Rep 29 feat img

Rep 29: Mark Rippetoe asks “Are physical therapists really frauds?”

Curated by 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

Rep 29 S ButcherDr. Scotty Butcher, BScPT, PhD, ACSM-RCEP, is an Assistant Professor at the University of Saskatchewan and co-owner of BOSS 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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48 responses to Rep 29: Mark Rippetoe asks “Are physical therapists really frauds?”

  1. Patti Crawford-Baxter

    Hello Scotty, one aspect of the equation not addressed is physiotherapists with multi degrees. I also have a kinesiology degree and I was a varsity level athlete. Strength training is a very familiar tool that I use with all my clients. I don’t feel defensive because I know what strength and knowledge I own. Everyone is allowed their own opinion. Although generalizing to all doesn’t make a person correct.

    • Scotty Butcher

      Thanks Patti – background training (or subsequent training) plays a big part in our belief systems and our treatment philosophy. Some therapists will be very comfortable teaching the big lifts and others would need more training. That’s where the personal experience side plays a huge role!

  2. Most PTs either under prescribe, or improperly dose strength training; I would say that carries over to the public at large. Thankfully we have PTs like yourself, Charlie Weingroff, Gray Cook, etc who go beyond what a typical PT/physio would do and merge the best of both worlds. I certainly would have never thought of teaching an older lady deadlifts. I’ll never forget the 70+ little old lady who had not been able to get out of a chair without significant knee and hip pain for years. I taught her kettlebell deadlifts and hip hinging after initially working on threat reduction and mobility, after 40 deadlifts of progressively heavier weights, she got out of her chair 20 times with no pain. Brought tears to her eyes!

    • Scotty Butcher

      Thanks Erson! That’s the type of story that I keep hearing about that helps to solidify this approach. Perfect!

    • Joe Castelli

      I am familiar with Mark Rippetoe ‘s work and often wonder why people like him bother to make these statements. Once someone generalizes like this they lose all credibility regardless of their background or nowadays ” amount of likes on social media.

      ” Most PT’s either under prescribe or improperly dose strength training” . How can you even touch this? It s so broad and generalized to our profession. How is it even reported? Accurately? Generalizing only frustrates me because we all deal with such diverse populations with different pain presentations and let’s not forget our limitations from insurance plans. We may never get to the progressive levels the author speaks of. I am in agreement with Erson in personalizing the program that fits the patient appropriately. No one does that with greater skill than physical therapists not trainers or strength coaches.

      • Luke

        ” It s so broad and generalized to our profession….Generalizing only frustrates me ”

        How can you say this and then follow it up with

        ” personalizing the program that fits the patient appropriately. No one does that with greater skill than physical therapists not trainers or strength coaches.”

        How many physical therapist can you find that will either help a 65+yr old with progressive resistance training in compound movements or get them to someone that will?

        What rip has done with numerous pensioners and even a 91yr old is unheard of in your world.

        • Barb

          “How many physical therapist can you find that will either help a 65+yr old with progressive resistance training in compound movements or get them to someone that will?
          What rip has done with numerous pensioners and even a 91yr old is unheard of in your world.”

          Hi
          I am wondering who Luke is that he has to denigrate “our world” – physical therapists use many different treatment approaches and I don’t find it credible when someone uses a set technique and feels it is the only way to treat a problem. Though this approach has something to offer it doesn’t need to be accompanied by the strong criticism of other professionals. Many physios work with strengthening older patients-functional, sport specific, and progressive resistance training . At a PCN inservice the other day they told us of one 80 yr old lady who came in unable to do one stand up from the chair in 30 seconds and when she ‘graduated’ she could do 17 – and without dead lifts. Now perhaps she could have done even more with your approach, but she improved function, strength, and balance with the exercise program they did there.

    • Brittney

      I totally agree. I think there’s a gap between rehab exercises and strength training where any and all rehab specialists tend to fall short. The experts you mentioned are perfect examples of bridging that gap.

