by Bret Contreras February 01, 2011
I’ve had some great conversations with Shon Grosse over the past year and a half. Shon is a good guy who really gets it. I’ll let Shon introduce himself.
1. Shon, please introduce yourself to my readers. Please include education, experience, and continuing education.
Bret, thanks for this opportunity. I am a physical therapist and athletic trainer in Colmar, Pennsylvania, which is 45 minutes from Philadelphia. My undergraduate training was in Exercise Science with Athletic Training emphasis from Penn State. My physical therapy training was at Hahnemann University in Philadelphia, where I received my Masters’ in Physical Therapy. Since this time, I have worked almost exclusively in orthopedic physical therapy. For the past 10 years, I have been in private practice, starting as an “on site” therapist in industrial settings, opening a small office in 2002, and ultimately building our current location almost 3 years ago. My current clinical practice is 80% physical therapy and 20% personal training/strength training. I have a staff of 3 other physical therapists with whom I am privileged to work with, as they are both colleagues and friends.
In addition to my physical therapy and athletic training licensure/ certification, I am CSCS certified, as well as RCEP and HFI credentialed with the ACSM. I also have Club Coach certification with USAW, in addition to Level 1 certification with USATF. As an athlete, I have shodan rank in both Shotokan and Isshin Ryu karate, and am training/ competing as a masters’ sprinter.
My continuing education is varied and vast; at this point I have over 700 hours of workshop/ seminar time, not including independent study. I’ve taken courses with Shirley Sahrmann, Stuart McGill, Dave Tate, Kevin Wilk, Loren Seagrave, and Jenny McConnell, to name a few. I also have regular contact with great coaches such as you and Eric Cressey. The key to great continuing education is to go outside of your field and listen to others who have had success, then implement these ideas carefully and appropriately.
2. That’s very impressive Shon. What are your thoughts on the topic of isolation of muscles and muscle function as it relates to Physical Therapy?
As a physical therapy student, among the first course you take is gross anatomy. The way it was taught when I was in school was body region by body region, origin, insertion (of muscle on bone) and action (independently, or in concert to affect 1 or 2 joints). Therefore the bias for isolated movements has already started within your first 6 weeks of formal education. Musculoskeletal evaluation testing is taught one joint at a time, one muscle test at a time, so “isolated movement” bias continues to be reinforced. Other coursework follows, and often it is like keeping your head above water just trying to keep on top of the information. As such, really digesting a comprehensive understanding of full body movement, both normal and pathological, can be difficult in your classroom education, as well as early on in clinical field experiences. Compound this with manual therapy training that is also taught in an “isolated” manner, and you can see a young therapist having a bias toward a “one joint only” approach to treatment vs. “joint by joint”/ movement impairment syndrome approach.
What happens clinically, as an example, is that a therapist treats a rotator cuff tendonopathy with theraband “strengthening” exercise exclusively vs. looking at middle/ lower trapezius weakness, thoracic spine mobility, pectoralis minor tightness among other things. The same thing happens in the lumbar spine/SI region. Manual therapy is used to “correct” an SI joint alignment, with no attention given to hip mobility or pillar stability as part of a home program. The problem that brought them to you in the first place re-surfaces within weeks or months, creating a vicious cycle.
This doesn’t mean that there are not excellent physical therapists graduating, and there are certainly many competent and great practicing physical therapists across the country. As a profession, I think we could do better (including myself), and we should keep striving for improvement in integrating whole movement system evaluation and treatment strategies. Shirley Sahrmann’s program at Washington University in St. Louis, integrates the well known and very effective Movement Impairment Syndrome classification and treatment approach throughout that curriculum, ensuring a common integrated movement language among therapists. FMS and SMFA are addressing these needs as well. Until this type of approach in looking at movement more comprehensively becomes universal, we will still have therapists treating like the aforementioned examples, leading to the patient to having a less than optimal outcome.
3. Do you believe that most Physical Therapists “push the envelope” far enough to prepare their clients for tasks they’ll face in the real world? In other words, are they too “sissy?”
