Strength coaches are not physical therapists and that is a good thing
Unpopular Opinion – Sometimes lighthearted and sometimes serious commentary on issues surrounding strength training, physical fitness, and culture.
Strength coaches are not physical therapists, which can be to the benefit of the client. Of similar vein, many strength coaches have begun to blur the lines and practice as poorly educated physical therapists, much to the harm of the client. This article will explore my issues with the practice of physical therapy and conversely my issues with strength coaches acting as pseudo physical therapists.
The profession of physical therapy traditionally works with injured and ill persons for the purposes of restoring baseline function and reducing pain. While there are individuals out there that are highly educated and incredibly effective, the majority of physical therapists are woefully inadequate at performing the task. There ineffectiveness is multi-factorial.
My primary concern is the complete disregard for the importance of strength and strength endurance in a rehabilitation setting. One of the main issues with injury is a loss of functionality of the given tissue that is injured. In a sense the tissue is weak, creating disability. The logical modality of treatment would be to give the tissue an appropriate challenge in a manner consistent with its function. Upon successful completion and recovery from the stress, a slightly greater challenge must be applied to cause further adaptation. Instead what I typically witness is the application of a variety of novel exercises with isolated load to the injured tissue. Once the client has achieved a satisfactory movement pattern a different stimulus is added. Once the client can perform a checklist of movements they are “cured.”
In this manner physical therapy is crossfit ultra-light. Since motor learning is a quick process, constantly varying movements makes clients feel like they are making rapid progress. However, any real progress made is mostly by chance or simply a factor of time. Instead focus on a small subset of movements pertinent to the function of the tissue and apply progressive overload.
What is the physical therapist to do once the client is moving without pain or disability? Typically discharge. Essentially the client is being discharged in a state of health similar or worse than before the injury occurred. The client may very well have some additional knowledge of movement prevention strategies but without an additional resilience. This is where the strength coach shines. Once the tissue can manage load, a strength coach can guide the client in gaining strength and strength endurance. With increased strength comes injury resilience and greater function then before the injury.
My secondary issue is the utilization of exercises that isolate the injured tissue from its surrounding components. Having issues with knee extension? Let’s perform band resisted or machine guided knee extension. How often do humans actually perform knee extension in isolation? As often as someone makes them do silly exercises. Is it so unreasonable to perform squats or squat variants? The injured tissue must be utilized in a manner consistent with its function, within the system it functions in order to create appreciable benefit.
This issue often stems from a lack of education, ironic given physical therapists are highly educated. Strength training movements are simply not part of the curriculum. Many physical therapists will exit school without the knowledge of how to properly perform a squat. Isolation and machine guided movements are simply easier and faster to teach.
The last issue I want to discuss is the obsession with muscles not firing. I had a physical therapist tell me that my glutes were not firing and were weak. I had pulled a 650 deadlift the week before. Someone please explain to me how one of the strongest hip extensors is absent in a heavy deadlift. Weak in comparison to another muscle group maybe? But actually weak… I don’t think so. Muscles do not simply forget how to work and stop firing. If a muscle group is contributing poorly to a movement perhaps it is simply unused and weak? Attempting to flex the muscle in isolation outside of its intended function, such as in the individual erector muscles of the back, currently has no merit.
Now let’s pick on strength coaches. Many strength coaches are poorly educated babysitters who lead clients from one machine to the next. They do not know there gluteus maximus from there epicondyles. At best they waste client’s time, at worst they cause injury. I witnessed a “strength coach” performing weighted sit-ups with a 70+ year old back pain patient. Thankfully unlike physical therapist our insurance does not dictate that we stay within a system and can easily seek alternative. Do your homework before selecting a coach!
Alternatively there are simply many strength coaches practicing outside of their scope of practice and have pushed into pseudo-physical therapy. These coaches perform with the same flaws as the average physical therapists but without the formal education. These coaches seek out the injured and disabled intentionally but lack the necessary skills to not hurt them. Remember that the primary role of the strength coach is strength. Navigating injuries is an extremely useful skill but treatment is not our primary role.
A subset of these coaches even practice manual therapies. Please make sure your fully understand the training and education of your coach before ever letting them place their hands on you. They may very well be illegally practicing outside of their scope of practice and can cause real harm. If someone wants to adjust, massage, or place a heavy weighted object on you and roll it around, be very skeptical. And strength coaches, stop doing this. You are not skilled in manual therapy because someone "taught" you how to put a chunk of metal on someone and roll it around.
And then there are the functional movement coaches obsessed with movement quality who forgot the importance of strength. Spending 50 minutes doing powerlifting yoga and practicing slightly loaded movements on unstable surfaces is simply a waste of time. This group of people has forgotten that movement quality is not independent of strength. If your warmup and mobility work is anywhere near the amount of time spent getting strong, find someone else.
The truth is physical therapists and strength coaches should exist on a continuum with overlap. Good physical therapists should be the experts in treating injured and debilitated clients while also being concerned about creating strength and resiliency. Good strength coaches should be capable of navigating injury and be experts in creating strength. Strength coaches should have a network of physical therapists and vice versa.
My final takeaways are this:
Do not assume a doctoral degree assures that a physical therapist is competent.
Do not assume that certifications or popularity speak to the competence of a strength coach.
Be skeptical of the strength coach that wants to put his hands on you.
Therefore know who you are hiring and what you are hiring them for. Think critically and seek out the best.
And finally; stress injured tissue in appropriate amounts, in a manner consistent with its function, within the system it will be utilized.