      I think the miscommunication comes in terms of “strength training”. That doesn’t have to be getting every 70 y.o. to deadlift 200lbs, but can the lift any weight off the ground with good form? And shouldn’t we overshoot the goal, so that when they are challenged they can withstand the stress? Strength training is related to better stability and overall life expectancy in aging populations. There’s something to that whether you believe in barbell lifts or not.

      • Scotty

        Thanks Brittney – your comments around the definition of strength training, in my opinion, are bang on. I do believe that every person, young or old, should be able to groove a good hip hinge to lift something off the floor. That’s a deadlift – regardless of what or how much is being lifted. I wish people would stop thinking about training as something that is only for athletes or for jacked up guys on ‘roids.

        I also think your opinion on overshooting the goal is a very valid and important point, although I think here is where I usually get the most pushback (ie. “if they don’t have to do it in their daily lives, why would I ever ask them to do it in training?”). Building resilience is a hugely understated and undervalued aspect of training – resilience in movement patterns and in load tolerance.

        Once again, thanks for your contributions!
        Scotty

  3. L

    Hey Mark, why don’t you go have a chat with the guys over at Medicare. I’m sure they’d love to pay more money so that our patients can deadlift 300 lbs.

  4. I strongly agree with your thoughts and feel there needs to be client follow up by either the Physio or ET to help cement the positive changes created during initial treatments. As you are obviously aware there are individuals such as Dean Somerset and Blaine Mackie that practice and firmly believe in the approach you are touching upon. I think the word is starting to get out to more and more practitioners. Through your symposium and similar events it will spread that much quicker. Great article and looking forward to the fall CSS.

  5. Nice work.

    I agree that far too many PTs don’t know how to lift heavy. I’ve always known how to lift and I have always been keen to progress patients back to full function but it wasn’t until I was lifting heavy (on and off since 2007) that I really understood what it felt like to be under something heavy.

    The only thing I would disagree with Rip would be unilateral exercises…I have found that those with good bilateral technique might still suck at different planes of motion such as transverse or coronal plane motion…I see unilateral exercise as a way to give the brain more movement options.

    I’m glad he ripped in and ranted hard…saves me having to do it!

    • Scotty Butcher

      Thanks Antony! I agree with this, but also don’t believe the two ‘types’ of exercise are mutually exclusive. Each has a purpose and specific set of goals. I think this is something we misunderstand frequently. Bilateral compound lifts are key for whole body strength and building muscle (the type of strength I’m referring to), but unilateral training is beneficial for other purposes (ie. applications of strength such as task specificity, sport, skill, balance, coordination) that build upon the foundation of strength. I agree with Rip that when training for strength, loading potential is crucial. You simply can’t develop those types of load with unilateral work and nor should you. But, I think that’s what you’re saying…

    • All well Antony providing the lifting does no damage. As a pelvic floor & lumbopelvic physio I can tell you the new trend for HIIT & lifting heavy is causing problems. The lift heavy mentality is fine, we all need to be stronger, but there is collateral damage that we need to watch out for.

      • Scotty Butcher

        Good comments, Robin. Something that I talk about all the time with strength training is the need for good progressions based on good movement. Most of the problems are associated with one of either poor technique and/or improper programming/progressions.

      • NickM

        Robin, do you think that HIIT/heavy training is a problem because it is progressed too quickly (or beyond the ability of the various pelvic slings to accommodate)? Or that clients are being taught to “brace” too much?

        Have any of your patients recovered sufficiently to resume training? I imagine that once someone has sufficient pelvic floor control, then gradual, progressive loading shouldn’t be too much of a problem. I’d like to hear some success stories please! (I have a girlfriend, and my mother, who have continence problems and are afraid of any kind of exercise).