Bret, this dovetails from what I just finished discussing. As physical therapists, we have to really understand what our patients real world activities are like; i.e. what their mobility, stability and strength demands entail. We then can apply our skills to that particular patient, safely improving mobility and strength in a progressive manner, careful not to exacerbate the problem(s) they were sent for. When the patient has met their goals, they are finished with you. Hopefully they have learned something along the way, and have been given activities, drills, and exercises for continued use independently, understanding “why” they need to do them. We need to tread lightly at first, then progress as aggressively as tissue healing parameters allow at each stage of recovery. Believe it or not, “sissy” exercises or activities actually have a place in acute injury or post-operative phases to allow safe tissue maturation, and gradually allow one to add additional tissue stress in the form of mobilization, stretching or strengthening later in the process.
That said, over the past 20 years, I have seen repeatedly in physical therapy clinics that just blew my mind. Things that kept the bar so low for patients, that I wonder if anything of value was done at all for the person. An example was a patient who had elbow tendonitis/ tennis elbow in a clinic where I worked early in my career, being treated by a different therapist. The therapist’s discharge exercise was wrist extension (reverse wrist curl); the weight for that patient was 2 lb. for 3 sets of 10! This patient generated more force opening and closing their car door coming to and leaving the clinic than they did in the clinic, never mind possibly returning to tennis!
You have to ask yourself this question: why not a more comprehensive approach to this person’s exercise progression before they finish with you for good? How about actually re-training the extensor muscles just shy of symptom reproduction, then progressing time under tension, sets, and weight? How about offering hub grip exercises, push-pull activities with wrist extension, even static racket holds in symptom provocative positions, modifying them as pain allowed? You have to apply appropriate controlled stresses to the injured tissues, progressing and adjusting accordingly. A 2 lb. may be appropriate to see if the injured tissues can handle contractile stress, especially in post operative conditions, but you would be remiss as a therapist if you didn’t have a plan to progress beyond this arbitrary level. The same thing holds true for low back pain, balance/gait disorders, patellofemoral pain or any other patient condition. If you don’t progress the patient in the clinic and at home/in the gym, maximizing mobility, external load, balance/ proprioceptive challenges, as well as progressive return to their activity of choice, expect that patient to have continued problems outside your clinic in their real world.
4. I know that you train pretty hard. Do you believe this improves your ability as a Physical Therapist?
I believe this is true. My training started in junior high school and laid the foundation for my career. When I train, I reflect on how I can continue to safely improve my performances and this helps me brainstorm techniques and/ or ideas for use in the clinic and with my training clients. For example, the hurdle mobility series I use for my low back, hip and knee patients had its’ genesis with a left lower extremity mobility and stability I suffered with since I was in high school, and only really understood for the past 4-5 years. Weight training and gymnastics are all about maximizing power while maintaining proper position, particularly in the spine and hips. Traditional karate training teaches you about pillar strength, core stability as well as static/ dynamic hip power. Sprinting is the summation of all the basic training that I do. Running fast at my age is like eating dessert after dinner as a kid-something you earned for doing things the right way for an extended period of time.
Training also serves as a great BS detector. I once had a significantly overweight manual physical therapist tell me at a seminar that you only need “a few pounds of pressure” to stabilize your spine for lifting tasks. This guy then went on to do the obligatory “suck in” maneuver to demonstrate for me. Others in our group nodded in passive agreement. Pretty sad, as this guy was otherwise a greatly accomplished and talented physical therapist. Joe DeFranco had a great quote I read that said something like “Unless you’ve spent time with a very heavy weight on your back, you are not allowed to take part in this discussion” on the topic “drawing in” the transverse abdominis vs. bracing the obliques/ rectus abdominis during lifting. While some may say this statement is a bit extreme, I agree with it in theory, i.e. don’t tell someone (especially a patient) to do an activity, exercise or movement drill, unless you’ve practiced it yourself and know what you want as an outcome from performing it.
