Strength is Functional Because Weakness Impedes Function Absolutely (2017)

*This is a truncated re-post from a final year physiotherapy speech.

Without question, physiotherapy is a revered profession that has become increasingly difficult to enter. The physiotherapy degree attracts the top echelon of students, whom possess the aptitude necessary to solve complex problems that pertain to human function and movement. The curriculum is accordingly intricate but, though stimulating, omits the teaching of certain concepts that are so simple yet intrinsically linked with physical performance; that is, the fundamentals of strength training and exercise prescription. Perhaps the tendency for the typically astute thinker within our field to overcomplicate things is what obscures the necessity to apply basic strength training principles. An emphasis on ‘evidence-based practice (EBP)’ permeates the physiotherapy coursework, and yet what is arguably the most scientifically-backed means of rehabilitation, not to mention injury prevention, is essentially neglected (Hautala, Richards, Takahashi, Tulppo & Hills, 2016; Morley, Anker & von Haehling, 2014). If the physiotherapy curriculum is to truly fulfil its reputation as being grounded in up-to-date scientific science, a greater proportion of the credit units should be dedicated to progressive resistance training (PRT). 

In order to eliminate bias one would perceive from a proposal of this nature, the current physiotherapy cohort of 2017 was surveyed privately to gauge consensus; of the forty-eight responders 98% concurred with the demand for a subject predicated on PRT and exercise prescription. Exercise for Health & Well-being (PTY3EHW) was a second-year subject run for the last time with the current cohort before its abolition. As its name suggests, this subject aimed to explore the role of exercise in improving quality of life in addition to exercise selection for various musculoskeletal and chronic disease populations, both in a theoretical and practical sense. For a subject that boasted great potential, it was ultimately made redundant because it lacked structure and stimulation. Although PTY3EHW provided access to the health sciences faculty gym which is replete with state of the art strength training equipment, time was squandered with students wandering around purposelessly. The abolition of PTY3EHW was unwarranted since exercise, particularly PRT, is so crucial across the entire rehabilitation continuum for any disease state (Gentil, Steele & Fisher, 2017; Kraschnewski et al., 2016). Despite the indisputable benefits linked to PRT, a meagre 10% of Australians perform a sufficient muscle-strengthening activity levels (Bennie et al., 2016).

Having been a strength coach for over two years now, developed an advanced standard of strength, and immersed myself in the scientific literature, it must be said that my conception of strength diverges considerably from the way it is implicitly defined throughout the physiotherapy degree. ‘Strength training’, as used by the vast majority of physiotherapists I have come in contact with, appears to erroneously confuse true strength training with muscular endurance exercise. Training and exercise are distinctly different. This dichotomy lies in the fact that ‘training’ honours a pivotal concept that too often gets overlooked amidst the fixation with ‘functional’ exercise: that is progressive overload. This principle carries substantial weight because it underpins our primary aim with patients’ rehabilitation. This aim is, of course, to promote more robust musculoskeletal structures.

Progressive overload comprises three cornerstones: a stressor, recovery period, and an adaptation (see appendix A; Rippetoe, Kilgore & Bradford, 2006). The first year subjects of human biosciences, that thoroughly explore homeostasis, provide context through which the progressive overload model may be conceptualised. The applied stress must be sufficient to suppress basic cellular processes, and thus stabilise cellular structure and metabolism until the withdrawal of the stressor. Noticeable musculoskeletal discomfort may accompany this stage, indicating the disruption of homeostasis and concomitant events that trigger structural and functional changes. Subsequently, the body responds to this imposed stress via an upregulation of hormones, altered gene activity, increases in metabolic proteins; these processes constitute what is otherwise known as recovery. Rate of adaptation is highly individual, based on previous exposure to specific stressors, but inevitably elapses with adequate recovery. As a result, the threshold at which stress disrupts homeostasis in the individual has increased by virtue of systemic adaptation. Perpetually imposed stress is a crucial element in the progressive overload cycle, but care must be taken as to avoid excessive stress that may negate one’s adaptive capacity. Essentially, an appropriate amount of stress disrupts an organism’s state without overwhelming the capacity to adapt, thus allowing progress to be made in the form of enhanced function or physiological resilience. This understanding is crucial to differentiate between exercise and training and provides insight into effective rehabilitation.