        • Julie Wiebe, PT

          Chiming in here as the incontinence in female athletes (of all ages, and post-baby or not status) is one of my favorite issues to treat. IMHO, this group is where the strength model falls apart. The idea I think we have all suggested here is that a coordinated mov’t foundation is first, then strength can be applied on top of that. This is not the model we have used for pelvic health issues. They have historically been treated as primarily a strength issue of the PF acting alone, without regard for the performance enhancing relationships it has with other deep and superficial stabilizers. And the issue isn’t one of just muscular balance either, it is a pressure balancing issue as well. IAP is often seen as the enemy, however, it is a part of athletics. We just need to train folks to stay in the lower IAP ranges with attention to alignment/form, motor recruitment patterns, and central stability strategies. Again a focus on foundation before strength. Otherwise strengthen reinforces faulty strategies. Incontinence during exercise is an expression of a faulty deep strategy….and we need to address it that way. Like we would back pain, or hip pain while lifting. I have written about these issues on my blog, for Nick M’s mom and girlfriend: IAP: Friend or Foe? https://www.juliewiebept.com/fitness/intra-abdominal-pressure-pelvic-health-friend-or-foe/ and Butt Wink and the PF https://www.juliewiebept.com/?s=butt+wink . For some the weight of a lift, or the strain of a Pilates move, or the fatigue of a 10 mile run may get the best of the strategy a woman can muster, and then we have to adapt the program. And in some cases there is significant damage that puts certain kinds of workouts off the radar. But I think there is a lot more we can do for this population than tell them you simply can’t participate.

          • Scotty Butcher

            “Again a focus on foundation before strength. Otherwise strengthen reinforces faulty strategies” Agreed completely. Where we as PTs tend to excel is with the foundation, but don’t always know how to progress beyond.

  6. Perhaps it would benefit patients and PT’s to refer clients to those properly trained in strength training? I owned a post-rehab company and tried to develop relations for referrals with PT’s but they always resisted.

    • Scotty Butcher

      I agree that those who are teaching the movements need to be properly trained. At present, entry-level PT education does not adequately do this. This, in my opinion, is a flaw in the educational system for PTs that goes far, far back. The current practice of those who do not know is to refer (or not), but I think this is a role for PTs (assuming they have enough experience or training with strength).

  7. Ailene Rivera

    Calling our peers “fraud” is a disgrace to our profession. Strength training is only one component of Physical Therapy. If you are a licensed physical therapist here in U.S. You would know that the practice here is evidenced-based. You shouldn’t call people fraud without knowing what setting they practice, the type of cases or population they serve or the type of insurance payer they deal with. Most of us deal with the most vulnerable and fragile population and lifting 300lbs is not the priority. Our priority is to make the patient’s overall quality of life better and for him/her to return home with his family. The title of this article upsets me as it shows how “self righteous” other people are. And to think they know more than others just because they can physically lift heavier weights? That is not physical therapy if that doesn’t correspond to your patient’s daily function.

    • Scotty Butcher

      Thanks Ailene for the comments. EBP is not limited to the U.S., of course. The evidence, however, can be misconstrued, misinterpreted, or poorly informed. Check out the deadlift research example in my post.

      As for as the role of strength training in rehabilitation, yes, it is only one component, but I believe it is very much undervalued. There are multiple health benefits that are similar, or greater, than that achieved by other types of exercise training. I would encourage you to read the two posts I wrote on this topic that are linked under ‘digging deeper’ (The Strength Insurgence and Prioritizing Strength in Older Adults).

      Lastly, I disagree with your last sentence. Getting stronger does improve our patients’ daily function and is physical therapy.

    • Steve

      There are some videos of a 91yo woman that Rip has lifting weights. She started coming to the gym with a walker, which is now in her closet. She benches and presses and is working up to deadlifting (doing rack pulls now, iirc). Hasn’t fallen since she started slinging iron. That seems like “quality of life” and “daily function” to me.

      That 300lb figure you reference hits home for me. I had a bad back, until I worked up to putting 300lbs on it for low bar back squats. Now it’s perfect. It’s improved my quality of life and daily function, too.