Here is Shon doing tick-tocks: https://www.youtube.com/watch?v=jMjnPxHpa1I
5. How does manual therapy fit into the big picture? Do most physical therapists go overboard as it pertains to manual therapy at the expense of plain old exercise? In the same vein, do you feel that personal trainers overvalue the importance of SMR?
Manual therapy is integral to treatment of musculoskeletal disorders. However, the acquisition of skill takes time in both the classroom as well as in the field. In a physical therapist, these skills are widely varied, from joint mobilization to myofascial release techniques to Graston type massage, to PNF techniques. In addition, excellent palpation skills proceed the application of any of these techniques. You need “time in” the field to develop these very different skills, in addition to knowing the “when” and “how” of application. A therapist also needs to recognize when to decrease the use of manual techniques and increase the use of exercises/ drills/ activities as symptoms allow.
Most manual therapy course work is taken after a physical therapist graduates. Manual therapy courses and certifications are “big business” in many (but not all) cases, costing a significant amount of money and time investment. You can literally cherry pick your courses and/or your philosophy. As such, a newly minted and “certified” manual therapist may be eager to use his or her new set of “tools” for everything that walks in the door of the clinic. You can see the problem developing- someone has a hammer and everything looks like a nail!
The opposite is also true. Many therapists feel manual therapy is a “temporary” fix, which doesn’t have lasting effects, so exercise is the only modality given (I had a student recently who stated this was the philosophy in another local clinic). The mistake here is that appropriate manual therapy actually prepares the injured tissues for additional mobility work and/ or strength work. If you deny the patient this intervention, then you limit the overall effectiveness of your subsequent treatment. I personally think this is taking the easy way out, as spending actual one on one time with a patient performing manual therapy requires significant physical and mental energy.
Self myofascial release as a tool should be used when needed. Are there “knots”, trigger points etc. that need to be “rolled out”? If there are, by all means roll them out. However, I am of the belief that most trigger points that are chronic have a root in some sort of joint mobility issue proximally or distally to the site as well as an odd agonist-antagonist over/underactivity problem. I rarely use SMR on myself; I just don’t have trigger point/ tissue quality issues, because my overall program addresses the other components well. Unless you address specific impairments, you will keep treating the symptom over and over until you find the root cause of the tissue restrictions. Learn to look beyond just the soft tissues at some level, and investigate joint mobility restrictions, muscle length limitations, as well as muscular activation patterns either independently or with the help of a competent professional.
6. Is being a great strength coach just about understanding Functional Anatomy? In other words, would most Physical Therapists make better strength coaches than the actual strength coaches?
Great strength coaches are great because they are COACHES first and foremost. A physical therapist is not a coach, and no, coaching your daughter’s soccer team doesn’t count! A great strength coach has a strong understanding of anatomy, but doesn’t need the micro specific knowledge that a physical therapist has. More importantly, a competent strength coach should know movements as well if not better than the anatomy, and how to coach and correct the specific patterns they are teaching. Functional movement is more important than functional anatomy in the S&C progression. Excellent coaches have also seen enough people move to know what is “right” vs. “wrong” without writing a dissertation for the athlete (Read Malcolm Gladwell’s “Blink” for more information on this). They can correct “wrong” simply and gracefully so athletes of all ages and education levels can understand and improve.
To my point earlier about physical therapists early training in anatomy: It is generally taught muscle by muscle, origin-insertion-action. Again, this is a tough bias to overcome, as we only move with integrated function, through a combination of concentric-isometric and eccentric contractions, stabilizing some joint complexes, while allowing allowing mobility concurrently at others to perform an infinite number of tasks. The movement skills that a therapist is trying to re-integrate in a patient vs. an athlete are different. Strength coaches are concerned about the end result of movement in an athletic context- very different then teaching someone how to lift a laundry basket or push a vacuum cleaner safely, or even stepping up and down a flight of stairs without aggravating symptoms, which is what physical therapists are dealing with much of the time.
