When Do We Need Specific Exercises In Rehab?

                If you’ve followed the physical therapy literature over the last 5-10 years you’ll notice that more and more, the literature is challenging the longheld belief that you need to do X,Y and Z exercises to get out of pain. The ideas of “you need to activate your TVA” or “you need to get your scapula set first” are slowly (sometimes very slowly) becoming a thing of the past.

                With research like this it begs the question – do we need specific exercises in rehab? That is the topic of today’s article.

When are specific exercises needed?

Specific exercises are for specific adaptations in specific tissues and can also be influenced by your clients’ tolerances. Breaking this down by section ….

1) Specific adaptations

If your goal is to build the muscle & tendon strength necessary to withstand sprinting – doing 10 minutes of jump rope probably isn’t going to help. If your goal is to develop neuromuscular control of your knee to prevent a repeat ACL injury – doing bicep curls isn’t the best choice.

Some clients, particularly elderly and/or those with persistent pain, can be so weak and deconditioned that simple tasks like getting out of a chair can be very difficult. As much as I am all for people doing activities that they want – when you don’t have the baseline strength or mobility to do IADLS … that’s a big problem that needs to be addressed.

If your goal is to develop specific adaptations – be it strength, hypertrophy, power, endurance, mobility, and/or neuromuscular control – the exercise needs to be tailored towards that. Plain & simple.

Whether or not those adaptations are relevant to getting out of pain is up for debate as research has shown that improvements in strength, muscle timing, kinematics etc don’t always correlate with changes in clinical symptoms. I look at in terms of what the client needs from an activity demands perspective versus where they’re at.

2) Specific tissues

Over the course of the decade we’ve worked to move away from structural diagnoses – which is a much needed move for the better.

That said – some injuries, such as tendinopathies and muscle strains, do require more specific exercise to allow the area to heal, adapt & recover. Arm curls don’t do much for a hamstring strain nor does your biceps tendinopathy benefit much from calf stretches. Can general exercises help? Most definitely – but to rehabilitate the specific tissue you need specific loading.

It’s important to note that even within the category of “specific” exercises you have a large range of options to work with that can range from strengthening, mobility and neuromuscular exercise all the way to practicing the desired activity with some modifications as needed (i.e. “sprinting” with reduced speed). Again these are all based on the individual.

3) Based on your client’s specific tolerances

Sometimes, in more nociceptive presentations, people may not tolerate specific movements or postures and may tolerate others very well. In those cases, emphasizing exercises in well tolerated directions & postures is a wise decision – at least during the early stages of rehab. This is where approaches like the McGill method make a lot of sense as they take away what hurts and emphasize painfree movement & exercise.

How long painful movements are avoided, if at all, is a controversial topic that depends on numerous individual factors.

When are specific exercises not needed?

For more general pain relief where there are no major structural tissue concerns, and where there are no major physical deficits that need to be addressed, you can incorporate more general exercises and some more valued, leisurely activities such as walking, gardening, skiing, handyman work, whatever you like.

Best of both worlds

And to be honest – an ideal rehab program for most (not all) people incorporates valued activities that people enjoy & want/need to get back to as well as specific exercises to address specific physical deficits.

So there you have it – a very simple explanation of where specific and general exercises & activities fit within the scope of rehab. As always – thanks for reading.

Pain Science Education: What It Is And What It Isn't

            Over the course of this weekend two main themes filled my social media feed. The first were videos of the amazing feats of strength from the various events at the Arnold Sports Festival (side note: props to two-time Arnold Strongman Classic champ Hafthor Bjornsson as well as to powerlifting world record breakers Blaine Sumner and Stefi Cohen for their successes). The other was this study that provided a systematic review & meta-analysis on pain science education (PNE). The article showed that…

·         PNE did not significantly reduce pain or disability

·         But PNE did reduce catastrophizing and kinesiophobia

It created a lot of controversy and debate amongst therapists from different backgrounds & ideologies as well as a need for clarification as to what PNE is and isn’t – the topic of this article.

What PNE isn’t

PNE is not

1) A cure or magic bullet

As we’ve discussed above pain science education doesn’t create significant improvements in pain. This review showed a reduction in pain of 3.2/100 – less than half a point on a 0-10 pain scale.

