The Rehab Renaissance: The Good, the Bad, and Where We Can Improve in Bridging The Gap Between Rehab and Training

                Earlier today I read a post by Nick Tumminello where he shared a link to a book entitled “The End of Physiotherapy” and discussed some of the fallacies trainers make by looking up to therapists. It made me think – where have we gone wrong in this bridging of the rehab & fitness worlds?

                As a Physiotherapist who does exercise programming for people with chronic conditions and some sports rehab, does some fitness consulting on the side, and competes in powerlifting … I’ve seen, worked with, and/or learned from all sides of the rehab & fitness continuum from people who can barely squat out of a chair to people who can squat over a grand. While I’m excited to see rehab & fitness professionals learning from each other this “Rehab Renaissance” (to quote Craig Liebenson) has its pitfalls which I will discuss in this article.

At a Push/Pull/225 Bench for Reps at a seminar with Stan "the Rhino" Efferding. 

Disclaimer: For simplicity’s sake, I am painting rehab & fitness professionals with a broad brush. There are people in both circles that do and don’t do some of the things that I’ve mentioned below so I apologize if it sounds like I’m stereotyping.

The Good: Bridging the rehab & fitness worlds has created a great knowledge boom in many ways…

I’ve often said – I’ve learned more about exercise coaching, cueing, progressing, regressing & modifying from personal trainers and strength coaches than I have from most PTs & DCs. It’s a sad state as many of the educational systems focus too much on manual therapy & modalities and not enough on exercise (I am working on that) so I, and many other rehab professionals, look to fitness professionals for guidance in that avenue.

In addition strength coaches are the foremost experts in building their clients’ fitness in order to enable them to tolerate & perform well at their desired sports. Learning how to progress someone in end stage rehab towards a desired sport is a must if you’re a therapist who works in orthopedics & sports rehab.

Conversely you have fitness professionals learning how to improve mobility & movement from rehab professionals. You can debate about the FMS all you want – but it’s got people looking at movement, how to assess it and how to improve it. While I disagree with the idea that there’s one right way to move, you gotta admit that it’s pretty tough to give someone a well rounded exercise program when they’re new to exercising and their hips, shoulders, knees & ankles are stiff as boards. Yes mobility work does get taken WAY too far (and I will write about this in a separate article) but an increased focus on mobility & movement, compared to what we’ve done in the past, isn’t a bad thing.

Lastly trainers have learned a lot from rehab professionals & biomechanists on how to modify exercise programs for people in pain – which isn’t a bad thing but can have issues as I describe below.

The Bad: this shift has also brought some less than desirable changes to our fields including

1) The biggest issue: managing people away from load

The over-cautiousness by some (not all) rehab professionals and the trainers that learn from them has lead to a “rehab purgatory” (to quote John Rusin and Craig Liebenson) where many trainers & therapists fall too far in the direction of trying to optimize every little movement, posture and muscle activation detail before ever loading someone & working the client towards the activities that are meaningful for them. This is problematic – especially for fitness clients who want to lose weight, look better, feel better & be healthier … not score a 21 on a FMS. Same goes for physical therapy clients who want to be able to go out for a walk in the mountains and don’t care about having perfect TVA activation or scapulohumeral rhythm.

Don’t get me wrong – as I’ve written about before some biomechanical variables matter a lot and can benefit from specific exercises & attention but one of the biggest biomechanical variables that needs to be managed is load. As Tim Gabbett said – methodically building the client’s workload tolerance to prepare them for their desired activities is one of the best things we can do for them.

2) Rehab & fitness professionals overemphasizing each others techniques and using questionable practices

On one end you see trainers doing a lot of corrective exercises to “treat” pain & dysfunction (and even some doing manual therapy) whereas on the other side you see therapists doing a lot of strength training movements with clients who aren’t athletes or gym junkies.

In physical therapy strength training (not referring to basic rehab exercise) has a place such as

-          In improving the health & function of people with chronic diseases and

-          In returning clients with pain to sports and/or the weight room

But I’d be wrong if I said that everyone in pain just needs to lift big weights and everything will sort itself out. Sometimes patients can’t do these exercises due to pain or a mobility limitation …. or its just not plain in line with their goals.

Side note: when working on this piece I was reminded by some words of wisdom from Jason Silvernail. While we are quick to criticize our own fields many (if not all) interventions by rehab professionals have a better risk/benefit ratio than opioids, unnecessary medical imaging, and many common orthopedic surgeries.

