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REP 29: MARK RIPPETOE ASKS “ARE PHYSICAL THERAPISTS REALLY FRAUDS?”

Dr. Scotty Butcher

 

Got your attention? That’s what this prominent US strength coach with over 30 years of experience in the fitness industry was trying to do when he posed this question about our profession on a popular bodybuilding blog.

Is he right?

The big idea

Mark Rippetoe (Rip) is known for his bravado and polarizing opinions, but also for his expertise in coaching barbell-based strength training to the general population (young and old). Among many other books he’s written, his best-selling Starting Strength is in its third edition and is, in my opinion, the definitive resource on coaching the major compound lifts.

In his article, Rip discusses the differences between training large, bilateral, compound movements and movements that are more in isolation or unilateral; more of what we would call therapeutic or corrective exercises. His main arguments are around enhancing muscle activation with good movement, restoring function through movement, and developing strength through loading. Certainly, the APTA has recently suggested that we tend to under-prescribe strength training loads in older individuals. I hope we can all agree that these are important considerations for clinical exercise prescription.

My take on things…

Before you read Rip’s post, revisit the information presented earlier in the 30reps series. Both Bruce Craven (Rep 1) and Mireille Landry (Rep 5) suggested that we take a big picture view of our expertise and think of ways that we can improve our skills in exercise prescription to best meet the needs of our ever-growing clientele. Both have also referred to the importance of improving strength in our clients after establishing a solid movement foundation, and as a base for more advanced training. I wholeheartedly agree with these suggestions and, perhaps strangely at first glance, I think that this is the message that Rip wants us to hear.

Take the time to read Rip’s article now, and please excuse the odd use of expletive language.

Now that you’ve read it…

Are you angry? Are you feeling defensive? In both cases, I think you should be, but perhaps not for the most obvious reasons.

Defending what we do as a profession only holds validity if we are willing to objectively examine what we do and make appropriate changes as necessary. I urge you to look past the inflammatory remarks about the profession and look at the meaning and reasoning behind them. If we truly wish to remain the fore-running profession responsible for clinical exercise prescription, don’t we owe it to ourselves to try to see a bigger picture as part of our self reflection?

If we truly wish to remain the fore-running profession responsible for clinical exercise prescription, don’t we owe it to ourselves to try to see a bigger picture as part of our self reflection?

So, are we really frauds?

Of course not. Are we unintelligent? Again, no. I do wonder, though, if we are sometimes both uninformed and short-sighted when it comes to deciding the type of the programs we prescribe to our clients.

Consider this:

  • As evidence-informed practitioners, we rely on both research and professional/clinical/personal experience to guide what we do.

Unfortunately, research studies and our experience with clients each tend to be extremely short lived. The average length of a training research study hovers around 8-10 weeks and the typical length of time we see patients in an exercise prescription capacity may be only 4-8 weeks. Is it any wonder that the bigger picture is difficult to see?

  • We are rarely afforded the opportunity to track our patient’s continued progress following discharge.

The advantage that a strength coach, such as Rip, has over the average PT is the ability to see clients over multiple years of training; way beyond the initial phases of training or rehabilitation. Herein lies the problem for us. We rely on providing the biggest bang for our clients’ (or third party payers’) bucks. As such, we focus on big wins in a short period of time. In many cases, the training methods that provide the greatest short-term benefit are the ones that are sufficiently novel to promote large gains in function to occur over a short time period. However, these also tend to be the ones that have a reduced ability to produce meaningful long-term gains. In contrast, the methods that tend to be able to provide a greater longer-term benefit are also the ones that take the longest to develop. Minus the odd longer-term study, the only way that we would legitimately know this is to become active strength trainees ourselves.

  • Most of us don’t spend that much, if any, time strength training ourselves to better our understanding of technique, coaching, and program development.

One of the best lessons I’ve learnt as my career has developed is that in order to fully understand how to train our clients, we must become proficient at practicing what we’re preaching. I’ve partnered with an excellent strength coach and spent a significant amount of time under a barbell myself. Through this, I now know that as simple as an exercise’s technique seems on paper, it becomes very complex when a trainee is placed under load. Add to this the fact that everyone moves differently and has different limitations, developing experience with training and coaching is incredibly important.