2) A standalone intervention

Some studies have shown better effectiveness of PNE mixed with exercise versus one or the other alone. Granted this is still being studied and is still up for debate.

3) An intervention that will produce the same results in everyone

Some qualitative studies have shown that PNE can create great reductions in fear and improvements with activity in some people but can be useless or even counterproductive with others.

Side note: studies like these, plus my own experiences, are why I disagree with (well meaning but misguided) practioners who think that everyone needs PNE. As with everything else the intervention needs to be tailored to the individual.

4) The only part of biopsychosocial rehabilitation

As Jarod Hall and Sandy Hilton say “pain science should be the air you breathe” – not something you just do to people. There are many components of biopsychosocial rehab (and proper rehab in general) including

·         Simply being a good person who’s attentive, caring and is a good listener

·         Acknowledging that there are numerous contributors to the pain experience, working to address these different areas and referring out for help when needed

·         Educating people on how to get back to a lifestyle that is meaningful for them through pacing

·         Also educating people on healthy lifestyle habits

·         Experiential learning & graded exposure to activities: to me this is a great way for people to experience that hurt doesn’t equal harm and that they can likely do more than what they’re capable of

·         Getting people more physically active

·         Using positive language & self-management skills to empower the patient and build their self-efficacy

What PNE is

PNE is

1) A means to explaining the science of pain and the contributing factors behind a person’s pain

2) A means to (hopefully) decrease some of the anxiety, fear and negative beliefs surrounding pain and a means to get people more physically active & working towards the lives they want to live.

I hope this article sheds some light for you (and others) on what PNE truly is & isn’t and where it fits in the grand scheme of things. As always – thanks for reading.

Is Strength Training The Newest Fad In Sports Injury Prevention?

Image courtesy Focus Fitness

Earlier this year I watched a video on Canadian trainer Omar Isuf’s YouTube channel where he interviewed DPT and 20x world record breaking (as of the time I’m writing this) powerlifter Stefi Cohen. As a physiotherapist who competes in powerlifting Stefi is definitely someone whom I greatly idolize for her insane athletic accomplishments as well as the success she’s had getting her DPT and starting a fantastic performance gym & company with her fiancée Hayden.

            In the video Omar asked Stefi about her thoughts on strength training as a means of preventing sports injuries and Stefi discussed that it may be or may not be a fad. She also brought up the fact that we seem to shift from fad to fad with common trends (over the last 2 decades) in sports injury reduction including (but not limited to) bracing, transverse abdominnis exercises, movement screening & functional movement, workload ratio and other topics. So it raises the question – is strength training a fad in sports injury prevention?

First the term “injury prevention” is a misnomer and should be changed to sports injury reduction as we can never truly prevent injuries. There are some injuries; particularly contact injuries; that you can’t prevent no matter what – short of completely removing yourself or your athletes from the sport.

Now that that’s out of the way let’s look at the evidence ….

A 2018 systematic review and meta-analysis in the British Journal of Sports Medicine (free access link here) showed that a 10% increase in strength training volume reduced sports injury risk by 4%. It’s a heterogenous paper with many different sports & many different protocols … but it gives us something to work with.

But with this evidence comes a few caveats, one more opinion based and one more evidence based

#1: Past a certain level of strength; which is sport & athlete specific; increasing strength comes with a point of diminishing returns. The stronger you get the harder it is to get stronger; from an eating, sleeping, rehab, and recovery perspective; plus there is (in my anecdotal opinion) a higher risk of injury as you push the envelope of maximal strength. For most athletes (excluding powerlifters, Olympic lifters & strongmen); past a certain level of strength; more time could be spent improving other components of athletic performance such as speed training, conditioning, and most importantly skill work over trying to get your athletes stronger.

#2: Sports injuries are multifactorial and can be influenced by training workload (and fluctuations in workload), sleep, psychosocial factors, nutrition, genetics, previous injury, movement skill, anatomy & anthropometrics, and other factors. As such we have to take a multi-faceted approach to sports injury reduction rather than simply relying on a single cure-all. I plan to elaborate on these topics on more detail in future articles for both my site and for Mash Elite Performance.

I hope this brief article provides some food for thought on a complex and popular topic. As always – thanks for reading.