There are great S&C coaches who are physical therapists and/or athletic trainers; Mike Boyle and Gray Cook, as well as Don Chu immediately come to mind. Their academic experiences and coursework do much enrich their coaching abilities. However, they still put their time in early morning and late evenings, weekends and holidays on the field, in the weight room as well as the clinic and/ or the training room. A physical therapist with no S&C background that doesn’t step out of the clinic and spend time at a field house, weight room, or track has about as much business telling an athlete how to train as an MIT trained engineer whose hands have never turned a wrench does fixing your transmission.
7. Are many personal trainers and strength coaches who have read the works of Sahrmann, McGill, and Myers overconfident about their abilities to assess and correct dysfunction?
I have had Shirley Sahrmann’s book for 10 years, have taken courses with her, re-read the book several times, and I still consider myself a neophyte with some of her information. Same with Thomas Myers-his book is an anatomy book for someone who has gone through at least 2 or 3 general anatomy/ kinesiology courses including gross cadaver dissection. I actually think a valuable course in a physical therapy curriculum would be an “Anatomy Trains” based class, looking at the integration of the fascial/functional lines in daily activities as well as in treatment of our patients-this would really help with some of the “origin-insertion-action” issues I discussed earlier.
I can see potential problems if books like these are a first foray into assessment for a newly certified S&C professional. There is just too much information here, as well as the fact that neither Shirley Sahrmann nor Thomas Myers are really writing for the S&C profession. I saw Thomas Myers this past summer at the Perform Better Summit, and he essentially said to the audience “I don’t know your world (S&C, personal training)”. He knows what he knows- fascia, fascial research, cadaver dissection and manual therapy. Same with Shirley- she teaches in the neuroscience and orthopedic departments at Washington University. The first research I ever read from her was on upper motor neuron healing in the post stroke patient. I bet neither has ever been in a proper weight room in their life. If you have been in the field for 10 years or so, I think both books are “nice to have”, not “need to have”. If you have been in the field less than 10 years, there are better ways to spent ~$150 or so.
8. These days there seems to be more “crossover” between strength coaches and physical therapists, which is definitely a great thing. We can both learn a lot from each other. However, why is it important that both fields understand the distinction?
As long as strength coaches, athletic trainers and physical therapists keep their own little fiefdoms, the end user (athlete, patient) suffers. Strength coaches and physical therapists should work to ensure they have an appropriate network of other professionals, local, regional and national whom they can refer for areas outside their content expertise. As a strength coach, it is healthy to “suspect” a problem that may have a deeper, more complex issue that a physical therapist (or chiropractor, or nutritionist) may have insight to. If you try to “fix” the problem yourself, you potentially can miss a complex issue that can take longer to resolve, possibly with a poorer outcome. Want to keep your athletes happy? Just refer out to someone you trust. Your athletes, parents and coaches will all thank you.
The flip side is true also. Recently I had one of my students visit another physical therapy clinic, as I wanted him to see differences in the way we practiced. He overheard a parent ant a therapist discussing strength training for his 11 year old boy, who was a baseball player. The crux of the conversation was the therapist telling the parent that strength training would “stunt the growth” (actual quote; I’m not making this up) of his child and should be avoided. No discussion on any pertinent research, no mention of the NSCA guidelines, no “that’s a great question; here’s someone who knows more about this than I do…” The parent smiled and nodded, and felt he was given sound advice from an expert. Again, this is a sad example that perpetuates my profession probably more than we know.
My network includes other physical and occupational therapists, strength coaches, family physicians, orthopedic surgeons , chiropractors, podiatrists, and orthotists to name a few. We refer to each other because we respect each others’ unique abilities, and ultimately we help the people who sought us out in the first place.
9. Where can my readers find out more about you? Thanks for the interview Shon!
Thanks again Bret, and best of luck in NZ! Readers can reach me at email@example.com, or check out my blog: www.shongrosse.com. The crux of my blog will be case studies in physical therapy, athletic training and strength & conditioning, based on critical thinking, problem solving, and research/ evidence gleaned from my 22 years in practice. I plan on giving great content, and plenty of food for thought and discussion. My clinic website is www.comprehensivecolmar.com for anyone interested in a consult.
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