Generally, physiotherapists are renowned for having an expansive arsenal of exercises. This gives rise to an unnecessary tendency to vary exercise selection with patients. While the naïve patient may be more than content when administered a wide variety of low-level exercises, or paying for regular physiotherapist-led personal training sessions, the physiotherapist must recognise that this approach to rehabilitation and injury prevention is sub-optimal. In other words, the approach many physiotherapists appear to take (and what we are taught at university) with rehabilitation sparks an initial stress that is not overloaded by a subsequent, specific stress of requisite greater magnitude to elicit ongoing adaptations. Exercise is fantastic in its own right, but it educes health benefits rather than enhanced strength and functional performance that should be at the crux of our professional practice.

Irrespective of whether the patient is provided with low-level exercises, injured tissue will almost invariably normalise when the natural healing course is respected. While caution is necessary to circumvent further injury during the acute phase of healing, the subconsciously held philosophy that optimal rehabilitation can occur in the absence of progressive overload exemplifies a failure to comprehend the basic tenets of human physiology and biomechanics.

‘Functional training’ is undoubtedly a trending theme in the physiotherapy world, representing a practice predicated on closely simulating given task(s) a client is endeavouring to improve in. This movement carries a certain degree of credence in that it upholds the law of specificity which is necessary to advance in any relevant skill. However, ‘functional training’ as it is portrayed by physiotherapists conflates the principles of strength training with task-specific practice. This begets inferior results when compared to dichotomising the two entities, strength training and skill acquisition. Strength is a very generally acquired and expressed characteristic, accumulated through the process of lifting increasingly heavier weights over time. Yes, physiotherapists frequently utilise basic thera-band and bodyweight exercises such as the famous glute bridge and its many variations, but these have their respective shortcomings; they are self-limiting and, quite frankly, inefficient. It is neither necessary nor productive to completely mimic either a sport’s movement pattern or its exact metabolic pathways in the gym. In the extensively common attempt to be sports or function-specific with strength training, many practitioners have gotten so specific with regard to both the metabolic pathway and movement pattern that an increase in strength is severely impeded or impossible. Fundamental barbell exercises like deadlifts, squats and the overhead press are the most ergonomically efficient means of acquiring strength; they are non-specific but develop useful power and strength that can be applied in any context of both athletes and the general populace. With strength training gaining increasing attention, as it deserves, physiotherapy as a profession must recalibrate its standard and understanding of strength. This change starts with amended university curricula, in a manner that serves to revolutionise the way forthcoming generations of physiotherapists think and apply exercise intervention with patients.

Staying within our scope of practice as physiotherapists is a seemingly plausible counter-argument to this proposition. Nonetheless, budding physiotherapists require a firm grasp of strength training and coaching fundamentals if we are to truly consider ourselves ‘movement experts’, and to endorse the indisputable science. In breeding physiotherapists whom appreciate the essence of progressive overload, that underpins effective strength and conditioning, our profession will only be enhanced in a way that sets ourselves apart from other similar fields. Just as clinical Pilates is a commonly attained accreditation by post-graduate physiotherapists, so too should the competency to strength coach be at the very least espoused. The argument for strength coaching aptitude to fall within our expertise outweighs its absence, and its use should by no means be confined to private practice physiotherapy. In fact, correct application of the progressive overload principle is perhaps even more pertinent in the hospital setting.  

Hospital-associated deconditioning (HAD) is an increasingly prevalent concern, with rehospitalisation rates post-discharge comprising a substantial percentage of all admissions (Berry et al., 2013; Dharmarajan et al., 2013; Vashi et al., 2013). Hospital-bound patients undergo extended periods of immobility which often engenders declines in muscle protein synthesis (MPS), muscular strength, and independence with activities of daily living (ADLs) to name but a few constituents of HAD. These commonly observed deficits in acutely unwell patients may be noteworthy contributors to the above mentioned hospital readmission rates. The decline in function seen in acute hospitalisations may be avoidable with appropriately dosed physiotherapy intervention; indeed, Lafont, Gerard, Voisin, Pahor & Vellas (2011) go as far as labelling it iatrogenic disability. Physiotherapists play pivotal roles in the hospital environment and post-acute care (PAC) setting as to restore patients to their pre-admission level of function (LOF), and thus ultimately improve the unlikelihood of rehospitalisation. Considering the alarming hospital readmission statistics, however, exhorts us to identify potential physiotherapeutic deficiencies that may be at fault.

