Introduction 

Physical therapy is a profession that, through its progression in recent decades, has become thoroughly connected with the field of exercise science. Physical therapy has been an historically effective medical treatment method that has been prescribed to orthopedic patients in some form of another for centuries. However, its use and the widespread understanding of its implementation increased significantly in the mid to late twentieth century (Moffat, 2003). 

Physical therapy can be simply defined as a method of treating various injuries or ailments using physical techniques and exercise. Therapists use controlled movements and physical resistance to relieve symptoms, pain, and other physical issues in patients and develop physical strength (Bentley, 1926). Exercise science is the study of physical movement patterns that affect and increase fitness and overall health, and much of the understanding and ideas that come from this field influence the way physical therapy is practiced (Petrizzo, 2013). The fields of physical therapy and exercise science are therefore deeply intertwined and follow similar principles.

The primary aspect of physical therapy that will be observed in this research is that of outpatient orthopedic rehabilitation. This division of physical therapy deals with patients with specific musculoskeletal or neuromuscular injuries or impairments, and this can include everything from patients rehabilitating after surgical operations to people with various types of chronic or acute conditions (Huynh, 2019). This specific section of the physical therapy industry is one of the most widely administered forms of physical rehabilitative treatment, distinct from less common practice areas such as neurological or cardiopulmonary physical therapy. This is the type of physical therapy that most people seem to be familiar with, and it is often characterized by images of stretching on yoga balls, and exercising with neoprene dumbbells and brightly-colored resistance bands (Blochowiak, 2019). All physical therapists share the common goal of improving their patients’ conditions using corrective strengthening exercises, however some doctors differ in their treatment methods and, in particular, exercise selection, with some approaches being more advantageous than others (Barnes, 2019).

The purpose of this research is to determine why a vast majority of physical therapists are still practicing methods of strength development with their patients that research and reasoning have suggested are sub-optimal when compared to alternatives. Strength development is incredibly important in rehabilitative treatment, as it is an important method in resolving the root cause of a debilitating condition, and is also the primary means by which joints of the body can be protected from external stressors (Sports Medicine Institute, 2018). Strength, in addition, is quite likely the most important physical attribute that can be developed in an individual as its improvement leads to improvement in nearly all other areas, including mobility and balance (Rippetoe 2019). The aforementioned yoga balls and resistance bands have been features of physical therapy practice for decades, and this is a primary result of the influence that exercise science has had on it. However, critical examination of the uses of such equipment will demonstrate that more effective rehabilitative protocols exist.

Some more progressive doctors of physical therapy have begun to replace these outdated modalities with more aggressive protocols in their clinics, particularly barbell training. Most people seem to associate resistance training using barbells only with powerlifters and other intense athletic populations, but recent research combined with clinical experience and inductive reasoning has shown that its proper implementation can have significant results in a clinical setting (Baraki, 2015). Despite their misconstrued social connotations, barbells can easily be used in the clinic because, when used correctly, they are safe, dosable, and infinitely scalable (Sullivan et al., 2016). The overwhelming majority of physical therapists, however, have been hesitant to adopt and begin utilizing basic barbell movements (Petrizzo, 2013), and this study aims to determine why.

Review of Literature 

Before diving into specific details about the way physical therapy is currently practiced, it is essential to understand the fundamental principles that dictate the way humans heal and adapt. In 1936, a Hungarian researcher named Hans Selye concluded that all living organisms demonstrate what he referred to as the General Adaptation Syndrome. A basic tenet of this idea is that “anything that causes stress endangers life, unless it is met by adequate adaptive responses; conversely, anything that endangers life causes stress and adaptive responses” (Selye, 1950). Stress, in this context, is any form of internal or external threat to a vital organ system and can be anything from a sunburn to a deadly disease or injury. What Selye pointed out is that in order for an organism to survive in an ever-changing environment, it must adjust itself to protect against all forms of danger and maintain a homeostatic condition. 