  8. To me it’s about working as a team. I have 3 fitness instructors in my clinic and work with P& C guys on the sports teams I contract to.Once I feel the patient, who usually initially attends by limping through the door is ready ,I hand them over for whatever type of fitness work suits them best, with the aim of strengthening but never without the main emphasis being on quality movement. Currently I also have a very elite soccer & rugby clientele on top of my more chronic pain patients. I can say the guys who lift as per Rip’s ideas don’t move as well as the guys who don’t formally lift.The lifting guys are having more rotatory injuries despite doing the same agility etc training as the non lifters…..just because you can lift a truck doesn’t mean you are useful. I think Rip needs to think team work. I don’t think I nor my physiotherapy colleagues are unintelligent frauds, we are just another part of the machine. I couldn’t get the results I do without my fitness trainers & vice versa.

    • Scotty Butcher

      Thanks again, Robin. One of the comments I’ve made on this previous is that strength is a crucial foundation, but that it has to be a) built upon a solid movement foundation (many of the guys you are referred to I would guess don’t move well because they don’t train well), and b) is the platform for more specific life, sport, skill, or task demands. Strength isn’t everything, but progress in rehab/performance/health can be very limited in the absence of strength.

    • Luke

      ” I can say the guys who lift as per Rip’s ideas don’t move as well”

      “The lifting guys are having more rotatory injuries despite doing the same agility etc training as the non lifters”

      Nothing about Rip’s position on movement patterns and loading impedes mobility. I think you’re conflating what the average self guided gym goer does with weights and the researched methods of an experienced expert in Rip.

  9. Barb

    Interesting for sure. Simplistic. When someone gets some good results with basically one approach it is easy to think that cures everything. Manipulations, IMS, massage, acupuncture, strengthening, orthotics, cross fit, religion- – it is too easy to have tunnel vision because that is what you know and negate any other treatment approach. It would make my life so simple if I gave my older arthritic patients, young gymnasts with Sinding Larsen J. syndrome, national team athletes, fractured wrists, post elbow dislocation capsular patterns, acute lumbar discs, cervical nerve impingements, rotator cuff tears, post op ACLs, anterior hip impingements, labral tears etc etc all deadlifts. That being said it is always valuable for physios with our eclectic approaches to continue to assess what we are achieving, and explore referral options for exercise progression in our own communities.

  10. Scotty Butcher

    Personally, I think most of the clientele you mentioned would respond very well to a well coached deadlift (and strength) program! I do get your point that strength isn’t the only method of treatment and that other concerns do come more in the forefront. I think we do our clients a disservice, though, when we don’t plan for their long term needs rather than only the short term ones.

  11. Len

    Hi Scotty, As a former national powerlifting competitor and 20 years in the clinic, all this resonated with me. I do agree that the initial stages of rehab need to address the smaller components of physical function. I have had some of my worst cases equating and deal offing with incredible results. The main issue here is that not enough therapists spend time with a bar or kettlebell in there hands.

    All the best with your lifting!

    • Scotty

      Thanks Len – took me a second to recognize powerlifting sausage finger typing, but I see you meant squatting and deadlifting haha! Agreed with your comments. Cheers

      • Len

        Good catch on the autocorrect. Glad it wasn’t anything worse than that. I did a Anderson Silva Tib/fib fracture 4 months ago playing soccer and I’m back in the gym squating and deadlifting. Feels great!

        • Scotty Butcher

          I love stories like this! How do you feel your strength training benefitted your rehab and recovery? I’d love to hear more if you would like to share. If you want to share privately, you could send me an email (scotty.butcher@usask.ca) if you like.

  12. I didn’t find Rip’s comments offensive because I don’t practice that way! I think neuromuscular/motor control training is at the heart of most folks deficits and retraining/re-patterning with good form are critical. That is the foundation that needs to be re-built first…then build challenge on that. IMHO, the level and type of challenge needs to be patient and goal centered. If the patient wants to do CrossFit, or any kind of lifting…then my job is to do that. But if it is swimming, or ballet or hiking and they are 100% uninterested in lifting heavy, I don’t agree that I have to put lifting heavy in their program to get them better and return them to their function and goals. I think we as a rehab community have historically not pursued, often poo-poo-ed and discouraged heavy lifts for a variety of reasons, and I think the evidence no longer supports this. But I think we also have lots of tools in our tool bags that can create a positive outcome for our patients and heavy lifting doesn’t HAVE to be in every program. The lifting community seems to think everyone should lift, I simply don’t agree. Neither do I agree with those outside the lifting community who think that people shouldn’t lift, period.