Physiotherapists are described in the literature as administering low-intensity exercises, that do not meaningfully improve functional reserve or maximise physical function, to patients with HAD because they perceive these intensities as safer (Kortebein, 2009). Higher injury incidence in strength training athletes is a pervasive misconception held not only by antiquated physiotherapists but so too the general public. To dispel this concern, it is important to acknowledge the drastically lower prevalence of injuries across the weightlifting sports when compared to team sports (Keogh & Winwood, 2017). ‘Functional reserve’ denotes the capacity for older adults to tolerate additional stressors or illnesses without loss of independence, so it is a crucial biomarker that needs to be improved upon. It appears that physiotherapy in this population is almost entirely based on historical tradition rather than scientific rigour, with a lot of strength training coming only as an afterthought to gait and transfer re-training. The importance of PRT in this setting cannot be overstated to improve functional outcomes and ultimately reduce rehospitalisation rates.

Traditionally, physiotherapists have used general conditioning as treatment for older adults with HAD, which may encompass basic ambulation down the ward corridor, group exercise classes that do not satisfy training principles, or haphazard active range of motion (AROM) exercises. According to Seynnes et al. (2004), this approach does not adequately address impairments in physical function that are strong predictors of adverse events, and should henceforth be reconsidered. Endorsing a rehabilitation hierarchy that instead emphasises high-intensity PRT carries the most scientific merit and may significantly improve long-term outcomes in acute hospital patients (Falvey, Mangione & Stevens-Lapsley, 2015). The latter authors juxtapose the traditional paradigm with their proposed paradigm shift and a convincing premise that appropriately dosed PRT is more feasible than aerobic conditioning in this population (see appendix B). Strikingly, it is the older adult with HAD that has a dose-dependent response to strength training, carrying the implication for higher intensities to foster sustainable gains (Koopman & van Loon, 2009).

Further, Theou et al. (2011) allay the misconception that higher intensity PRT is inherently more injurious than conservative exercise prescription in this demographic of vulnerable patients. Advancing supine bed exercises and relatively unfruitful AROM drills to weight-bearing movements with external loads, up to 70-80% of 1RM, is required to truly stimulate physiological adaptations. The American College of Sports Medicine concurs with the notion that PRT be endorsed as a first-line intervention in frail elderly patients (Chodzko-Zajko et al., 2009). Again, the distinguishing factor between the antiquated paradigm and this proffered paradigm is that of progressive overload.

Undeniably, my background lends itself to some degree of bias in light of the fact I have both witnessed and experienced significant benefits from strength training. In saying this, the science does not lie and only continues to mount in favour of getting stronger. Quite profoundly, a recent systematic review discovered a statistically significant correlation between grip strength and prolonged lifespan (Leong et al., 2015). Assayed from a sizeable cohort of 139,691 35-70 year-old subjects, it was found that grip strength predicts not only all-cause mortality but also cardiovascular (CVD) mortality, non-CVD mortality and CVD disease occurrence. In fact, magnitude of subjects’ grip strength was considered more telling than the more frequently implicated systolic blood pressure. These findings are nothing short of remarkable but alas, sit-to-stands and 1kg dumbbell curls will not elicit meaningful adaptations in grip strength.

Now that the deficiencies of the common physiotherapy approach to exercise prescription have been comprehensively expounded, the new curriculum should address these needs. I am well aware of the rigorous process implementing a new subject to the course entails. As such, I believe the most feasible course of action is to initially incorporate lectures and corresponding practical classes within second year subjects such as ‘Physiotherapy Practice & Development A (PTY2PDA)’ and ‘Physiotherapy Practice Development B (PTY3PDB)’. Placing this module proximal to the second year anatomy subjects will facilitate a sounder grasp of functional anatomy and physiology. The lectures would explore the fundamentals of progressive overload, powerlifting, gymnastics or bodyweight training, Olympic weightlifting and bodybuilding. Quintessential rehabilitative physiotherapy, namely theraband resistance training and clinical Pilates, may also be unpacked in this series of exercise-based content. To consolidate the theoretical knowledge gleaned from this series of lectures, students will have the opportunity to partake in entry-level practical classes that cover the essential elements of these training modalities. Each of these resistance training methods have relevance in a rehabilitative and physical performance sense, and thus a basic familiarity with them embodies a key objective in this module. Accordingly, students will have an elementary competency to both coach and execute the core lifts. This learning is paramount for several reasons: it will solidify our profession as the true leaders in human performance and movement; new graduates will have the capacity to take patients from early stage to the advanced stage of rehabilitation while ultimately enhancing performance in the given individual’s sport; and our expertise will cater to patients of any athletic or non-athletic disposition. Within the next decade, I envisage strength training becoming the new clinical Pilates – it really is that powerful when done properly.

Recommended reading for this SBP module:

Rippetoe, M. (2013). Starting Strength: Basic Barbell Training (3rd Edition). The Aasgard Company.

