Category: Rehab

Isn’t this just personal training?-Physical Therapy vs Personal Training

People are often unsure of the difference between physical therapy and personal training. During a clinical rotation, I even had a patient refer to me and my clinical instructor as “the trainers”.

To confuse matters more, many physical therapists (including myself) are also personal trainers.

However, there are key differences in what each profession is trained and licensed to do.

Physical therapists are licensed and trained to diagnose and treat injuries and help those with disabilities or pain improve their level of function. Physical therapists use exercise, and sometimes other approaches, to improve function. Physical therapists are also trained to screen for more serious medical pathologies. They may make a referral to a specialist for further medical evaluation. For example, in rare cases shoulder pain could be related to a cardiac problem. A physical therapist might refer a patient to a physician because there could be a more serious cause of the pain that needs to be addressed.

There are several branches of physical therapy. Orthopedic physical therapists focus on musculoskeletal injuries. Some examples of patients would be:

-A teen who sprained their ankle and wants to play soccer again
-A dad with chronic low back pain who has trouble playing with his kids
-An elderly lady at risk of falling who wants to safely go to the grocery store

On the other hand, personal trainers are trained to help people reach fitness and athletic performance goals, such as building muscle, losing weight, and getting stronger. They often work with people who have an injury, disability, or pain. However, trainers are not licensed or trained to diagnose and treat injuries or pain (despite those online who claim that certain exercises or stretches cure pain). Some examples of clients would be:

-That teen soccer player who wants to get stronger and faster
-That dad who wants to improve his endurance so he can play with his kids for longer
-That elderly lady who wants to maintain her strength

Also, the titles used by each profession are slightly different:

-In the U.S., most physical therapists now have a “DPT” (Doctor of Physical Therapy) degree along with a “PT” (Physical Therapist) license. On a physical therapist’s business card you will likely see “PT, DPT”.
-Personal trainer titles, on the other hand, vary widely since there are many certifying organizations. Some trainers use the title “CPT” (Certified Personal Trainer). And some coaches use the title “CSCS” (Certified Strength and Conditioning Specialist).
-For more naming confusion, in many countries besides the U.S., “PT” actually refers to a personal trainer and physical therapists are called physiotherapists. 

There is overlap in the types of exercises physical therapists and personal trainers use. And often a client may be seeing a personal trainer and physical therapist at the same time.

In short, physical therapists and trainers both use exercise but usually the goals differ and the scope of practice is different

Staying Slim After Injury

Losing weight and keeping it off can be tough. Compound that with the challenges of dealing with an injury or pain. People often say things like “Since my knees started hurting, I packed on weight” and “After my back injury, I gained a bunch of weight” and so on.

Many people believe that weight gain is inevitable after injury or pain, since one “can’t” exercise anymore.

There are two issues with this sort of black and white thinking. First, there is probably a way to modify and continue exercise. Second, there are many other factors related to keeping weight off. This article will address the second part-the factors related to keeping weight off, also known as “weight loss maintenance”.

With over 40% of U.S. adults being overweight or obese, there has been ample research in this area (1). Varkevisser et al in 2018 performed a systematic review (a study of studies) of over 8,000 articles on weight loss maintenance (1). They examined all the factors that would predict weight loss maintenance (or lack thereof i.e. regaining weight).

They identified these following factors as most predictive of keeping weight off*:

-Monitoring weight

-Self-monitoring eating

-Increased physical activity

-Portion control

-Cutting “unhealthy” foods (sweets/junk food, fried food, fast food)

-Decreased energy intake**

-Increased consumption of fruits and vegetables

-Decreased consumption of sugar sweetened beverages, juice

-Decreased fat intake

Note that only 1 of these factors is related to physical activity. Now this doesn’t mean that exercise and physical activity don’t matter. It simply means that there are other factors we can influence as well.

Also, note that there is no reference to a single “best diet”, rather these are general strategies that work whether or not you follow a specific diet. Many patterns of eating can work to stay slim.

So how do these factors translate into practice? Here are some example tools and behaviors I use with clients:

Example Tools and Behaviors
Recording weight twice per week and taking the average as your weekly weight**
Using hand portions like these or a calorie calculator like this to adjust daily intake**
Keeping a food log like this**
Getting 1 hour of physical activity per day (2).  Logging activity could be as simple as writing in a journal or using an activity planner like this
Having “unhealthy foods” as a treat for special occasions.   An example strategy is not keeping these foods regularly at home**
Consuming whole foods that are lower in fat.  Examples could be choosing leaner proteins (chicken breast, 90/10 ground beef, fish, etc)**
Having alcohol and soda as a treat for special occasions.  An example strategy is not keeping soda or alcohol on hand at home**
Purchasing fruits and vegetables that require minimal preparation.  Some examples include apples, oranges, bananas, cucumbers, carrots etc**


This is a bird’s eye view strategy for staying slim after injury-each person will have unique considerations when applying.