Selye demonstrated this pattern by showing that when organisms were exposed to various forms of stress, they responded with adaptations that were specific to protecting itself from that particular stress. These scientific conclusions from Selye had an enormous impact on anthropologists’ understanding of human physiology (and scientists’ understanding of life in general), and the application of these principles became useful in both the medical and exercise communities. 

Expounding on Selye’s research 63 years later, Mark Rippetoe and Andy Baker wrote the third edition of Practical Programming for Strength Training 3rd edition, which features an in-depth examination of how Selye’s General Adaptation Syndrome applies to athletic performance and strength training. Rippetoe and Baker’s work provides the most comprehensive organization of the basic principles that were being utilized in the strength training community for decades. The simple extension of Selye’s principle they coin in the book is known as the Stress/Recovery/Adaptation Cycle, and explains (generally) how organisms respond to stress. The understanding is that humans respond to stress by recovering to homeostasis with the new stress environment, adapting themselves to gradually escalating stress events, and that this is easily observable in and applies well to the concept of physical training (Rippetoe & Baker, 2013). 

The application of this principle to general fitness development (not only strength training) is that any form of physical exercise is, in and of itself, a form of stress to which the body must adapt. The body responds by making itself more physically fit to handle that stress, whether it be long-distance running or heavy barbell training (Rippetoe & Baker, 2013). This has been the basic idea behind rehabilitative protocols, with therapists ultimately using various forms of exercise to stress a body part or area to therefore force an adaptation to occur in the tissues that will make the area stronger, healthier, and more resistant to injury (APTA, 2003). According to Rippetoe and Baker in Practical Programming, “while caution is necessary to avoid further injury, the belief that rehabilitation can occur in the absence of overload [progressive resistance training] represents a failure to comprehend the basic tenets of the physiology and mechanics of the living human body” (Rippetoe & Baker, 2013). 

Mark Rippetoe, a barbell strength coach with 40 years of experience, also published the third edition of another book in 2011 titled Starting Strength: Basic Barbell Training, 3rd edition, which makes what is perhaps the most clear and convincing case for basic barbell exercises being the most effective means by which to develop strength in humans. Backed by deep explanations using principles of physics and human physiology, the models presented in this work demonstrate that basic exercises that utilize the most muscle mass, the longest effective range of motion, and the most weight resistance are the most valuable resources for generating significant adaptations to increase strength (Rippetoe, 2011). Such exercises include the low-bar back squat, the deadlift, overhead press, and bench press, among others. Exercises that fit these criteria, with a few exceptions, can only be accomplished using barbells. A barbell, as it is typically referred to, is a 45-pound (20kg) straight metal bar that can be fitted with round weight plates. Contrary to what some may believe, they are not one-size-fits-all, and can be scaled to nearly any weight using lighter bars and fractional plates, to meet the specific needs of any individual to allow them to perform these highly beneficial movements. 

Strength is arguably the most important physical fitness characteristic, and the majority of other notable fitness characteristics are based almost entirely upon this single attribute (Rippetoe, 2019). Strength is also most efficiently developed through training, which is a process made up of constituent steps or workouts done to achieve a longer-term goal, as opposed to exercise, which is movement done for its own sake or without a clearly defined goal (Rippetoe, 2013a). Physical therapy, then, would clearly fall under the umbrella of training as it helps patients along a path to the goal of improving physical fitness and relieving symptoms. It would seem intuitive then that physical therapists, who are tasked with rehabilitating people and returning them to normal function and health, would use tools such as barbells to their advantage in the clinic. This is not the case however, according to Austin Baraki MD and John Petrizzo DPT SSC, and others, who point out that very few physical therapists have taken advantage of these methods. 