What Role Do Physiotherapists Play In Managing Psychosocial Factors?

Over the course of the decade we’ve seen a shift in physiotherapy practice guidelines from a focus solely on tissue and biomechanics to looking at biological, psychological and social factors as part of the individuals’ pain and disease experiences. While many are slow to adopt these new guidelines the shift is encouraging.

The increasing focus on psychosocial factors begs the question; especially for those of us who aren’t trained psychologists, psychotherapists, or psychiatrists; “where does the line get drawn and what’s our role in managing psychosocial factors in our patients?”

Getting something important out of the way first

Regardless of whether you’re a medical or rehab professional working with diseased and/or pained populations, or a strength coach working with high performance athletes, psychology feeds into everything you do whether it’s motivating a client for behaviour change or helping an athlete achieve peak performance. What we do does not operate in vacuums and almost always has both physiological and psychological effects.

Where our boundaries lie in managing psychosocial factors

This is going to be controversial, but I partially disagree with the opinion of some people that I’ve seen (no names mentioned) post in threads on social media that state that we should be directly managing psychosocial factors in our patients and that our scope of practice should be expanded.

The reason is … as physiotherapists we are responsible for a ton of information and skills when it comes to assessing, diagnosing and treating musculoskeletal, cardiopulmonary, neurological and systemic conditions. I’m of the belief that you can be good at anything but you can’t be good at everything (to quote Stan Efferding). I don’t know of anyone who’s great at nutrition, strength sports, orthopedic physical therapy, pediatrics and the like all at the same time. Doing 8-10 years of post-undergraduate schooling; along with tons of post graduate courses & continuing education; to excel at both physical therapy and psychology is both expensive, unhealthy and impractical in my opinion. That’s where you network with other professionals and refer out as needed.

I think we would overstep our boundaries if we

1) Diagnose mental health conditions: Just as we can’t diagnose cancer or infections or heart issues as physios (at least in Canada) we shouldn’t try to diagnose PTSD, OCD or other mental health conditions. We just need to recognize the symptoms and refer out.

2) Try to treat psychosocial factors that aren’t related to pain, injury, movement, or activity: We aren’t trained to grief counsel a mother who’s lost her kid and we aren’t trained to treat the PTSD of someone who has been sexually assaulted. That ain’t our skillset and just as we get POed when a trainer tries to be a therapist we shouldn’t try to be a psychiatrist if it’s something outside of our ballpark.

Where can we help with managing psychosocial factors?

We can help our patients with psychosocial factors by

1) Finding ways to help get them active: Exercise can help for chronic pain and for mental health conditions

Image courtesy Focus Fitness

2) Educating our patients on the importance of sleep hygiene: Given how poor sleep can be a contributor to (and result of) pain and mental health issues we’d be remised if we didn’t discuss this (and ways to improve it) with our clients.

3) Quite simply being a good person to be with: I open any (non WSIB specialty) assessment with “tell me your story.” This allows patients to say what they need to say and helps them get whatever they need to get off their chest – which can be therapeutic in and of itself. There’s a lot to be said; especially in chronic cases where a client may have been mistreated by employers, coworkers, family members and/or friends; for being the first “good guy” they talk to and by being attentive & caring.

4) Helping to decrease anxieties and unhelpful beliefs regarding pain, injury, and activity: Educating patients on the many factors involved in pain & hurt versus harm; as well as gradually increasing your client’s tolerance to both feared & desired activities (barring any medical or orthopedic contraindications); can be helpful in improving the function & well being of your clients.

5) And obviously referring out as needed

So, in a nutshell, that’s where the role of physiotherapists is in managing the psychosocial factors of patients. Not everyone’s gonna agree with me but that’s my opinion and as always – thanks for reading.

Case Study: How I Rehabbed My Own Knees

In today’s article I take you through a case study. Because of rules set by our regulatory body, The College of Physiotherapists of Ontario, I cannot give specific confidential details of any patients I have formally treated. However, I can and will share my own story of how I rehabilitated my own knees.

                Before we get started – from January 10^th to the 13^th I will be taking part in Travis Mash’s “Feats Of Strength” online meet (link here to register) to help raise money for his weightlifting team and to get back into the mindset of competing after a year long hiatus. Check out the link to compete or at least make a donation to Coach Travis Mash’s non-profit weightlifting team.