Regarding trainers & corrective exercise – some of the research done on the FMS as well as Hewett’s ACL research has shown that changes in “movement quality” are more due to changes in body awareness & motor control and less due to fixing tight, weak, immobile, or unstable joints & muscles. Sometimes correctives have their place – such as if someone can’t deadlift with a neutral spine due to super tight hips – but in many cases I believe exercise technique can be changed by simple coaching & cueing. Also a lot of the pseudobiomechanical variables that trainers (and therapists) try to assess & correct either can’t be reliably assessed and/or don’t correlate well with pain.

Manual therapy is not as high skill a technique as many therapists would like you to think but it does need to be done safely and I get concerned when I see trainers stretching clients far more forcefully than I (at 255 lbs) ever would.

Which brings me to …

3) Overstepping scope of practice

My biggest concern, on both ends, with the Rehab Renaissance is when personal trainers try to be physiotherapists & when therapists try to be strength coaches.

I have nothing wrong with fit pros working with people with pain but as Charlie Weingroff said

-          The client needs to be assessed to rule out medical issues AND

-          Trainers don’t treat pain, they don’t diagnose, they don’t treat the neck and they don’t do manual therapy

I’ve heard stories of personal training clients who had pain secondary to serious medical conditions that weren’t detected in time as the trainers tried to treat pain without referring out. In my experience in Intensive Care Unit I saw patients who didn’t have red flags detected until it was too late. You don’t want that happening to you.

As Greg Lehman said – the most important part of a physiotherapy assessment is to make sure pain is the problem, not pain secondary to something sinister.

On the flipside I do see therapists try to be wannabe strength coaches, which can also be dangerous if the lifts aren’t coached and programmed effectively, but to me that’s a much smaller issue than the other way around.

How we can improve: as with all my articles I like to offer some positive suggestions to improve the rehab & fitness fields. That comes in large part for mastering “the basics.” We know through the training & rehab research that

-          Well tolerated movement, exercise & physical activity are good and important

-          Activity should be progressed in a methodical way (i.e. Tim Gabbett style) to build up people’s activity tolerance while minimizing injury risk

-          Having good physical and psychosocial health (i.e. healthy body weight, proper sleep, minimizing stress) are huge

-          And that having positive beliefs about the body, whether you’re a high performance athlete and/or someone trying to get out of pain, are critical

These should form the framework for what we do regardless of whether you’re a rehab or fitness professional.

I hope this article has given you some thoughts on the Rehab Renaissance and where it can go from here.

On December 4^th I will be posting my last article of the year before the XMas/New Year’s break.

McGill Big 3 For Special Populations

By Eric Bowman in consultation with Dr. Stuart McGill

The original article was published for PT Perspectives on January 28, 2014.

If you have been around the rehabilitation or functional training world over the last three decades you’ve likely heard of the name Stuart McGill. Dr. McGill is a Professor Emeritus in Spine Biomechanics at the University of Waterloo who has authored the popular books “Low Back Disorders” and “Ultimate Back Fitness and Performance” together with several hundred peer-reviewed journal papers documenting research findings. In addition, he sees patients with painful backs ranging from everyday people to elite athletes.

The McGill Big Three core exercises have become popular with clinicians and personal trainers as they train the core muscles while providing less stress on the lumbar spine in comparison to traditional exercises such as situps, reverse hypers, and leg raises (1,2). While those exercises aren’t necessarily evil and can be applied & programmed properly many elderly people suffer from osteoporosis – a decrease in bone density predisposing people to fracture. Biomechanics research has shown us that osteoporotic vertebrae are more likely to fracture under end range, loaded, repetitive spinal flexion (3).

Here is a video of the McGill Big 3 (along with Stir The Pot) in their basic forms. Each exercise has progressions and regressions that are described in more detail in his books.

http://www.youtube.com/watch?v=kukmaW9CmSU

As with any training system or exercise, the McGill Big 3 must be tweaked to suit the needs of the individual. Elderly clients have other health conditions that must be accounted for when designing a training program.

Having worked with seniors who have cardiovascular disease, osteoporosis, and other conditions; I’ve developed some modifications to the McGill Big Three that are addressed in this article.

Concern #1: Hypertension

In many individuals blood pressure rises with age and isometric exercise is known to elevate blood pressure (4). For some individuals, a 10 second hold of a core exercise may rise blood pressure to levels of concern.