So, in order to explain the issues and inadequacies present in current physical therapy practice, it is important to focus on the shortcomings in understanding faced in the medical community as a whole when it comes to strength training and exercise. In a 1999 survey done by Walsh, Swangard, Davis, and McPhee, it was found that only 12% of primary care physicians reported being aware of the current American College of Sports Medicine (ACSM) recommendations for exercise, which includes recommendations for resistance training of some sort. This gap in knowledge is seen in the exercise science/medical research community (which is closely related to that of physical therapy and rehabilitative training/injury prevention), where students are allowed, and often required, to conduct research on topics that they and their professors themselves have limited knowledge on or experience in (Petrizzo, 2013). These studies are typically published as “peer-reviewed,” which has allowed for many possibly inadequate or simply false conclusions to be made part of the exercise science literature (Rippetoe, 2015). According to Jonathan Sullivan MD SSC, and co-author (with Andy Baker) of The Barbell Prescription: Strength Training for Life After Forty, “Conventional wisdom is highly flawed, consisting primarily of small, short studies using what I call ‘low-dose’ resistance training, poorly programmed and administered” (Sullivan et al., 2016). 

A prime example of this flaw in the research is the 2016 study by Morton et al., which claimed to have found that “neither load nor systemic hormones determine resistance training-mediated hypertrophy or strength gains in resistance-trained young men.” A review of this study by doctors and strength coaches Sullivan, Baraki, Petrizzo, and Gotcher, in a 2016 formal panel, displays the countless flaws in its methods and conclusions, and simply shows that some researchers are just not on the same page when it comes to an understanding of basic strength training, and its effects and proper implementation (Sullivan et al., 2016a). This problem stems from, and is juxtaposed with the fact that the educational institutions that teach exercise science or rehabilitative sciences do not actually discuss “the basic concepts of stress, recovery, and adaptation,” and do not provide exposure to the most effective ways of applying the basic principles of physical development (Petrizzo, 2013). 

These problems have become widespread in the physical therapy industry, particularly when it comes to outpatient orthopedic rehabilitation. Many physical therapists fail to prescribe appropriate exercise programs to patients that would elicit sufficient strength adaptations in them, and this problem is rampant in hospitalized patients along with outpatient orthopedic patients (Baraki, 2015). According to John Petrizzo, DPT and SSC, physical therapists need to shift their focus from “functional training” and other modish exercise concepts, and prescribe basic barbell exercises in a linearly loaded fashion to optimize patient outcomes. A more in-depth examination of the effects of these problems would help to determine exactly why physical therapists fail to incorporate more effective exercises for strength development in patients. 

Physical strength is the most important physical determinant and attribute, and its correct and optimal development is crucial to physical performance and ability (Rippetoe, 2011). For example, 2019 and 2017 studies by Welling and Pua, respectively, have both shown that knee strength and muscular strength development have significant positive functional outcomes in patients with an ACL reconstruction. In addition to this, a 2007 study by Seynnes, de Boer, and Narici, and a 2015 study by Bohm, Mersmann, and Arampatzis, both demonstrate the significant muscular adaptive changes that bodily tissues experience as a result of resistance training. And the powerful anecdotal story of Brian Jones (Schudt, 2013), a patient who fully recovered from severe back and pilon fractures, demonstrated that it was most productive for patients to utilize exercises that most effectively and rapidly develop strength. 

As explained by Petrizzo and Baraki, many therapists attempt to use sub-optimal exercises for strength development, and have varying degrees of success with them. Mark Rippetoe and Doctor of Physical Therapy Michael Mash both effectively explain that these exercises are substandard when compared with basic barbell exercises, like the low-bar squat and the deadlift. These exercises are actually good for the health of muscles, bones, joints and their surrounding structures (Gotcher, 2018). Contrary to what seems to be popular belief, their proper implementation in rehabilitative protocols results in stronger patients and therefore superior outcomes (Goldenberg et al., 2018).

Methods

Given the condition of popular physical therapy practice as discussed previously, this research was designed to identify reasoning and correlations that may help explain why many therapists hesitate to practice more effective and advantageous methods of rehabilitation. A survey was used to collect this data; this method being helpful in allowing a fairly large and diverse sample to be reached remotely, and with consistent interaction and collection. The survey was created using Google Forms and emailed to potential participants, an attempt to cater to the busy schedules of Doctors of Physical Therapy with convenience, to ideally yield a higher response rate than alternative survey distribution methods.

