What They Don’t Teach You in Physical Therapy School

Strategic Integration: Elevating Physical Therapy with Strength and Conditioning Principles

Physical therapy and strength and conditioning have traditionally been viewed as distinct entities, each with its own set of goals and methods. However, a growing body of evidence suggests that the gap between rehabilitation and training isn't as wide as it may seem. In fact, bridging this gap through the integration of strength and conditioning principles into rehabilitation programs can lead to more comprehensive and effective outcomes.

At the heart of this integration lie the basic principles of training, and the concept of periodization, a systematic approach to training that involves planned variations in intensity, volume, and specificity. While both are commonly associated with sports training, the principles are equally applicable to the field of physical therapy. It is all too common for physical therapists to tell a patient they need to stretch more, give them 3 sets of 10 repetitions with a TheraBand, and then put e-stim on the painful joint. The body needs movement, load, and challenge to overcome pain and injury. By strategically manipulating training variables, therapists can tailor rehabilitation programs to meet individual needs, ensuring a gradual and progressive return to optimal function.

To understand and implement periodization, the basic principles of training must be well understood:

1. Progressive overload

One of the fundamental principles of training is progressive overload. This concept involves gradually increasing the amount of weight you lift over time. The key is to keep challenging your muscles beyond their current capabilities to stimulate the change you are trying to achieve. Stress is required for adaptation.

2. The exercise does not determine the adaptation; application determines the adaptation

Application of an exercise is referring to how the exercise is dosed; the frequency (number of strength training sessions per week), intensity (external resistance), and volume (number of sets and repetitions) are what drive change. You could do the perfect exercise to make your biceps get bigger, but if you don’t choose the correct load, sets, repetitions, and frequency, very little change will occur.

3. There are no good or bad exercises, there is only good or bad application

A deadlift is not a dangerous exercise; a deadlift itself does not cause injury. What causes injury is poor technique or too much frequency, intensity, or volume. The user application is what makes it good or bad, not the exercise itself.

4. Move all the joints through their full range of motion

Whether you are trying to make a muscle bigger (hypertrophy) or a movement stronger (strength), you will see greater gains with a larger range of motion.

Rehabilitation

As stated earlier, body needs movement, load, and challenge to overcome pain and injury. However, when dealing with an unhealthy tissue in rehabilitation, it is not always feasible to move through the full range of motion initially. The most obvious example is post operatively, when weightbearing and range of motion restrictions are present. Another example is if a movement is painful through the full range, or if there are significant mobility or stability limitations that make it difficult to achieve full range of motion safely. But if a movement is painful or difficult, stopping the movement completely is not the solution. Instead, back down to just below the threshold that causes pain to improve tissue tolerance and desensitization. See the article Squats and Sprints which talks about utilizing other movements or partial range while developing the requisite mobility and stability to perform the desired movement safely. See my previous article Enhancing Athletic Potential which explains how to use corrective exercises to improve movement quality. Once the tissue is healthy, pain levels are low, and post operative restrictions are lifted, then the goal transitions from improving tissue health to improving tissue performance. This is when strength and condition principles are of utmost importance.

Let's delve into practical examples of how the integration of strength and conditioning principles can be seamlessly woven into a rehabilitation program.

Endurance

Increasing muscular endurance is typically the goal of the first phase of rehabilitation, particularly post operatively. If your goal is to increase muscular endurance, the exercise choice would be body weight or an active range of motion exercise, and the intensity would be light resistance. You would need to do 15 or more repetitions, and 2-3 sets with a short rest break of less than 30 seconds. Some examples would be body weight squats, or a push up variation.

Hypertrophy

Increasing the size of muscles (hypertrophy), is a very common goal of rehabilitation. Hypertrophy is always a goal post operatively, or in the case of chronic avoidance due to pain, fear, or having never regained proper function of a muscle or joint after a past injury. To increase the size of a muscle the exercise choice should be an exercise that can be done through the joints full range of motion and should target a specific muscle. In the rehabilitation setting where someone has had an injury or surgery that results in atrophy or poor neurological connection, an isolation exercise is needed to avoid compensations for the muscle that has poor tissue health. In healthy individuals where the goal is tissue performance, multi-joint exercises are effective at producing hypertrophy. The intensity for increasing hypertrophy can range from 30-70% of a 1 repetition maximum, and the repetitions typically range from 8-15, but you must train to or close to muscle failure. In other words, each set should be completed until you could only perform 1-2 more repetitions until failure. To increase the size of a particular muscle, you must perform 20-25 working sets per muscle per week, with 2 minutes rest between working sets. The sets can be divided up however you like throughout the week. Moreover, time under tension (TUT) – the total time your muscles are under strain during a set - can help elicit greater muscle growth. This can be achieved by controlled eccentric (lowering) and concentric (lifting) phases via tempos such as taking 2-3 seconds to lower and lift the weight.

Here are 3 questions to ask yourself to know if you are properly training for hypertrophy:

1. Can you feel the muscle contract during the exercise?

2. Do you have a big pump after?

3. Are you a little sore the next day?

Overall, the key to hypertrophy training is challenge individual muscles with high volume!

Strength

The key to strength training, however, is to move weight with high intensity (load). The exercise choice for strength must also be an exercise that can be done through the joints full range of motion, but strength training is more about moving more weight instead of targeting a specific muscle. For example, a deadlift will get you stronger than a hamstring curl, because you can do much more weight on a deadlift. The intensity for strength training is at or above 85% of your one repetition maximum. The volume is simple: 3-5 repetitions, 3-5 working sets, 3-5 minutes rest. Strength training should be done 3-5 times per week. Therefore, in a rehabilitation setting it is inaccurate to tell a patient they are strengthening their muscles if you are not meeting these parameters. If the external load is not heavy and the repetitions being done are much more than 5, you are likely improving muscle endurance or hypertrophy, not strength.

Speed / Power

If you are working with athletes in rehabilitation, once the muscles are the same size and have reached the strength goal you determined appropriate, then the focus shifts to speed and power. The exercise choice should be something that can be done fast! The intensity will be between 30-70% of the one repetition maximum. And the volume is the same as strength: 3-5 repetitions, 3-5 working sets, 3-5 minutes rest, 3-5 times per week. When training for speed and power, the intent to move fast is just as important at the movement itself – you should be exerting maximum effort to move as quickly as possible. This goal needs to be communicated to achieve the best results.

Integrating Domains

The integration of strength and conditioning principles into rehabilitation programs represents a paradigm shift in how we approach recovery. By embracing periodization and incorporating principles of training, physical therapists can empower individuals to not only recover from injury but also to thrive in their physical pursuits. This holistic approach not only improves outcomes but also promotes a culture of proactive well-being, where rehabilitation is not just about returning to baseline but reaching new heights of strength and vitality. To change the narrative that physical therapy is just TheraBands and e-stim, physios should understand and apply strength and conditioning principles to their patients. As we continue to explore the synergies between these disciplines, the future of physical therapy is undoubtedly one of integrated excellence.

Sources

Huberman, A. (Host). (2022, Mar 288). Dr. Andy Galpin: How to Build Strength, Muscle Size & Endurance. [Audio podcast episode]. In Huberman Lab.