Strength and Conditioning; a new frontier in Workers Compensation?

I have some frustrations about the Workers Compensation (WC) system, it’s probably not hard to tell. In my team, we have highly qualified strength and conditioning (S&C) coaches working in a WC system and they have developed their own frustrations. We share some of the same frustrations, so this post is as much about them as it is me.

As a physiotherapist and level 2 strength coach, I think I’m fairly well positioned to comment on the matter BUT there are countless of other more highly qualified personnel that could, and no doubt want to, weigh in on this debate. Please do, but please respect my opinion as I respect yours.

For me, my journey in S&C started with an unimpressive rugby union career and like most physiotherapists it was cut short by injury, which promptly brought me to the dreaded long slow distance and triathlons; I got interested in being strong and resilient but obviously just wasn’t doing it well. What I realised after completing my first 3 -4 years of clinical practice was that when it came to prescribing exercise and progressing someone to performance, my university training had me woefully ill-equipped. While physiotherapy, as a profession, is leading the way in the allied health sphere when it comes to neuroscience, I honestly don’t think the same can be said about exercise therapy. S&Cs, increasingly, have to have tertiary level qualifications to begin their career. Generally in Exercise and Sports Science or similar; in fact in my experience, S&Cs sometimes have multiple tertiary qualifications (many gigs, won’t look at you unless you have a PhD) to their name before they really begin their paid career (before that internships are common). So, they are well versed in the basic sciences, just like any other professional.

Exercise Science is a degree (although I didn’t do it), that I think should be a pre-requisite for any profession in the musculoskeletal therapy realm. I would combine it with basic psychological theory and management, but that’s another story. It is a complex science that is should be the keystone of further training in the field. Because this still isn’t the general course for those entering a physiotherapy degree, then I don’t think we can call ourselves experts in exercise therapy. And those in glass houses shouldn’t throw stones. So now that I’ve laid bare my gaping inadequacies (now somewhat improved) in exercise therapy, we can move on to the point.

In musculoskeletal therapy, those people that should be termed experts in exercise therapy are the professionals who do this – and only this – day in and day out. A good analogy might be that you wouldn’t trust your GP to remove your wisdom teeth – on the surface that seems like a pretty simple procedure BUT let’s leave it to someone who does this day in and day out. We don’t expect it from other medical professions, so I think maintaining the same standards in allied health is important. Now I would accept that there are exceptions, as there almost always are. Generally, your sports physiotherapist, who has worked closely with the high-performance staff for years are exempt from this classification, as they have built an intimate knowledge of the complexities in loading and periodisation parameters. But your run of the mill generalist; to get real, targeted exercise therapy from this practitioner in a musculoskeletal condition would be a snowball’s chance in hell. Proper training and experience is needed, not just a side gig, in-between interferential sessions.

Although the Australian Strength and Conditioning Association (ASCA) are far behind in many aspects (we’ll get to that), it has remained true to its most successful element – the fact that to get anywhere in the profession, you need to have some runs on the board. S&C is a profession where the career pathway is experiential and that is important when it comes to exercise therapy. I have a bias and I will certainly admit that, but when it comes to a profession that requires intimate knowledge of exercise theory and concepts, I don’t know if you can trump S&C. In WC cases, exercise therapy is increasingly being preferred as the primary treatment option; so for pure ‘skin in the game’ factor, why wouldn’t S&C be considered?

Whilst there are similarly qualified professionals who deal in solely exercise therapy, namely Exercise Physiologists, they also suffer from lack of specificity. I’m not saying they aren’t going to do the job, and generally better than a physiotherapist, I am saying that in a discussion about specificity of exercise therapy in musculoskeletal populations, there are professionals who I consider of a higher order. And I’m not even saying that EPs shouldn’t have a large stake in Worker’s Compensation, because yet again, they probably create more active individuals than a physiotherapist (who also may have all the best intentions – but this patient is coming to a physio expecting some of those magic hands..), I’m simply saying that if you want to get this beaten up Hyundai and transform it into a Ferrari, I want to use the professional who knows how a Ferrari is made.