The survey was provided to practicing physical therapists, holding a Doctor of Physical Therapy degree (DPT) or previous iterations of it such as a Master of Physical Therapy (MPT). To obtain as comprehensive a research sample as possible, participants were se1ected from all major areas around the Charleston, South Carolina, area including John’s Island, James’ Island, Mount Pleasant, West Ashley, Daniel Island, North Charleston, and Charleston. All areas within this geographic boundary fall within Charleston County, with the exception of Daniel Island (Berkeley County). Participants were identified via two methods: the administrative list from a major hospital system and from online listings. Outpatient orthopedic physical therapy clinics were identified using these resources and each was contacted via telephone to obtain preliminary consent and the email addresses of individual therapists. The majority of clinics contacted agreed to provide therapists’ email addresses while some offered the email address of an office administrator, all of whom expressed intent to distribute the survey once it was received. A link to the online survey and a consent and authorization form, which discussed risk and provided information about the research, was then emailed to each requested participant.

The design of this survey was based on two similar studies: one by Walsh et al., a survey of physicians about exercise counseling in San Francisco, and one by Li and Bombardier, a survey of physical therapist approaches to low back pain treatment in Ontario, Canada. Both of these studies used specific and detailed questions to identify demographic information about participants and to collect responses on their practice preferences and perceived understanding of certain topics. This research study surveyed participants with questions derived from these two studies to explore similar topics of practice of habits and understanding among physical therapists.

After first requiring the participant to confirm that they had received and reviewed the consent and authorization form, the first section of the survey asked participants to provide demographic information about themselves including age, sex, practice status, number of patients treated per day, and personal exercise habits. The second section of the survey had the participants respond to specific treatment questions, with several ways to respond. Physical therapists were asked to specify the types of training equipment available to them, checking boxes to indicate yes and included a write-in option as well. Respondents were also asked to rank their personal confidence with barbell-based movements, including their understanding of, comfort with teaching, and willingness to use these movements in their own practice. These questions could be responded to with a yes/no/maybe, a ranking on a scale from one to five, or a scale from very comfortable to very uncomfortable. The therapists were also asked to rank their agreement with a statement about physical strength in patients, on a scale of strongly agree to strongly disagree. These respondents were asked to review a list of potential barriers to using barbell movements in their clinics and to indicate those which they believe to be significant (a write in option was also included). This brought the survey to a total of 12 questions.

Results

The survey was sent via email to a total of 84 people, including therapists and clinic directors, who were asked to complete the survey or distribute it to those who could. The response rate for the survey was 45% or less, with 38 therapists completing it (exactly how many therapists received the survey is not known since clinic directors were included).

Respondent characteristics are described in Table 1. Half of all therapists who responded were over 35 years of age, and half being younger than or equal to 35. The respondents were 55% male and 45% female. 92% of therapists claimed to be working full time, and on average each respondent reported treating about 12 patients per day. 87% of therapists reported exercising regularly, for an average of 3.4 days per week.

Table 1. Demographic characteristics of therapists responding to survey (N = 38)

Characteristic		Mean or %	S.D.
Age
>35 years old (n = 19)		50%
<35 years old (n = 19)		50%
Sex
Female (n = 17)		44.7%
Male (n = 21)		55.2%
Practice Status
Full time (n = 35)		92.1%
Part time (n = 3)		7.9%
No. patients seen daily		11.66	3.28
Exercises regularly		86.8%
No. days a week exercises (n = 33)		3.4	0.73

Therapists’ equipment availability, attitudes, and prescription behaviors are described in Table 2. Over half (57.9%) of respondents reported having access to barbells in their clinic, and 100% agreed (to some degree) with a statement that indicated strength development being critical to the rehabilitative outcomes of patients. Over two-thirds (68.4%) indicated that they are currently or would consider using barbell movements with patients. 57.9% of respondents claimed to have the greatest level of understanding possible of barbell exercises, and almost three-quarters (73.7%) reported feeling very comfortable teaching new movement patterns to patients.

