Do Physios suck at exercise prescription?
I just put out a Movement Optimism Podcast on whether Physios suck at exercise prescription. It is in response to a trend over the past few years where I hear physios/rehab pros being criticized. The criticism is that Physios don’t understand the basics of Strength and Conditioning and that if they knew these better they would get better results with their patients.
From putting this out there and the discussion that ensued you could see a lot of misunderstanding of my points and a lot “talking around each other”. And I’ll admit that a lot of that miscommunication was my fault.
It’s hard to define the terms “S&C basics”. And to talk about this I would have to hear specific claims that detail exactly how physios are lacking. I could only go on the examples I have heard through the years. So, I will try to address what I have heard and add some nuance to my posts.
My contention was:
1. Physios do know the basics of S & C.
2. However, the basics of S&C are often not relevant for a number of rehab scenarios
3. A physio rehab program might be negative judged because it doesn’t meet an arbitrary standard of what a good S&C program is even though those standards could be inaccurate.
This is where I have heard that physios are lacking. Some of this feels like people consider S&C to merely be lifting heavy loads with your traditional lifts (squats, deadlifts etc) or primarily gym based resistance exercises with traditional rep ranges. Let’s go through some of the arguments/ideas here.
1. Physios don’t know the basics of S&C
This is actually a very difficult question to answer but I challenge the idea that they don’t know these things in two ways:
a. I’ve taught 1000s of physios and a huge part of my course is exercise prescription for athletic injuries. The vast majority of people in the course do a great job at creating good exercise based rehab programs. They develop specific attributes (strength, power, tendon stiffness) and seem able to progress and regress exercise.
b. My physio training had the basics of S&C (at least my interpretation of the basics).
However, these basics probably wouldn’t have satisfied what people consider the basics. We weren’t taught how to teach the deadlift, or how to squat with a heavy barbell. We didn’t not go into the details of periodization or go down the rabbit holes of the repetition range continuum (although when you do you realize how easy it is to prescribe exercise).
However, we would do a task analysis of what someone had trouble doing. If someone had difficulty getting out of bed, had limitations in a sit to stand, slow gait etc we would certainly design activity based rehab programs that used sit to stand, gait modifications/prescription or getting up and down from various heights. There would certainly be squatting and lunging in there. That to me is strength and conditioning. And that is good rehab. Were we taking people in to the gym and doing deadlifts or dumb bell split squats? No. So, if you consider that barbell/dumbbell based approach superior than you could negatively judge what physios do. But, I reject that.
2. Physios are told they underload people and 3 sets of 10 sucks.
I’ve heard physios told numerous times that there rehab is inferior because they use intermediate loading (8-12 reps). They are told it is inferior for strength gains, function and therefore pain and recovery. This is the physio/exercise pro who thinks they have some advanced knowledge about S&C and that people need to load 5x5s to get stronger. Again, I reject that and so is the S&C literature. 3 sets of 10 can absolutely get people better.
Related, is the idea that a number of conditions (Patellofemoral pain, Knee OA, GTPS, low back pain) need heavy loading. And that low load exercises or interventions (stretching, Glute bridges, Manual Therapy) are inferior for pain and function. Again, I reject this even though I like to load people with these conditions heavy. Its my style but I don’t think I get to shit on others. Because these issues are often PAIN problems. It’s the pain that corrupts the function not the other way around. Meaning lots of different movements and exercises can help with pain which will in turn help with function. This well laid out in Jared Powell’s paper here. We also see this with the knee OA literature where strength gains don’t seem to mediate recovery (here) and heavy loading doesn’t outperform low loading (link here).
3. But Gregrrr, what about function? Why are you caught up on pain. We do so much more than pain and S&C is needed.
Yes, agreed. That’s why I’m not saying S&C is irrelevant. But, S&C principles are more than just heavy barbell or gym based programs. Rehab is more than just following traditional strength training programs. If you have someone struggling with walking up stairs then your rehab program can simply have people walk upstairs. You just dose this appropriately. You don’t need to get caught up in some 5x5 program. That person could also benefit from boring old hip bridges, clamshells and yellow theraband hip abduction exercise.
Now, would that routine be great for a 17 year old, who fractured her tibia and is returning to Volleyball. Well, maybe initially but we would of course progress that. And traditional S&C resistance training, a jump program, plyos/hops would certainly be indicated.
Because S&C is absolutely important.
I don’t think our biggest issue is people not knowing these basics. The issue is our clinical decision making knowing when are the basics of a traditional heavy loading /gym based program needed for recovery. When are the development of specific attributes needed for recovery. These are the questions we want to ask.
Because when they aren’t needed it means we have more options.
4. Gregio, lots of physios don’t feel like they can teach resistance exercise.
Sure. That’s fine. I know people feel that way and this is why I support my friends at CALU and my buddies at Barbell Medicine. Resistance training/gym based exercise is absolutely helpful for both health, longevity, aging and rehabbing a number of specific conditions.
And it’s certainly an option for a number of conditions that other options would also be helpful for. This approach has great side effects and its why I support it.
But, it is way simpler than you think. And what I again reject is people who try to make it out to be difficult with a small bandwidth of how you can prescribe these exercises.
To reiterate, where the discussion should go is asking when are these specific exercises or traditional S&C resistance programs absolutely needed for rehab recovery. I think you’ll find that its not as often as you think and we might negatively judge the rehab programs of our Physio Phriends far too soon than what is deserved
I hope this clears things up. Probably not though.