I developed patellofemoral pain a few years back during my days as a runner which carried over into the beginning of my powerlifting career. Unfortunately, this was compounded by getting some bad advice from other professionals (which I’ll elaborate on). In this piece I share my story of how I, as a powerlifter and physical therapist, returned to painfree squatting and running.  

Disclaimer: I’m a N=1. Pain can be influenced by numerous factors so as such this is strictly anecdotal. Also this is not intended to be specific medical advice for anyone else.

My rehab plan came down to the following components which form my philosophy.

1) Minimize what worsens symptoms

2) Find well tolerated movement & move … a lot

3) Address maladaptive beliefs, psychosocial factors, and general health factors

4) Eventually build up tolerance to the desired activity

Going through these step by step

1) Minimize what worsens symptoms

The McGill and McKenzie influenced therapist in me looks at what movements, postures, and loads exacerbate symptoms … and what are tolerated. For me running and deep squatting past a certain weight were what caused problems. As such I removed the running (which partly came due to my injury and partly due to me beginning powerlifting) and set all squatting weights below a weight & depth threshold that caused pain

In certain rehab situations, which I’ll write about in another article, sometimes painful exercises are supported in the literature. That said, I’m not a fan of pain during high skill strength, speed and power activities (in most situations) due to the negative effects of pain on motor control. Also, while some research supports painful exercises in PFPS I’ve found it not to work to my liking for me or my patients.

Which brings me to

2) Find well tolerated movement & move a lot

When I work with physically active clients I do my best to find painfree exercises that they can do in their own exercise routines to help with maintaining (and if possible improving) mobility & fitness and to help with not making the rehab process seem boring.

For me – I could tolerate hip dominant exercises such as good mornings, swings, deadlift variations, GHRs and leg curls. Low impact conditioning options such as the rower, sled pushes/pulls and the recumbent bike were the main tools I used to help with cardiovascular fitness and GPP. I also regularly performed the McGill Big 3 and weighted carries.

Quad/knee dominant training was more difficult as most every exercise that involved a lot of deep knee flexion initially bothered my knees. The way I beat this was through three steps.

First was through doing 20-rep sets of leg presses (with a neutral spine), leg extensions, and walking lunges. I got this idea after watching one of Stan Efferding’s videos & reading his Vertical Diet package. The leg presses & lunges were initially done with a more vertical shin angle and then were progressed to deeper levels of knee flexion as my tolerance improved. My best explanations for how these worked can be attributed to a combination of

-          Simply lighter weight & load being used

-          The novelty of the stimulus: if you’re used to doing sets of 1-5 in your training like a powerlifter doing sets of 20 rep leg presses with a 90-120 second rest between sets definitely provides a new stimulus. As a side note it can provide a good training stimulus if you’re just looking for something different.

-          Increased blood flow & post-exercise analgesia from the higher reps & volume used

-          And the other components of any treatment that can affect recovery such as patient expectations, natural recovery etc etc

Second was through very high volume warmups. I got this idea from Matt Wenning and other proponents of conjugate training but had gotten away from it recently. In my high volume warmups for leg days I would do

-          Recumbent bike for 5 minutes

-          The McGill Big 3

-          2 (and later 3) sets of 20 of leg curls and leg presses using a weight that was just heavy enough to give me a “pump” at the end of the sets

While this style of warmup added a good 8-10 minutes to my training session, and took a few weeks of adjustment from a recovery perspective, the results were well worth it. I got my heart rate up & got a good leg pump, snuck in some extra volume to help with hypertrophy & work capacity, and my knees were a lot less stiff when I began to warm up for squats with the empty bar.

Third was through building up squat tolerance (more on that below).

3) Address maladaptive beliefs, psychosocial factors & general health factors

At the time I initially developed patellofemoral pain we didn’t have the same understanding of pain science that we do now. As such I believed that all pain was due to tissue damage and I felt like “oh I have cartilage damage I’m just going to wear my knees out.” As such I initially, permanently avoided everything that hurted. While my knees became painfree with 99% of tasks the fitness wasn’t where I wanted it to be & I still couldn’t tolerate deep squatting. Once I realized the adaptive capability of my body and used a graded exposure approach to build my squat tolerance … while training what I could do to build my fitness … things took off.