Table 2. Respondents’ equipment availability, attitudes, and prescriptions (N = 38)

Characteristic	n	%
Available equipment
Resistance bands	38	100%
Dumbbells and/or kettlebells	38	100%
Variable-resistance exercise machines	29	76.3%
Barbell(s)	22	57.9%
Yoga ball(s)	34	85.9%
Medicine balls	32	84.2%
Stationary implements for bodyweight exercises	33	86.8%
“Physical strength development is critical to rehabilitative outcomes”
Strongly agree	27	71.1%
Agree	11	28.9%
Disagree	0	0%
Strongly disagree	0	0%
Currently using or considering using barbell movements with patients
Yes	26	68.4%
Maybe	1	2.6%
No	11	28.9%
Rank understanding of barbell exercises (scale 1-5, lowest to greatest)
1	0	0%
2	0	0%
3	3	7.9%
4	13	34.2%
5	22	57.9%
Comfort teaching new movement patterns to patients
Very comfortable	28	73.7%
Comfortable	8	21.1%
Uncomfortable	0	0%
Very Uncomfortable	2	5.3%

Figure 1 describes frequency in which barriers were reported by therapists as factors relevant in their decision not to prescribe barbell exercises to their patients (only therapists who do not use barbells were asked to respond to this question). Most therapists who answered this question reported not having access to barbells, and it was not inquired whether they would use them if they did. Many respondents also answered that barbells were not applicable or appropriate for their patients, and others reported needing more personal experience, space in their clinic, or had insurance concerns.

Discussion 

From Table 1, it can be seen that the survey was evenly distributed to a fairly diverse sample of therapists. The surveyed group was demographically balanced between male and female respondents, along with having a wide range of ages. The majority of therapists surveyed reported working full time and exercising regularly, which means that this would appear to be an ideal sample to survey about barbell training in the clinic because most respondents have plenty of experience with physical exercise and therapeutic treatment. 

Table 2 supports the idea that barbells are available quite infrequently in physical therapy clinics, being the least-indicated of possible available equipment. It is anticipated that they have even less availability in clinics than suggested by the data, due in part to a potential knowledge gap surrounding barbells – a likely limitation that will be noted shortly. All therapists surveyed prioritize or at least understand the importance of strength in physical rehabilitation however, with one-quarter of respondents noting that they “agree” and three-quarters that they “strongly agree” with the idea that strength development should be a critical element in their approach to treatment. Over two-thirds of respondents then went on to indicate that they were currently using barbells in their practice or were open to the idea of it. This data point limits the conclusions that can be drawn from the data, as multiple limitations have made possible various conflicting ideas that can be developed from it. The majority of the respondents also claimed to have the utmost knowledge of barbell exercises and confidence in their ability to teach movements to patients, which could be a potential example of overconfidence and the knowledge gap referenced earlier. 

Figure 1 lists the barriers to utilizing barbell movements given by those who fail to do so. This data point is problematic in ways similar to the one previously mentioned, as it fails to provide an accurate view of the problems at hand and is bound by various limitations. Nonetheless, this data indicates that the most frequent reason that barbells are not used is due to their unavailability in clinics, closely seconded by the claim that they are not applicable or appropriate for most patients. The claims that barbell movements are not appropriate for many patients can be used as evidence of the knowledge gap in physical therapy, in light of the overwhelming evidence supporting the use of barbells. 

Overall, this data, despite its being somewhat convoluted, confirms this researcher’s hypothesis that a significant number of therapists are not utilizing barbells in their clinics, and it appears that the main factors that deter them are the lack of equipment availability in their clinics and their own lack of experience and knowledge, likely due to the relevant educational institutions. However, this data is unfortunately lackluster in comparison with what it had the potential to reveal,  due to the many limitations that will be addressed in detail. 