    I also don’t think that pure strengthening is the end all, be all of how the brain gains access to muscles to apply to in other circumstances. I think functional patterning does this best (with and without challenge), and creates a strategy that can be applied in multiple movements. I think this is particularly true when it comes to rotational patterning. Lots of injuries occur in rotation, most WODs are very straight plane. All that straight plane strength does not prepare them or their brain for a rotational activity or load and that’s where they tend to get hurt and end up in our care.

    One last thought…. I think that it is hilarious that someone would think any PT is in it for the money….hahaha tell that to my bank account. I know that is not the crux of your discussion of Rip’s article, but in terms of the intention behind most practitioners efforts or lack of efforts, I doubt finances are at the heart. We simply don’t make that much money ☺!

    Thanks for the thoughtful discussion! Julie Wiebe, PT

    • Scotty Butcher

      Thanks for the comments, Julie! I once heard “the best exercise is that which you will consistently do.” In this, finding something each client will stick with, whatever it is, is always the best plan. Here is where we have a multitude of options and the CSEP and/or ACSM-type guidelines are very appropriate.

      Having said that, I always look for the ‘big bang for your buck’ options to present as ‘best practice.’ This is where strength training on a solid movement foundation trumps many other types of training over the long term. I do agree that activities that are more an expression of strength (athleticism, skill, balance, coordination, etc) will enhance overall performance (life, not just sport) and may have a big impact on prevention, but the top end performance is often dictated by absolute/relative strength.

  13. Kyle

    Man, if only it was as easy as –
    Back/lower extremity diagnosis: deadlift, squat (progressively overload)

    Neck/Upper extremity diagnosis:
    Bench, military press (progressively overload)

    Talk about fraudulent. I’m all for compound movements and advancing to them once appropriate; but this guys opinion was one sided seemingly uneducated as to the practice of physical therapists. I like your post but wish I wouldn’t have clicked on his as I feel it was just to make himself seem relevant.

    • Scotty Butcher

      Hey Kyle – yeah, Rip is known for his click-bait posts and this one always causes a stir. I think the message that we’re all saying is the same: PTs use their ninja diagnostic skills, start with retraining basic movement as able, then progress to compound, eventually loaded lifts.

  14. Nice post. I tend to agree with much of your interpretations.

    Question — would you refer a patient to Rippetoe? There are a lot of quality strength coaches out there. Ones that are inflammatory toward the profession probably won’t get my vote. Build bridges between professions, not walls. In my own experience, growth, and reflection, I have come to realize that there are a lot of variables at play. Ultimately, we as profession need to get back to the drawing board, decide to actually BE the profession that keeps being ‘Visioned’ as the providers of choice, and start being proactive instead of reactive. Of course, this is based on being in the US, and it seems there is a disparity between the amount of time spent defending our practice acts versus developing our actual profession and public awareness of what we do. Articles like Rippetoe’s can be looked at as a positive catalyst to discussions like this, but unfortunately I think most of that they do is feed the public more propaganda of why they should just go see their personal trainer…and the saga of “Trainer play Doctor continues.”

    Not all PTs are trained in strength & conditioning or coaching the lifts. Is this a weakness in Curriculum? I don’t know. I would guess if you ask Academia they will say there is only so much to pack into an entry level program, at that point it really is on the PT to fill in the gaps via quality continuing education. How many Outpatient clinics have you been in that do not even have a barbell…or kettlebell…or dumbbell over 15# yet advertise as specializing in Sports Medicine. How many clinics operate in a model where the PT evaluates and writes plans only, and by ‘treat’ they mean spend 8 minutes of manual therapy for each of the 4 patients they have that hour while an often unqualified “tech” carries out the exercises…The model needs to change, which pushes the discussion into the realm of insurance-based controls over care. Seeing who’s posted above makes me hopeful that we can change this, but it will be through collaboration and building a multidisciplinary care model.