Boyle, M. (2011). Advances in Functional Training. On Target Publications.

Wade, P. (2011). Convict Conditioning: How to Bust Free of All Weakness-Using the Lost Secrets of Supreme Survival Strength. Dragon Door Publications.

Everett, G. (2016). Olympic Weightlifting: A Complete Guide For Athletes & Coaches. Catalyst Athletics.

References

Bennie, J. A., Pedisic, Z., Van Uffelen, J. G., Charity, M. J., Harvey, J. T., Banting, L. K., . . . Eime, R. M. (2016). Pumping iron in Australia: prevalence, trends and sociodemographic correlates of muscle strengthening activity participation from a national sample of 195,926 adults. PLoS One, 11(4), e0153225.

Berry, J. G., Toomey, S. L., Zaslavsky, A. M., Jha, A. K., Nakamura, M. M., Klein, D. J., . . . Kaplan, W. (2013). Pediatric readmission prevalence and variability across hospitals. JAMA, 309(4), 372-380.

Chodzko-Zajko, W. J., Proctor, D. N., Singh, M. A. F., Minson, C. T., Nigg, C. R., Salem, G. J., & Skinner, J. S. (2009). Exercise and physical activity for older adults. Medicine & Science in Sports & Exercise, 41(7), 1510-1530.

Dharmarajan, K., Hsieh, A. F., Lin, Z., Bueno, H., Ross, J. S., Horwitz, L. I., . . . Suter, L. G. (2013). Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA, 309(4), 355-363.

Falvey, J. R., Mangione, K. K., & Stevens-Lapsley, J. E. (2015). Rethinking hospital-associated deconditioning: proposed paradigm shift. Physical Therapy, 95(9), 1307-1315.

Gentil, P., Steele, J., & Fisher, J. (2017). Why intensity is not a bad word–Benefits and practical aspects of high effort resistance training to the older. Clinical Nutrition.

Hautala, A., Richards, M., Takahashi, T., Tulppo, M., & Hills, A. (2016). Strength training in physical therapy. Physiotherapy, 102(1), 5-6.

Keogh, J. W., & Winwood, P. W. (2017). The epidemiology of injuries across the weight-training sports. Sports Medicine, 47(3), 479-501.

Koopman, R., & van Loon, L. J. (2009). Aging, exercise, and muscle protein metabolism. Journal of Applied Physiology, 106(6), 2040-2048.

Kortebein, P. (2009). Rehabilitation for hospital-associated deconditioning. American journal of physical medicine & rehabilitation, 88(1), 66-77.

Kraschnewski, J. L., Sciamanna, C. N., Poger, J. M., Rovniak, L. S., Lehman, E. B., Cooper, A. B., . . . Ciccolo, J. T. (2016). Is strength training associated with mortality benefits? A 15year cohort study of US older adults. Preventive medicine, 87, 121-127.

Lafont, C., Gérard, S., Voisin, T., Pahor, M., & Vellas, B. (2011). Reducing “iatrogenic disability” in the hospitalized frail elderly. The journal of nutrition, health & aging, 15(8), 645-660.

Leong, D. P., Teo, K. K., Rangarajan, S., Lopez-Jaramillo, P., Avezum, A., Orlandini, A., . . . Kelishadi, R. (2015). Prognostic value of grip strength: findings from the Prospective Urban Rural Epidemiology (PURE) study. The Lancet, 386(9990), 266-273.

Morley, J. E., Anker, S. D., & von Haehling, S. (2014). Prevalence, incidence, and clinical impact of sarcopenia: facts, numbers, and epidemiology—update 2014. Journal of cachexia, sarcopenia and muscle, 5(4), 253-259.

Rippetoe, M., Kilgore, L., & Bradford, S. E. (2006). Practical Programming for Strength Training (Vol. 222): Aasgaard Company.

Seynnes, O., Fiatarone Singh, M. A., Hue, O., Pras, P., Legros, P., & Bernard, P. L. (2004). Physiological and functional responses to low-moderate versus high-intensity progressive resistance training in frail elders. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 59(5), M503-M509.

Theou, O., Stathokostas, L., Roland, K. P., Jakobi, J. M., Patterson, C., Vandervoort, A. A., & Jones, G. R. (2011). The effectiveness of exercise interventions for the management of frailty: a systematic review. Journal of aging research, 2011.

Vashi, A. A., Fox, J. P., Carr, B. G., D’Onofrio, G., Pines, J. M., Ross, J. S., & Gross, C. P. (2013). Use of hospital-based acute care among patients recently discharged from the hospital. JAMA, 309(4), 364-371.