Deadlifts: a case in point

Anyone who knows me or follows my work knows that I am a huge fan of deadlifting variations for clinical purposes. I want to use two recent studies on the use of deadlifting for clients with low back pain as an example of my argument. Each of these studies was conducted in Dr. Peter Michaelson’s lab at Lulea University in Sweden.

The first was an RCT comparing the use of low load motor control exercises (stability and movement training) tailored to address individuals’ dysfunction with progressively loaded deadlift training over 8 weeks. Participants were supervised by physical therapists to ensure good technique and the promotion of a neutral lumbar spine throughout training. As a whole, both groups increased lifting strength and reduced pain symptoms similarly, while only the motor control training group increased functional activity, movement control, and muscle endurance. At first glance, we might infer superiority of the motor control protocol in these patients, but when digging deeper, two interesting findings confound this interpretation.

First, the group of patients in the motor control group reached a self-perceived plateau in symptoms, function, and movement control after only 6 sessions, whereafter further subjective benefit was not realized. This report corresponds very nicely to a study on core stability I performed as part of my MSc degree. We found that low load core stability training improved jumping performance only in the first three weeks of training. Subsequent progressions of loading the stability exercises resulted in no further improvement. It appears that once you’ve adequately developed control, there’s not much further you can go with these motor control exercises given their limited ability to progress loading.

Second, the group performing progressive loaded deadlift training had a huge variability in their responses and progressions. This finding led the authors to conduct a follow up analysis study on the same group of participants, in an attempt to predict who would benefit from deadlift training. They determined that lower baseline pain intensity and higher muscle endurance were predictors of benefit. They suggested that a preparatory period of motor control training to increase endurance and reduce pain would have likely increased the effectiveness of deadlift training in those with higher pain and lower muscle endurance.

The point I’m making with this is that our ‘weenie’ therapeutic exercises serve a big purpose in many individuals early in rehabilitation, but all too often, we make the mistake of failing to progress patients to bigger movements that can be adequately loaded over the long term. While therapeutic exercises can help with the foundation, they can’t adequately improve whole body strength over a longer period of time. Once our patients’ movement foundation is solid, we should be looking toward longer term benefits and progressions.

the loading potential of an exercise is key ingredient in the design of an appropriate training program. As such, in my opinion, variations of deadlifts, squats, and presses trump banded isolation exercises every time over the long term.

The model I advocate, which is in line with Rip’s teachings, is one of developing strength with a solid movement foundation and progressive loading of compound exercises. For this, the loading potential of an exercise is key ingredient in the design of an appropriate training program. As such, in my opinion, variations of deadlifts, squats, and presses trump banded isolation exercises every time over the long term.

As much as we may hate to admit it, Rip has given us an important message that we cannot afford to ignore.

Dig Deeper

You may be wondering what other physical therapists or medical professionals have written on the topic of barbell training in health, disease, and rehabilitation. Here are three articles on the topic written by Starting Strength coaches that provide some balance to Rip’s methods:

Barbell Training and Physical Therapy by physical therapist Dr. John Petrizzo

Barbell Training as Rehab by Professor Karl Schudt

Barbell Training is Big Medicine by physician and researcher Dr. Jonathan Sullivan

In addition, here are two pieces I wrote on the importance of strength training in health, fitness, rehabilitation, and performance: The Strength Insurgence and Prioritize Strength Training in Older Adults.

Lastly, here are two excellent peer-reviewed descriptive reviews that delve into the controversial topics of core stability and functional training (not open access).

Discuss

I’d love to hear if you agree with my interpretation of Rip’s attack or not. I’d also love to hear if you believe it should be our role to coach these compound movements with our clients. If so, what do we need to do to become competent at doing so?

Lastly, are you willing to learn how to strength train and spend enough time training to improve your personal experience side of the evidence information?

Share your thoughts using the comments box below, or via the CPA Facebook page or on Twitter(hashtag #30Reps).

About Scotty Butcher

Dr. Scotty Butcher, BScPT, PhD, ACSM-RCEP, is an Assistant Professor at the University of Saskatchewan and co-owner ofBOSS Strength Institute. He has over 15 years’ experience prescribing exercise to untrained clients and athletes alike. Formerly certified as a CSCS and currently a budding competitive powerlifter, he has a passion for strength training and translates this to promoting quality exercise training and rehabilitation practices for clinicians and students.

Connect with Scotty on Twitter (@InkedProfScotty and@BOSSstrength), Facebook, and YouTube.

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