Barbell Physical Therapy: How to incorporate Barbell Training into Post-op sports Rehabilitation plans
Two of the biggest things guiding post-operative physical therapy are surgeons' protocols and individual physical therapy benefits.
Unfortunately, this scenario often leads to delayed strengthening and incomplete return-to-sport (or recreation or prior level of function) because physical therapists fear defying surgeons' protocol or lack of reimbursement from the insurance company.
After all, your treatment did not fall under what they deemed necessary.
I'm grateful to have some orthopedic surgeon friends and clients who have allowed me to pick their brains about developing their post-operative protocols for specific surgeries, like joint replacements or large or small tendon repairs.
A great deal of evidence-based research goes into creating the protocols that outline what exercises to start and when; these surgeons admitted that they aren't trained in exercises and leave it up to the physical therapists to determine when to begin with each client.
Even when physical therapists are brought on to help develop the post-operative protocols, unfortunately, physical therapists aren't trained in exercise prescription or strength training (learn more about this here).
This creates a significant problem.
I thought this was so interesting because most of the protocols clients come to us with have detailed timelines and specific exercises, even amounts of loads and rep schemes, that the clients often expect the physical therapist to follow.
I know that many physical therapists will follow the protocols to a T.
The fear of pissing the surgeon off or some major malpractice issue occurring because they did a leg press or squat a week or two early, or heaven forbid they so much as talked about an overhead press after shoulder surgery, scares them.
Because of these protocols designed by individuals who are not trained in rehabilitation nor exercise prescription, physical therapists delay incorporating "return-to-sport" or higher-level exercise interventions into the treatment plan, ultimately delaying the client's success.
So why do surgeons make these protocols, and how can physical therapists more effectively support their client’s and athletes’ recovery process?
Surgeons design the rehab protocols based on the type of surgery and expected healing times of the repaired tissues.
The main goal of their rehab protocols is to protect the integrity of the surgery while it heals with the expectations that most people will do more than what they are instructed to do.
While a percentage of people will follow the doctor's recommendations to a T or even become fearful of movement and do less, doctors are creating these protocols for the people who are most likely to mess up the surgery.
Unfortunately, what happens is there is a disconnect between surgeons and physical therapists.
→ Physical therapists get "instructions" from the doctor, aka a generic post-operative rehabilitation protocol and a prescription for physical therapy with some other details, and assume they cannot deviate from it.
→ On the other hand, orthopedic surgeons don't communicate any special considerations for the unique individual when sending them to physical therapy.
Instead, they assume the physical therapist is the exercise specialist and will do what's appropriate, even though physical therapists are not exercise specialists.
This leads physical therapists to delay incorporating strength training into the rehabilitation process by focusing on range of motion, pain management, and isometric exercises for far too long.
What needs to happen is barbell physical therapy:
As soon as an active or active-assisted range of motion is appropriate based on the healing times of the tissue, active concentric and eccentric strengthening exercises need to be incorporated into the treatment plan.
Large multi-joint exercises should be prioritized instead of focusing on muscles in isolation and working with submaximal loads.
The most optimal choices of exercises are the squat, deadlift, bench press, overhead press, and horizontal or vertical pull.
And the best way to use these to get clients stronger and in "return-to-sport" mode early in the sports rehabilitation process is to load them treatment session after treatment session incrementally.
How can we do this if the client's range of motion is limited by pain, swelling, the surgical site still healing, the doctor's protocol doesn't include barbell training as rehab specifically, and the physical therapy clinic does not have optimal equipment to perform these movements in this fashion?
How can you start incorporating barbell training in sports rehab?
By modifying and adapting!
No matter what setting you're in, there are ways to integrate the principles of barbell strength training and progressive overload into your physical therapy treatment.
1. Think Globally, Not Locally:
First and foremost, we must remember that general fitness levels take somewhat of a hit when someone goes through surgery. Whether they are in bed for a month or at work the next day, there will still be a decline in fitness because they likely aren't walking around at their prior level of activity after surgery.
As physical therapists, we should ensure that we address the person as a whole and guide them on how to remain physically active within their surgery recovery.
Whether that's incorporating cardiovascular exercise in their plan, simply walking around a hospital room, up and down the hallway, on a treadmill, or pedaling on a bike, do something to help them maintain some fitness.Encourage them to do this on their own as well. We often find clients shy away from things like going for a walk, cooking, cleaning, or even going up and down the stairs after surgery because they think they can't.
Help your clients understand the benefits of being active within the limits of their abilities after surgery is a significant factor in athlete recovery and rebuilding their prior level of activity quickly and optimally.Incorporate strengthening for their whole body into the treatment plan. If this isn't optional in the constraints of time frames you have for working with your clients, then at least strengthen the entire limb affected and not just the area above and below the joint.