Injury or pain does not condemn one to regain weight. In addition to continuing exercise (in a modified way), we have many other strategies to maintain that hard won weight loss.

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*These were not the only relevant factors. There were other factors, but they had weaker evidence or had insufficient evidence. I’ve focused on the factors with the strongest levels of evidence here. 

**Decreased energy intake is critical and is the net effect of most if not all of these nutritional factors. For example, decreasing consumption of sweetened beverages, decreased fat intake, and cutting unhealthy foods all have the net effect of decrease total energy intake.

References:

1. Varkevisser, R., van Stralen, M. M., Kroeze, W., Ket, J., & Steenhuis, I. (2019). Determinants of weight loss maintenance: a systematic review. Obesity reviews : an official journal of the International Association for the Study of Obesity, 20(2), 171–211. https://doi.org/10.1111/obr.12772

2. Brown Medical School/The Miriam Hospital Weight Control & Diabetes Research Center. (n.d.).  The National Weight Control Registry. Retrieved January 04, 2021, from http://www.nwcr.ws/research/

Too Many Exercises, Too Little Adherence

50%

This is the typical adherence rate for physical therapy home exercise programs (HEP) (1). While we harp on the importance of HEP, we have a challenge with adherence.

Other professions struggle with adherence too. It is estimated that around 50% of patients do not take their medications as prescribed (2). And this includes medications for significant medical conditions such as cancer and cardiovascular disease. If it’s challenging to get people to quite literally take a pill, how can we expect people to stick to an HEP?

Thankfully, there are a couple studies in the research literature. While many factors can improve exercise adherence, one of the fastest to implement is simple: limit the number of exercises in an HEP.

First, Medina et al in Spain, studied patients with chronic neck and/or back pain (1). The patients were evaluated and given a plan of care, including HEP. After 1 month, adherence was assessed. There was a statistically significant difference in adherence for those given more than 6 exercises as compared to those who were given 3 or fewer exercises. Patients who were prescribed more than 6 exercises were less likely to adhere to HEP.

Then Eckard et al, studied U.S. military service members with various orthopedic pain complaints (3). The service members were evaluated and given a plan of care, including HEP. After prescribing HEP, compliance was assessed 4-14 days later. There was a statistically significant difference in compliance for those receiving 2 or fewer exercises (86%) and those receiving 4 or more exercises (54%).

Overall, these studies suggest that giving too many exercises decreases adherence. A likely upper “limit” would be about 6 exercises, with 1-3 seeming to be the sweet spot. Of course, these are not strict limits, but rough guidelines.

I think using fewer exercises actually demonstrates more skill and asks more of us as therapists. A mentor of mine commented that especially now with the doctorate level education, we should pick the few essential exercises, not throw a laundry list of exercises at patients. I couldn’t agree more.

Besides better adherence, a streamlined HEP helps us troubleshoot. If we give a patient 7 exercises and they come back with significantly increased pain, it’s hard to know how to adjust the HEP. There are simply too many variables.

In short: focusing on the few essential exercises sets us and our patients up for success.

References:
1. Medina-Mirapeix, F., Escolar-Reina, P., Gascón-Cánovas, J. J., Montilla-Herrador, J., Jimeno-Serrano, F. J., & Collins, S. M. (2009). Predictive factors of adherence to frequency and duration components in home exercise programs for neck and low back pain: an observational study. BMC musculoskeletal disorders, 10, 155. https://doi.org/10.1186/1471-2474-10-155
2. Brown, M. T., & Bussell, J. K. (2011). Medication adherence: WHO cares?. Mayo Clinic proceedings, 86(4), 304–314. https://doi.org/10.4065/mcp.2010.0575
3. Eckard, T., Lopez, J., Kaus, A., & Aden, J. (2015). Home exercise program compliance of service members in the deployed environment: an observational cohort study. Military medicine, 180(2), 186–191. https://doi.org/10.7205/MILMED-D-14-00306

Which Measurements Matter to Patients?

“When faced with a difficult question, we often answer an easier one instead, usually without noticing the substitution.” -Daniel Kahneman

As physical therapists we have many tools to track patient progress; outcome surveys, range of motion measurements, etc. However, which of these measurements meaningfully reflect patient outcomes?

This might seem obvious. But we often forget to ask these big picture questions in the clinic. We also forget such questions when reading research or choosing con-ed courses.

To pick the right measurements, we need to understand “clinical endpoints“. This term comes from clinical medicine trials. A clinical endpoint is “an event or outcome that can be measured objectively to determine whether the intervention being studied is beneficial”.1

There are three types of clinical endpoints2:

1. Direct clinical endpoints
These directly relate to patient outcomes. For example, consider a soccer player with knee pain. A direct clinical end point would be their ability to play soccer with an acceptable level of pain. We could measure that with the Victorian Institute of Sport Assessment–Patella (VISA-P). An improvement in the VISA-P likely means an improved ability to play soccer with an acceptable level of pain.