Solution: Do less more often. Instead of doing five reps of 10 seconds each, do more reps with shorter holds (e.g. 3-5 seconds).

Concern #2: Osteoarthritis

Osteoarthritis is one of the most common musculoskeletal conditions in the elderly (5).

Exercises such as the birddog aren’t always tolerated by seniors due to the kneeling position required to perform them. Kneeling is a risk factor for osteoarthritis (6,7) and some people with osteoarthritis experience pain when kneeling (8).

Solution: Perform the birddog standing against the wall, on a comfortable yoga mat, or supported by a chair. Be careful when coaching this exercise to ensure that the hips are extending and that the lumbar spine remains in a neutral position. To progress this exercise you can narrow the base of support and then add perturbations from the trainer/therapist.

Concern #3: Balance disorders

As we age our balance and proprioceptive abilities decrease, increasing our risk of falls (9). A fall in the elderly has a higher two year mortality rate than everything except for the death of a spouse (10).

I’ve dealt with trainers and Kinesiologists who shy away from the birddog and other core exercises for fear that they would lead to a fall. In reality these exercises just need to be modified a little bit.

Solution #1: Regressions

As outlined in Low Back Disorders, the birddog can be regressed in two ways. The first is to have the client extend either an arm or a leg (not both) and the second is to have the client lift one hand up a few inches and hold it in that position (1).

Solution #2: Gain a more stable base

Doing planks, side planks, and/or birddogs against the wall or against a stable chair can be a safer option for some individuals.

Concern #4: Cardiac Insufficiency

Supine exercise has been shown to decrease cardiac output (11,12). For individuals with angina, congestive heart failure, or other cardiovascular conditions; the curl-up may not be appropriate.

Solution: Switch to a front plank and have the client perform the exercise against a wall.

I hope this article gives you some thoughts as to how I modify Dr. McGill’s exercises for the populations I work with.

REFERENCES

1.       McGill, S.M. (2007). Low back disorders: Evidence-based prevention and rehabilitation (2^nd ed.). United States of America: Human Kinetics

2.       McGill, S.M. (2009). Ultimate back fitness and performance (4^th ed.). Waterloo, ON: Backfitpro Inc.

3.       Maquer G, Schwiedrzik J, Huber G, Morlock MM, Zysset PK. Compressive strength of elderly vertebrae is reduced by disc degeneration and additional flexion. J Mech Behav Biomed Mater. 2015 Feb;42:54-66. doi: 10.1016/j.jmbbm.2014.10.016. Epub 2014 Nov 11.

4.       Chrysant, S.G. (2010, September). Current evidence on the hemodynamic and blood pressure effects of isometric exercise in normotensive and hypertensive persons. J Clin Hypertens (Greenwich), 12(9), 721-726. doi: 10.1111/j.1751-7176.2010.00328.x.

5.       Michael, J.W., Schlüter-Brust, K.U., & Eysel, P. (2010, March 5). The epidemiology, etiology, diagnosis, and treatment of osteoarthritis of the knee. Dtsch Arztebl Int, 107(9), 152-162. doi: 10.3238/arztebl.2010.0152

6.       Fransen, M., Agaliotis, M., Bridgett, L., & Mackey, M.G. (2011, February). Hip and knee pain: role of occupational factors. Best Pract Res Clin Rheumatol, 25(1), 81-101. doi: 10.1016/j.berh.2011.01.012.

7.       Cozzensa da Silva, M., Fassa, A.G., Rodrigues Domingues, M., & Kriebel, D. (2007, August). Knee pain and associated occupational factors: a systematic review. Cad Saude Publica, 23(8), 1763-1775. Retrieved from http://www.scielosp.org.proxy1.lib.uwo.ca/scielo.php?script=sci_pdf&pid=S0102-311X2007000800003&lng=en&nrm=iso&tlng=pt

8.       Hassaballa, M.A., Porteous, A.J., Newman, J.H., & Rogers, C.A. (2003, June). Can knees kneel? Kneeling ability after total, unicompartmental and patellofemoral knee arthroplasty. Knee, 10(2), 155-160.

9.       Sturnieks, D.L., St George, R., & Lord, S.R. (2008, December). Balance disorders in the elderly. Neurophysiol Clin, 38(6), 467-478. doi: 10.1016/j.neucli.2008.09.001.