Limitations 

There are multiple limitations to this research that need to be addressed. The first of which is that the sample size is limited and may contain some bias. The method of distributing the survey was less than optimal, and future researchers would be advised to distribute to a larger sample via better means by using an official registry over a Google search. The respondent population also contained a group that likely skewed the data in a way that may not be representative of the greater physical therapy industry: the survey was distributed to a PT clinic from which the researcher received shadowing experience and expert advice. The four doctors at this clinic responded and made up 10.5% of the total survey group, a significant percentage, and from a clinic that is the only one to actually use barbells in the Charleston area. 

Another point of concern is the design of the survey itself. The survey was modeled carefully after those in similar research studies, yet it ended up with technical errors in the wording that were not realized until the collection of the data was complete. The issues in particular were in the two questions referenced earlier. One of these questions inquired as to whether respondents currently did or would consider using barbells for rehabilitative purposes. The question was phrased as such in an attempt to shorten the overall survey for compliance reasons, but should have been divided into separate questions to get two separate data points regarding the current frequency of barbell inclusion in protocols versus overall attitudes in those who do not. The second problematic question followed the previous one, and was unsatisfactory due to the confusion from the previous question. It requested that respondents who answered “no” to the previous question to indicate what was preventing them. This question did not clearly determine whether therapists would use barbells if they could, which is likely why the most frequent answer to that question was that they are not available in the clinic. 

The last major limitation in this research is the complex knowledge gap between exercise science and physical therapy. The information given to respondents about the survey did not provide a clear definition of what was meant by barbells and barbell exercises, which ultimately should have been included. But because physical therapists are not required to have any knowledge of these particular exercise movements, it is likely what caused discrepancies in the data. It is entirely possible, and even quite likely, that many of those surveyed may view barbell training as a foreign concept or do not have intuitive knowledge of barbells and the correct execution of their movements. This could be a reason why more people than expected reported having barbells available as they could have easily been mistaken for similar pieces of equipment. It is also worth mentioning that there is the possibility that some respondents’ confidence in their knowledge and abilities affected the data as well. As seen in one of the later questions, most therapists rated themselves as having the highest possible level of understanding of barbell movements, which is likely an overestimation as there are still a very limited number of colleges and organizations have begun to teach these movements in ways that are based on physics and biology as opposed to conventional wisdom. 

Implications and Future Research 

Because the research is limited in sample size and is geographically restricted, conclusions may only be made about this particular sample. However, the data collected from the examination of these medical professionals may be useful to infer greater conclusions about the physical therapy industry as a whole. In the context of the limitations surrounding the survey, the results suggest that barbells are in fact scarce in availability and use in PT clinics, or the least frequently available. The data from this research puts forth evidence that physical therapists are not adequately equipped with knowledge of and experience with barbells and their role in strength development, however limited that evidence may be. The conclusions pulled from this research sample can be reasonably extrapolated to the rest of the industry in general, and it is safe to infer that a majority of clinics across the nation may share the behavior and attitudes of this sample. 

A solution to this discrepancy in the physical therapy industry would be to improve the educational opportunities for physical therapists and exercise science majors about the correct use and application of barbell movements. Organizations such as Starting Strength have made great advancements in creating an effective teaching method and defense for these exercise techniques, and why they are important in a wide variety of ways. 

Further research should be done to further the understanding of this topic. Although the researcher established the current state of physical therapy and barbell training in Charleston, South Carolina, and identified major issues within the exercise science/physical therapy education process, there are still issues to be addressed specifically, such as how to overcome this knowledge gap and how to implement this beneficial rehabilitation model on a large scale. Barbell training is not a silver bullet that will solve every problem in a person’s physical existence, but it has had a dramatic impact in many peoples’ lives, and it has the potential to seriously improve the quality of life for multitudes.

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References

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