Wednesday 22 November 2017

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.

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


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