10.   Liebenson, C. (2013, October 3). Training the frontal plane by Craig Liebenson. Retrieved from http://www.youtube.com/watch?v=uVADBwPpzgk

11.   Cotsamire, D.L., Sullivan, M.J., Bashore, T.M., & Leier, C.V. (1987, March). Position as a variable for cardiovascular responses during exercise. Clin Cardiol, 10(3), 137-142.

12.   Takahashi, T., Okada, A., Saitoh, T., Hayano, J., & Miyamoto, Y. (2000, February). Difference in human cardiovascular response between upright and supine recovery from upright cycle exercise. Eur J Appl Physiol, 81(3), 233-239. 

What role do breathing exercises play in orthopedic rehab and in strength training?

                It seems like breathing is once again a hotly debated topic in the rehab & fitness worlds. Some think that breathing exercises are the greatest thing since sliced bread while others think they’re useless. My brilliant colleague Roderick Henderson posted a great video on the topic in early August and in this article I will give what I feel to be a balanced perspective on the topic.

Disclaimer: I will not be discussing breathing for people with cardiopulmonary disease in this piece – that’s another topic for another time.

Side note: as I was working on this article my brilliant colleague Adam Meakins put out a great article on breathing as well. If you haven’t read his opinion piece than give it a read.

                Believe it or not – I do see some useful applications for breathing exercises such as

1) A relaxation/recovery technique either as part of a post-workout cooldown and/or for a separate recovery session

2) To change patterns that are associated with pain

Anecdotally I have heard of people with rib and/or low back pain that find certain breathing techniques more or less comfortable than others. Anecdotally some people I work with who have rib pain find diaphragmatic breathing more comfortable than chest breathing. Some people I work with who have back pain that’s aggravated by extension find breathing more comfortable when emphasizing a 360 degree expansion of their belly (see video here by Chris Duffin for the technique https://www.youtube.com/watch?v=IZDVHVohtmE).

In those populations I have no problem with changing someone’s breathing technique to give them a way to breathe that’s more comfortable for them.

Side note: changes in pain with treatment can be due to a variety of factors so the caveat is that we have to be careful not to attribute changes in pain to changing a “breathing dysfunction¹.”

Side note #2: If you are a rehab professional who is working with a person who has pain with a given breathing technique you need to be cognizant to rule out any major orthopedic or medical issues that may be causing these problems including (but not limited to) a rib fracture or cancer. If you are a fitness professional DO NOT try to diagnose this stuff and please refer to a qualified professional – preferably one who understands lifting, pain science, and the biopsychosocial model. If you have trouble finding a good PT in your area that appreciates training message me – I’ll help you out as best I can.

3) To improve performance and/or comfort in a given exercise

If changing a person’s breathing patterns improves performance and/or comfort in a given exercise be it a squat, a deadlift, or an aerobic exercise session I have no problem with that.

In my article on core stability I discussed how bracing can be overdone and is only really relevant if you’re doing strength training or are in a lifting competition. This is more anecdotal than research based but I don’t know of any strength athlete/strength enthusiast that feels they can lift more in a relaxed state than in a “braced” state. For info on specific breathing & bracing technique I’m a big fan of Brian Carroll and Chris Duffin’s work.

Where we go wrong is

1) Assuming everyone in pain is in pain due to a breathing dysfunction and assuming that fixing people’s dysfunctions will cure everyone’s pain. Also the idea of a “breathing dysfunction” is problematic and without a definition as breathing, as is the case with many other movement variables, has a wide variation of “normal.”

2) Spending anymore than a few minutes of a personal training/S&C session on breathing when that time can be spent on more productive things.

So in summary there’s nothing wrong with giving people breathing exercises to help find less painful ways to breathe and/or improve exercise performance … assuming major pathology is ruled out. But understand that they’re not a panacea for everything and everyone.

Reference

1.          Hartman SE. Why do ineffective treatments seem helpful? A brief review. Chiropr Osteopat. 2009;17:10. doi:10.1186/1746-1340-17-10.

A Short List Of Truths About Persistent Pain Rehabilitation - For you, the patient

I was honoured when my good friend, colleague and former University of Waterloo & Western University classmate Nick Hannah (Facebook, YouTube, Instagram) asked me to help write an article with him on the truths of rehabilitating people with persistent pain. I've attached a link to the article here. I hope you read it, enjoy it and will share it.