In terms of psychosocial factors I had some stress and depression as I battled to get to and through physiotherapy school & the board exams. I have elaborated on these in a separate article but that’s as open as I want to be about this topic for the time being.

In terms of general health – due to the above factors (and getting sick) I ended up gaining a bunch of excess body weight. Reducing body weight through initially a IIFYM diet and later through Stan’s Vertical Diet helped a lot with sleep, knee health, and overall well being.

4) Building up tolerance to the desired activity

While I was grateful for the positive effect of all these painfree exercises – I realized that at some point I need to build myself back into squatting if I wanted to do full powerlifting meets again. I was nervous and realized that I protected myself a lot when descending in the squat as I was anticipating the pain + guarding. My squat descent was initially so slow it looked like I was in a multi-ply squat suit and had the tightest pair of briefs & knee wraps imaginable on.

Towards that end I realized that I, psychologically, needed to get out of my own head and get back to my usual “dive bomb” style of squatting – which I did initially beginning with body weight squats. Once I hit this stage – getting psychologically confident with squatting plus doing the 20 rep sets of quad dominant exercises got my knees painfree.

Then I realized it was time to add load. I squatted twice a week – once with knee sleeves & a belt and the other without equipment after deadlifting. I stuck to Prilepin’s Chart to get in volume while emphasizing proper technique. Over time I got to the stage where I could work up to a 3RM squat without pain.

As of now my strength is still not where I want it to be but it is building up fast.

Again, I’m just a N=1 but I hope this helps provide some insight into what I did to rehab my knees. If you have any questions DM me or message me at ericccbowman90@gmail.com. And as always – thanks for reading.

My 2018 In Review: Top Things I Learned + My Top 5 Most Viewed Articles Of 2018

2018, especially its Fall, was an exciting time for me. I’m grateful for all the people who I’ve met and talked to over the past year through working at Altum Health, SWIS, taking the Canadian Powerlifting Union Coaching Certification, guest lecturing at UW and becoming a writer for Mash Elite Performance. Thank you all.

Through all the excitements and highlights of 2018 I’ve learned quite a few things, some of which the hard way, that I’d like to share in the final article of 2018.

Side note: This does not include anything that I learned at SWIS 2018 as that would basically involve regurgitating another article that I have written here.

1) You may not always get all of your patients’ psychosocial factors on Day 1

In my career I’ve worked hard to gain a complete understanding of my patients’ psychosocial factors through subjective history, questionnairres such as the Orebro Questionnaire and just good interviewing skills.

I’ve had a few experiences this past year with patients where patients didn’t open up about various psychosocial issues, stressors or traumatic events until a few weeks (or even a few months) into therapy.

When you think about it – it seems like common sense. You wouldn’t tell a random dude on the street your most personal secrets on the first day … so as such I (and you) need to not assume that we’ve detected all of a patients’ psychosocial factors on Day 1.

This shows the importance of

-          Taking your time

-          Listening to the patient’s story

-          Validating their story

-          And just being an overall good person to build that rapport with your patients

2) Core exercises & core stiffness may not be a bad thing (at least for a short time period) in certain people with LBP

With some of the research that’s came out showing that core exercises are equal to (or maybe slightly better than) general exercise for LBP – many practitioners wonder why we even bother with them.

However in some LBP cases, to paraphrase a quote from Greg Lehman, people may be aggravated by specific movements/postures/or loads in a more “nociceptive” manner. These are the cases most people refer to when using terms like “flexion intolerant,” “extension intolerant,” and others. While we know back pain can’t be attributed to just mechanical factors – sometimes a person’s movement or posture can make a big difference on their individual symptom presentation.

In these populations I do believe there is a place for McGill-esque core exercises, if anything else, to teach them the control required to move in a way that doesn’t aggravate the problem. This is where approaches like McGill and McKenzie make a ton of sense – you move and exercise in a way that doesn’t exacerbate the symptoms long term.