    • Scotty Butcher

      Fantastic comments, Kristopher, and great question. Would I refer a patient to Rip? In some circumstances, yes, but my preference would be to learn what I can from a guy as experienced as him and, as you say, be the one to make a change in practice. I have both the advantage of seeing a larger picture in my academic role and the disadvantage of not seeing patients to apply this approach. There are many fantastic clinicians using this type of methodology, though, so the model and philosophy can, and does, work.

    • I_iz_a_fatass

      >Not all PTs are trained in strength & conditioning or coaching the lifts. Is this a weakness in Curriculum?

      If the goal of physical therapy is to return the patient to maximal functionality in the least time, it definitely is a failure.

    • Kielhen

      Hi Kristopher,
      Yes the model which you described is common in NY area :” How many clinics operate in a model where the PT evaluates and writes plans only, and by ‘treat’ they mean spend 8 minutes of manual therapy for each of the 4 patients they have that hour while an often unqualified “tech” carries out the exercises…”
      Furthermore this operating model is illegal because of the fact that it is ” unlicensed practice of the professions”. If someone has the situation that you has to deal with it should call 800-442-8106 or email: conduct@mail.nysed.gov. about it . Albeit I think that this link and phone is well known for many.
      Significant number of therapists , at least in NY area, have to deal with the same as you described, because they forced to do so in order to maintain their employment. Usually this model is carried over in outpatient clinics owned by MDs, group of MDs, less often by PTs, and often in multi professional practices with MDs, DCs, Acupuncturists, Massages therapists. I know that 4 patients per 1 hour is a luxury in such places and very often it goes higher. Moreover at the same time one have to bill at least 2 billable units. In this particular situation Rippetoe would be right that PT is the fraudulent profession. However he even didn’t touch the issue.

      The other thing or perhaps the most important for many PTs as an outrageous opinion, is in fact only one sided vision of PTs as a sort of strength coaches with false foundation. Well I would like to emphasize that within PT field we have to consider a little more than 1 RMAx to design POC or program for a patient. PTs on daily basis deal with : different pain level, fear/false beliefs/, comorbidities ( which we have to consider very much), time from onset of pain/injury/surgery, and ” a little more”. No doubt strengthening is important aspect of PT’s world but it is not only one aspect. Unlike Rippetoe and many of his disciples
      who are operating only with strength training as a tool we have to consider and utilized many other tools besides barbels, dumbbels, kettlebells, I understand though that it is difficult to blame someone who operates with a hammer to see everywhere only nails. Just my 3 penny. Have a GREAT MEMORIAL DAY.

  15. Ashley

    I am going to keep it simple here and say I respect the message, and this is how I practice, but I feel very disapointed in the CPA for letting the link to this guys work be published. It is an incredibly simplistic view.

  16. Brittney

    Rippetoe should check out leaders in the industry like Charlie Weingroff, Gray Cook, and Craig Liebenson. Rehab = Performance = Rehab.

  17. The answer to how this makes me feel has been well explored at this point. I think the more interesting concept, from an outsider looking in standpoint (as I am not a PT) is what appears to be a migration towards more symbiotic programming. People in strength training circles now talk about “mobility.” Therapeutic practices have made their way into weight room… the barbell weight room. It seems there is more mixing of practices, at least on an individual level. IMHO: The future of wellness is not so compartmentalized as it is today

  18. Matt C

    Hello, excellent article. In my experience as a PTA and former avid weight lifter, Physical Therapy practionors do not give our patients enough of a challenge to make gains. You must challenge the body in order to improve. Using 2 pound ankle weights and 1 pound dumbells are a joke most of the time…The idea of emphasizing challenging compund movements is excellent because these movements incorporate large groups of muscles working together in a quasi-functional way. That is ideal. The basic concept that the body must be challenged to improve is often not practiced in PT and most PT’s that I have worked do nothing of substance to help their patients strength improve because they are NOT giving the pt. enough of a challenge. The criticism in the article is valid.

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