et al. found that a lack of public awareness and limited third party reimbursement were the two primary barriers preventing physical therapists from seeing patients directly without referral by a medical physician. In short, the public doesn’t know what physical therapists treat or how we go about treating it.
Athletes Physiotherapy - Las Vegas, NV
Kristopher Bosch, PT, DPT, ATC, FAAOMPT is a practicing physical therapist and athletic trainer in Las Vegas, NV where he founded Athletes Physiotherapy. Located in Henderson, Athletes Physiotherapy specializes in Orthopedic & Sports Physical Therapy with a niche in High Performance.
Thank you for stopping by the Athletes Physiotherapy Blog! Kristopher Bosch founded Athletes Physiotherapy in Las Vegas, NV. He is a Father, physical therapist, athletic trainer, pilates teacher, & perpetual student!
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