 That said

-          You don’t want to have people avoid movements forever and/or walk like Tin Man from The Wizard Of Oz

-          For some people other factors (i.e. stress, poor sleep, fear of movement) may be bigger drivers of your clients’ sensitivity. In those situations I care less about “core stiffening” and more about managing these other issues.

3) You’re never gonna please everyone

Having worked at a couple different clinics, and having talked to many different clinic owners, I’ve learned that … you’re never gonna please everyone whether its patients or other physios.

Some want more manual therapy … some want less. Some want more exercise … some want less. Some want more education … others want less talking more doing. Some want more modalities … some want less.

At the end of the day you can’t please everyone. That said – it is important to ask patients (and clinic owners if you’re searching for a job) what their expectations are.

Therapy shouldn’t be a dictatorship but there has to be some give and take on both ends.

While I’m not a huge modality guy – if doing 5 minutes of ultrasound gets a patient to do everything I need them to do – I’ll take that tradeoff. That said if a patient doesn’t want to follow any of my recommendations outside of the clinic and just wants me to “fix” them – then we have problems and have some work to do.

I’m also more OK now with just letting the occasional patient go rather than feeling like I have to excessively bend over backwards to please everyone when I know it’s not in their best interest.

4) Don’t be intimidated by fibromyalgia & chronic pain diagnoses

This came partly through my last job at Impact Physiotherapy & Performance but was more solidified through my current job at Altum Health in Cambridge, Ontario, Canada. Approximately 80% or more of my caseload is people with persistent pain.

I, like most physios at some point, got intimidated by these more complex and more irritable cases & was more cautious with them. While you have to be careful to not flare them up – quite often many people, even those with chronic pain, are capable of more than we realize and a process of starting super slow and building up gradually can (in my experience) provide great benefits for fitness, mobility & health.

That said, as I said above, there are some patients that will be flared up regardless of how gentle you proceed with things. Again these people likely need more help in other areas (i.e. psychosocial factors, sleep management) to help with decreasing pain.

5) How great vacations are … when you actually take them

2018 was the first year out of physio school where I took all of my vacation days. Some of these were spent with family & friends and some were spent travelling across Ontario. As much as I enjoy working hard it’s great to take some restorative time and to catch up with friends – something that gets neglected in the pursuit of selfish goals.

 6) Sometimes you just gotta say “no” and set boundaries

Having a lot of great professional opportunities can be both a blessing and a curse. It’s a blessing in the sense that people value your work & your opinion – plus some of these come with financial benefit. But it can also be a curse as it’s very easy to get overloaded & overburdened.

Over the course of this year I’ve had to, for the sake of my own mental sanity & energy levels, say no to some big opportunities with some big names in the field. As someone who wants to help as many people as possible – that hurt. But it was something I had to do to take care of myself first.

Below is a list of my five most viewed articles of 2018 on this site….

5 – Barriers To Exercise In People With Chronic Health Conditions

4 – How I Assess & Treat People With Low Back Pain: Parts 1 and 2

3 – My Journey With A Learning Disability, Anxiety and Depression: Finding Strength & Confidence – I wrote this article in honour of #bellletstalkday and had no idea how well it would be received. Thank you.

2 – The McGill Method: Common Misconceptions – Co-authored with Dr. Stuart McGill

1 – An Evidence & Experience Based Critique Of The McKenzie Method (MDT)

I wish you all a Merry Christmas and a fun, safe and happy holiday season with friends & family. Thanks for reading and I will see you in 2019!!!

Do I Need A Strength & Conditioning Certification As A Physiotherapist And If So Which One Should I Take?

                Over the last couple weeks I’ve gotten several messages in my Messenger inbox and I’ve also seen several social media posts discussing whether or not physiotherapists should get involved in strength training clients and discussing which certifications to get. The past decade has seen a huge increase in “hybrid” physiotherapists & strength coaches and while it’s great to see people that can take clients from in pain to high performance it begs the question – do all physiotherapists need S&C certifications and if so what route to take?

                The answer is, to quote my friend and mentor Stuart McGill, “it depends.” It depends on…

1) The demographic you want to work with

This is the biggest decision-maker. If you work in pediatrics – good luck getting them into strength training. If you work in ICU, or acute care in general, spending a lot of money on a strength & conditioning certification probably won’t offer the same return on investment as courses & education more tailored to that setting. Same goes for pelvic health physiotherapy.