Of course, direct clinical endpoints are not the only meaningful measurements. But they most directly relate to patient outcomes.

2. Surrogate endpoints
These predict patient outcomes. We use these if we can’t directly measure an outcome. For example, we don’t know whether an elderly patient will fall – until they fall. But a measure like the modified 30-second Sit to Stand (m30STS) predicts fall risk.3 If we improve the patient’s m30STS score, they should be at a lower risk of falling.

A surrogate endpoint should be validated. Meaning that data supports its ability to predict an outcome.2

However, some surrogate endpoints are not validated. Such endpoints theoretically relate to an outcome. But data doesn’t show that connection. For example, consider the elderly patient at risk of falling. Low calf muscle strength might correlate with falls. However, there are many other factors related to fall risk, so we can’t predict fall risk with calf muscle strength alone.

3. Biomarkers
These correlate with biological activity in a patient. They are least relevant to patient outcomes. For example, a PT might use a tool shown to “increase blood flow” in a patient with low back pain. “Increased blood flow” is a biomarker. This biomarker might correlate with tissue healing. And tissue healing might decrease low back pain. But this is a weak connection. The increased blood flow is an interesting effect, but may not be relevant to improving low back pain.

As we see, clinical endpoints are not all equally relevant. Understanding them is crucial to interpreting research findings, picking con-ed courses, and tracking patient progress. The goal is to not forget the goal: getting patients back to activities they love.

References:

  1. NCI Dictionary of Cancer Terms. (n.d.). Retrieved November 13, 2020, from https://www.cancer.gov/publications/dictionaries/cancer-terms/def/endpoint
  2. Sullivan, E. (n.d.). Clinical Trial Endpoints [Powerpoint slides]. Retrieved November 13, 2020 from https://www.fda.gov/media/84987/download
  3. Applebaum, E. V., Breton, D., Feng, Z. W., Ta, A. T., Walsh, K., Chassé, K., & Robbins, S. M. (2017). Modified 30-second Sit to Stand test predicts falls in a cohort of institutionalized older veterans. PloS one, 12(5), e0176946. https://doi.org/10.1371/journal.pone.0176946

Is pain during rehab exercise “OK”?

*Medical Disclaimer: Please be advised, the information provided in this article is educational in nature and not meant to diagnose or treat any disease, illness, or condition. For individualized recommendations it is best to follow up with a licensed provider, like myself or another physical therapist.

A common concern among clinicians is when a patient experiences pain during exercise. Some clinicians rush to modify the exercise so that the patient has no pain whatsoever. Others ask the patient to describe the pain, trying to differentiate between muscle fatigue and nociceptive pain. And some say it’s just part of the rehab process.

Thankfully in the past couple of decades research has been building on this question. In 2017 Smith et al. did a systematic review trying to answer this question. Their review included studies that:

-Were randomized control trials that compared exercise where pain was allowed/tolerated vs exercise that was pain-free
-Had adults with chronic musculoskeletal pain (defined as >3 months)
-Measured pain, disability, or function

*Note that adults with “non-musculoskeletal pain” were excluded (this list ranged from cancer to headaches to fibromyalgia).

From their search, 7 studies made the cut: 1 trial on low back pain, 3 trials on shoulder pain, and 3 trials on foot/ankle pain. Patients in the studies were instructed that pain during exercise was acceptable (in some studies up to even 5/10 on the VAS), but that the pain should subside afterwards.

They then analyzed the effectiveness in the short (<3 months), medium (3-6 months), and long term (>12 months).

The results?

– Short term, patients who had pain during exercise had statistically significantly LOWER pain scores compared to pain-free exercise
-Reductions in pain levels were similar in the medium and long term between groups
-Improvements in disability and function were similar in the short, medium, and long term between groups

In short, for patients with chronic pain, pain-free exercises and exercises where pain was allowed resulted in similar outcomes (though short term, exercises where pain was allowed led to significantly decreased pain levels). However, we still don’t know about acute injury and post-surgical patients. We likely have to rely on clinical judgement for this. Also, the research doesn’t address other regions of the body (knee, elbow, neck, etc), but I think that we can reasonably generalize the results to other regions of the body-it is likely that chronic pain responds similarly to treatment, regardless of the region of the body. Lastly, a major limitation is that patients with conditions like fibromyalgia and migraine were excluded-this is a major group of patients who suffer from chronic pain! It would be helpful to examine the effects of painful exercise in these populations.

A few questions remain for me:
-Is there a ceiling on the “allowable pain” during exercise? Is there a point of “too much” pain?
-Related, is pain post-exercise “OK”? Would patients have better or worse outcomes if the pain from exercise lingered for a couple days?
-After discharge from therapy if a patient experiences pain with general exercise (a general training program), does this predict future pain?

Here is the original paper for review: https://bjsm.bmj.com/content/51/23/1679