You should also be strengthening the opposite limb just as much as you are on the surgical side. Research has shown that neuromuscular adaptations occur from strengthening the uninvolved limb in the absence of being able to truly load the surgical side.
2. Modify the Movement For The Individual's Range Of Motion And Strength Level:
The main barbell lifts that focus on maximizing strength and muscular development are the Low Bar Back Squat, Medium Grip Bench Press, Conventional Deadlift, and Overhead Press. These movements are the most functional strength training exercises because they move our bodies through gross functional ranges of motion in patterns applicable to every movement we can do. They utilize the greatest amount of muscle mass and should be moved through the greatest effective, efficient, and available range of motion.
While it's popularized that unilateral stance and balance exercises are more functional, these movements cannot be loaded as effectively nor address the same criteria as the main barbell lifts mentioned previously.
Instead, we want to focus on utilizing these movements as the main strength drivers in the rehabilitation process.
This may seem pretty silly to a lot of physical therapists thinking, "Well, Mrs. Johnson is 75 years old, just had a total knee replacement, and has restricted range of motion in her shoulders due to osteoarthritis, so how the heck is she going to low bar back squat?"
Fear not!
Each of the main barbell lifts can be modified to accommodate the physical abilities in strength, range of motion, and functional level.
The key is to find the next best option in exercise selection and apply the same exercise prescription principles using a variation of the main barbell lift.
For Mrs. Johnson, this may be the pin-loaded horizontal leg press or simply a sit-to-stand from the treatment table holding a dumbbell.
3. Find A Starting Load That Is Appropriate:
One of the biggest challenges faced with the idea of barbell training is that "heavy weight is dangerous."
Many doctors, physical therapists, and people don't understand that barbell training doesn't necessarily mean squatting 405lb and benching 315lb.
Even if Jason has a history of squatting that much, he shouldn't be jumping right back into "heavy" training loads after his lumbar fusion.
Incorporating barbell training into the rehab process means finding a load appropriate for what their tissues, pain, and strength can handle and building slowly and steadily from there.
This may mean that Jason begins with a high box squat and a 15-pound aluminum bar on his back at six weeks post-lumbar fusion and progresses in load and range of motion as best he can every session.
Jason is back to squatting 405lb to depth within the appropriate time without pain or interruption to his surgical site.
When you strip the idea of barbell strength training and progressive overload down to its core, it becomes less intimidating and more applicable to everyone in every situation.
You can see how a barbell back squat isn't always 315lbs, crushing your disks and exploding your knees.
You can see that it could be a sit-to-stand without weight or a leg press with 20lbs.
You can see how a barbell bench press isn't always 405lbs that will tear your pec and blow out a disk in your neck.
You can see that it may be an incline push-up or a supine dumbbell chest press on the treatment table with 3lbs.
The keys to barbell physical therapy are:
The movements must utilize the greatest amount of muscle mass through the greatest effective, efficient, and available range of motion. This is done by meeting the client where they are at in terms of strength, range of motion, tissue healing, and willingness to learn.
The load must be light enough to meet them where they're at without damaging tissue physiology.
The exercises must be progressed in load and range of motion as regularly as possible to continue challenging the body to get stronger while it's healing.
Unfortunately, however, this is something not taught in school, so physical therapists fall into three categories:
The physical therapist who blindly follows the surgeon's protocol because they don't know what they don't know and believe that's what they are supposed to do.
The physical therapist who knows standard rehab protocols fall short but is afraid to deviate from the surgeon's protocol because they don't know how to do it appropriately.
The physical therapist who deviates from the surgeon's protocol appropriately because they have sought out continuing education to help them be forward-thinking and progressive in the field of physical therapy.
Taking all this into account, we feel it's essential to have appropriate tools in your clinical setting to help each individual who comes to you for physical therapy and rehabilitation.
We understand that you may be working in an environment with little space for standard barbell strength training equipment.
We also know that there is often pushback in traditional outpatient s[prts rehab physical therapy settings from physical therapists or management who disagree with the idea of integrating barbell training into physical therapy.
But that doesn't mean you cannot clinically apply the principles of barbell training and progressive overload to every client who lands on your treatment table. You can.
We've put together a free starter kit to download to help you navigate what tools you can use to properly apply the fundamental principles of barbell strength training and progressive overload early on in the rehabilitation process.
This will ensure that you're focusing on rebuilding, restoring, and reconnecting your clients' strength and conditioning regardless of how old or young, strong or weak, athletic or not, they are.