So, although there is a place for both professions, the crying shame currently, is that those professionals who have a very high level of knowledge, experience and clout in the S&C world are not even allowed to enter the playing field. I am not espousing that anyone with a level 1 or 2 ASCA should be WorkCover accredited, but I do think experience – ‘skin in the game’ – and level of knowledge in a relevant field (most S&Cs work in musculoskeletal settings with athletes in pain) should be recognised. I certainly think that if performing a role in settings where they do encounter the complexities of workcover should be accepted and further training be offered to upskill where necessary. I think of the training physiotherapists have to do to become workcover accredited – a dinky online test that takes 3 hours, which has nothing about exercise therapy in sight…. To understand the complexities of neurophysiological mechanisms and behavioural drivers of pain is probably not where I’d want my S&C providing primary treatment, but that is where physiotherapists excel and we can fill in the gaps.

Strength and Conditioning is not just for athletes or those wanting ‘high performance’

This is true but oh so poorly understood. Where does a S&C coach perform best? Where there is a close alignment (or sometimes not so close, depending on where you go) of physiotherapists and S&C staff ensuring all variables are accounted for and the desired outcome is achieved. The current model for WorkCover is world’s away from this; once the physiotherapist has butchered the exercise therapy and taken their time with the initial injury, then there is a very well demarcated gap between this and the ‘commencement’ of exercise therapy – performed by the EP. This leads to poor outcomes, frustrated patients and can be done better. More cohesion, more synergy is needed and having a profession that is used to working intimately alongside physiotherapy rather than in a separate silo is important.

The ASCA need to improve their game to get on the playing field

I think part of the ASCA’s lack of ability to set strategic plans in place for the direction of the profession is, in part, because it is such a young profession. Still finding it’s feet after only 50-odd years of mainstream, burgeoning, practice. But it is a worrying trend that there continues to be an explosion of ASCA qualified practitioners, without much checks or measures to what they can or can’t do after they get the ticket. I know the level 1 trained ‘high performance specialist’ who opens a ‘high performance facility’ really grinds the gears of my team and friends. More scrutiny around the pathway already developed is important, alongside firmer adherence to remuneration based on level of experience.

The ASCA are incredibly good at broadening their scope of practice and widening the reach of S&C as a whole. In progressing the profession, this will always be important. But legitimising the profession amongst the biomedical sphere is a weak point; just as the kind of role S&Cs can play is poorly understood – as above – the profession isn’t targeted to areas where it can make a big impact. And for me, this means talking about Workers Compensation. To make SIRA (governing body for Workers Compensation regulation) take notice and approve S&C to provide services, the ASCA need to make a concerted effort to lobby. I think it is a case that is hard to ignore. To allow appropriately experienced (say ASCA Level 2, on the pro-scheme and above) S&Cs, with access to the right training (pain sciences, online WC legislation training) to provide services under Workers Compensation just makes plain old sense in my opinion.

The ‘coach’ element

A key element, that leads to outcomes in my current team, is not just that I am fortunate to work with high performers, it is that our coaches have taken the ‘coach’ element to the next level. Yes, S&C is a science-driven profession (in terms of evidence-based profession, I must concede it is a way behind physiotherapy or even exercise physiology) but there is another gamet of skills the coach must have. The Art of Science of Building Buy-In by Brett Bartholomew is a great example of the emphasis placed on ‘soft skills’ by the profession. Building rapport, building buy-in, the art of the sell; whatever you want to call it, it is a skill that the coach takes pride in. You need to have this in order for the patient in front of you to truly come to a more positive frame in life. The WC system breeds a negative world-view and sometimes needs a ‘coach’ to bring someone through it. The aspect of the profession that guides and directs a patient in what is necessary and important in movement, exercise, attitudes, beliefs and pain is different to EP; less clinical, more connective. I think this works.

So, in the long-run, I think coaches will live prosperously alongside EPs in the WC world. It needs a bit of firming up of the pathway and training by the ASCA, more solid work on lobbying SIRA. But in the end, why deny this valuable skill set a chance to change lives in a very, very broken system?




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