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.

________________________________________________________________________________________________

*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 Obesity20(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 disorders10, 155. https://doi.org/10.1186/1471-2474-10-155
2. Brown, M. T., & Bussell, J. K. (2011). Medication adherence: WHO cares?. Mayo Clinic proceedings86(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 medicine180(2), 186–191. https://doi.org/10.7205/MILMED-D-14-00306

The Evaluation Doesn’t End on Day 1

“This doesn’t fit with anything I learned in school.”

We often encounter this uncomfortable situation in the physical therapy clinic. In school, we are trained to fit each patient into a neat diagnostic category; grade II ankle sprain, subacromial shoulder impingement, radicular low back pain. These diagnostic categories often work in acute situations with a clear mechanism of injury. However, we also see atypical presentations, that is, a mix of signs and symptoms that don’t match any single diagnosis.

We can think of this like a spectrum. On the one end are “textbook” injuries that neatly fit a diagnosis. On the other end are atypical presentations that make one say “Hmmm”, those ones that don’t match a single diagnosis.

For those atypical, “Hmmm” presentations each subsequent visit is a mini evaluation. We learn more about how the person responds to therapy. We learn about their pain triggers. We learn about their adherence to home exercise. For example, we assign a patient with chronic low back pain the “bird dog” exercise. On the next visit, they have more pain. So we adjust the exercise (such as the range of motion, volume, etc). Or we select a new exercise. Every visit gives us more information and we better adapt the program to that patient.

On the flip side, the evaluation for “textbook” injuries doesn’t end on day 1. Every patient responds differently to therapy. Every patient has different goals. Every patient has unique factors that impact their rehab (psycho-social, economic, etc). For example, consider two people post total hip replacement. One has a telework job with flexibility and a gym in their apartment building. The second works long shifts in a factory and has to drive an hour to get to therapy. Do these people neatly fit into a diagnostic category? Yes. But will they respond the same way to therapy? Probably not.

The process of evaluating is iterative-it is not something we “complete” on the first visit. The evaluation starts in that first hour with a patient, but continues at every following visit.

The Clinic is a Trojan Horse for Exercise

“In the 21st century, health care is increasingly about long-term condition management and thus about health behavior change” [1]

Inactivity is a major worldwide problem. The World Health Organization (WHO) lists “physical inactivity” as the fourth leading risk factor for mortality [2]. Unfortunately, the rates of exercise participation are shockingly low. In the U.S. it is estimated that less than 30% of adults meet current exercise recommendations [3].

We, as physical therapists, are uniquely suited to combat this problem. The PT clinic is the perfect Trojan Horse to get clients exercising regularly.

Why PT’s Should Promote Exercise

Promoting exercise doesn’t just improve general health-there are musculoskeletal benefits that may prevent the need for PT in the first place.* Exercise, specifically resistance training, has preventative musculoskeletal health benefits including: preserving cartilage, preserving/increasing bone mineral density, improving tendon stiffness (a good thing for tendon function), and reducing frailty (which relates closely to fall risk) [4].

However, beyond the preventative benefits of exercise, many of the conditions we treat require long term management. Physical therapists no longer just treat acute injuries. For the chronic conditions we are increasingly working with, patients need tools like exercise, to manage pain and improve function.

The Unique Advantages of PT’s to Promote Exercise

PT is one of the few healthcare professions that spends massive amounts of time with patients. A PT might see a patient for several weeks for 30-60 minutes per session. On the other hand, a physician might only see a patient for an annual checkup for 10-20 minutes.

With so much time spent with patients we are able to:

-Understand and change beliefs about exercise like “lifting weights is dangerous” or “just swim because it’s low impact”. We not only have the time to discuss these beliefs, but the context of the clinic can help patients feel “safe” while exercising. Patients can gradually build up confidence exercising in the clinic in order to exercise independently upon discharge from PT.

Design exercise programs that fit a patient’s life. We get to know our patients well. We deeply understand their exercise preferences and the constraints of their life. So we can create exercise programs that a patient will actually stick to.

For example, I would love all patients to have gym access. However, this is not always possible. For some patients a bodyweight exercise program would have to suffice. Sometimes, the “optimal program” is the program that patient will stick to long term.  

-Help patients build support to exercise. Having support from loved ones and social groups helps many patients stick with exercise. As PT’s we often meet patients’ loved ones and can talk directly with them about how to exercise long term. For example, we often need the buy-in of loved ones to help a patient get exercise equipment, make time to exercise, and to motivate them.

However, even if we don’t meet a patient’s loved ones, we can still help them build support for exercise. We can help them involve their loved ones in exercise. Or we can even help them connect to groups to make exercise social.

But won’t this take away from “treatment” time?

We shouldn’t see exercises for fitness as distinct from exercises for “treatment”.  Many rehab exercises are quite similar to general strength and conditioning exercises. For example, with rotator cuff tendinopathy, we often use isolated strengthening exercises and then progress towards compound movements like pushups and rows. With the right dosage of load and volume, the same exercises that were once rehab exercises become general strengthening exercises.

The clinic need not be only a place for PT “treatment”. The clinic can be the Trojan Horse to empower patients to transform their health through exercise.  

*We cannot truly “prevent” injury or pain, but we can reduce the risk of injury. I use the word “prevent” since “reduce risk of injury” is too verbose.

References:

1. Rollnick S, Miller WR, Butler CC (2008). Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: The Guilford Press.

2. GLOBAL HEALTH RISKS GLOBAL HEALTH RISKS WHO Mortality and burden of disease attributable to selected major risks. (2009). Retrieved November 19, 2020, from https://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf

3. Piercy, K. L., Troiano, R. P., Ballard, R. M., Carlson, S. A., Fulton, J. E., Galuska, D. A., George, S. M., & Olson, R. D. (2018). The Physical Activity Guidelines for Americans. JAMA320(19), 2020–2028. https://doi.org/10.1001/jama.2018.14854

4. Maestroni, L., Read, P., Bishop, C., Papadopoulos, K., Suchomel, T. J., Comfort, P., & Turner, A. (2020). The Benefits of Strength Training on Musculoskeletal System Health: Practical Applications for Interdisciplinary Care. Sports medicine (Auckland, N.Z.)50(8), 1431–1450. https://doi.org/10.1007/s40279-020-01309-5