When it comes to neuro rehab it’s a grayer area as it depends on how well functioning your clients are. If many of your clients have at least Grade 3/5 muscle strength than hell yes it’s worthwhile to know this stuff. If many of your clients tend to be more flaccid and lack that strength than learning more neuro-rehab specific techniques is likely a better use of your time & effort. As Stan Efferding said “you can be good at anything but you can’t be good at everything.”

If you work in orthopedics in a more general population setting I don’t believe a S&C certification is essential although it can be helpful if you have athletes and/or lifting junkies come through the door on occasion. That said I do believe a basic knowledge of exercise prescription is essential for all physios in any setting.

The biggest populations where having a personal training or strength coaching certification can be helpful are

- When working with chronic disease populations such as osteoarthritis, osteoporosis, cancer, diabetes, heart disease and/or lung disease due to the number of safety precautions and rules that you have to be aware of.

At UW KINNection 2018 where many Kinesiology students get their first experience making exercise programs for people with chronic diseases.

- The big one … if you work in a clinic with athletes and/or people who love weight training. This is self-explanatory as you need to, to do your job effectively, have the knowledge to transition those clients from pain & potentially very remedial levels of exercise to being able to do high performance movements such as lifting, sprinting, jumping, and potentially throwing based on their activities.

This may seem like common sense but, as strength coach Trevor Cottrell said, a lot of physios don’t know strength training and athletics & spend more time strengthening their clients’ glute med than they do physically preparing them to withstand the demands of athletic + strength training endeavours. It’s as big of an injustice to underload and underprepare someone and put them through “rehab purgatory” just prior to returning them to sport as it is to overload them.

Under Trevor Cottrell's coaching earlier this year at the Intro To Olympic Lifting course at The Vault Barbell Club

2) If you need it for a job

Some clinics, particularly sport rehab clinics or clinics in a gym, will require you or recommend you have a strength coaching or personal training certification.

So now to the second part of the article … which certification should I take?

Option #1: I work with elderly and/or diseased populations

In that case the best certifications are the CSEP (in Canada) or ACSM (in the US) Exercise Physiologist certifications. I do believe you should spend a fair amount of time working with those populations, under the direction of someone highly qualified, before working with that population on your own as there is great potential to help people but also great potential for harm if things are done incorrectly.

The GLAD (GoodLife with osteoArthritis in Denmark) courses done worldwide are fantastic for understanding lower body exercise prescription, not just for osteoarthritis, but in general.

BoneFit, done by Osteoporosis Canada in Canada, is quite useful as well.

Option #2: I work with athletes and/or weight training clients

CSCS is the most popular one that people go with. That said there are a couple holes that CSCS, in my opinion, leaves uncovered which are

-          Understanding how to coach, program and progress speed movements (I.e. sprinting & jumping): I recommend Joe DeFranco, Lee Taft, and Nick Winkelman’s work as resources for speed training as this is essential for returning team sport athletes to sport after certain injuries (i.e. ACL tear, hamstring strain)

-          Understanding how to coach and modify the powerlifts for clients: I did the Canadian Powerlifting Union Coaching Certification this year and found it insanely valuable. It was probably the best training related certification I’ve done specifically on the powerlifts.

At the CPU Coaching Certification earlier this year at The Vault Barbell Club

As with Option 2 – you still need to, in my opinion, spend time working with these populations under the supervision of a qualified coach before working with these populations on your own. That’s why, despite my certification, I don’t call myself a powerlifting coach.

Bonus: Who are good people to learn from?

People that I recommend other physios learn from in regards to strength training are

Physiotherapists: Scotty Butcher, Charlie Weingroff, Stefi Cohen, John Rusin, Dani LaMartina (Overcash), Christina Prevett (Nowak), Michael Mash, Zach Long … and myself.

Strength Coaches: Nick Winkelman, Brian Carroll, Chris Duffin, Travis Mash, Meghan Callaway, Mike Boyle, Eric Cressey, Mike Robertson.

I hope this article provided some useful advice and guidance and I hope you will share it with other physiotherapists & physiotherapy students who may have the same question. As always – thanks for reading.