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The PT and performance coach on the evolution of the field.

In between events at APTA CSM in Boston, APTA Practice Specialist Stacey Schwartz, PT, DPT, JD, interviewed Kelly Starrett, PT, DPT, about the evolution of physical therapy to encompass human performance and lifestyle medicine.

Our Speaker

Kelly Starrett, PT, DPT, is the co-author of the New York Times bestsellers "Becoming a Supple Leopard," "Ready to Run," and "Built to Move" and the Wall Street Journal bestseller "Deskbound." He is also the co-founder and CEO of and co-founder of San Francisco CrossFit, the 21st CrossFit affiliate.

The following transcript was created using artificial intelligence and may contain typos, omissions, or other errors.

Stacey: Hi, my name is Stacey Schwartz, physical therapist and practice specialist at APTA and I'm here with physical therapist Kelly Starrett.

Kelly: Hey everyone, I'm a physical therapist and a performance coach.

Stacey: Awesome, we're so happy to have you and you haven't been to CSM for about a decade.

Kelly: Thanks for bringing that up.

Stacey: Sorry, but I just want to know, A, how has it changed and B, what brought you back?

Kelly: Great question. First of all, I've been a member of APTA for a long time and even though I'm not CSM, I haven't been to CSM. Every all the physical therapists out there who sometimes feel like the APTA doesn't really represent them, we all benefit from the advocacy of this group and the advocacy of the body. So it's important. I think the last time I was here, the biggest change that I've seen is, number one, I haven't seen a single pair of white new balance shoes. I haven't seen any khakis and very few polos.

What we've started to see is in the past 10 years there's really been a growth and sophistication of physical therapy to encompass high performance, not sports rehab. That's a really different model, but sort of our ability as physical therapists to see a bigger picture and to be at the forefront of human performance, working alongside people who aren't just trying to get back to basics or return to function, but are in fact trying to see what are the limits of the human condition.

And suddenly I see, even from the vendors here, from the people here, we're seeing there's a big shift and that means that APTA has sort of, it's caught up with the rest of the profession and suddenly once again we are here.

The second thing is that's sort of really important is we're starting to see the emergence of lifestyle medicine and the APTA has a real opportunity to say hey we're not going to expand our practice boundaries. But we're going to reclaim or actually own the practice boundaries we already have. No one is better set up. Physicians aren't set up for this lifestyle medicine piece. Physical therapists are best set up for it. So the combination of sort of the advocating for this human performance aspect of the job and this lifestyle medicine component, which really in some ways really overact, the APTA now is in a place where they can really sort of wrap their arms around that. And that's bringing this generation of PT's who maybe we're a little ahead of the bubble or ahead of the curve. We're back in realizing that this is a great place to be.

Stacey: That's so exciting to hear. I'm so glad that you're finding that niche here at APTA and CSM. You spoke yesterday, you're speaking again today. What were some of the highlights from your day yesterday?

Kelly: I think what's amazing is to see so many people excited about all of the different ways that physio can sort of be represented. I think if we look at physical therapy as a system institution, the things that get us here aren't necessarily the things that keep us here. And we're at an influx. I think everyone's like, the APTA of last year was the, you know, I think there's this sense that we're always evolving. Which is the right thing. The number of people I talked to yesterday who are beginning to expand their practices into less traditional models, you know, are, I think we made a tradition, a really calculated decision about attaching ourselves to this reimbursement model insurance to become legitimate as a field. I mean, it wasn't that long ago that it was heat packs and it's 10s and, you know, massage. I mean, that was literally what physicians were writing in the '80s. And here we are with some of my physio friends at the top of military groups,  the top of NASA, the top of professional sports teams working alongside the leading edge of human performance. And so I think what's interesting is to see the number of people I talked to yesterday who are starting to think, hey, I can pivot this incredible skill set into a proactive piece, where I can be the true primary care musculoskeletal provider for a community, for a team and that's really exciting.  

Stacey: Absolutely, so you have your it's not super new anymore, but you have your book and you talk a lot about vital signs.

Kelly: You're talking about Built to Move?

Stacey: Talking about Built to Move.

Kelly: Not my obscure paddling book. All right.

Stacey: No, no, we're obviously talking about the paddling paddling book. Built to move and I read it and it adopted some of those vital signs for myself. How do you think APTA and the book are parallel or different?

Kelly: I think what's, one of the things that we, remember my background is human performance, right? Really at that edge of working alongside these elite groups, military, professional sports. And we've always in our company and family have viewed sports as a living laboratory where we can understand inputs and outputs. We can test ideas and really see sort of best practices.

And what we've always said is, well, if it's the highest calling of science is to transform the humanities. The highest calling of sport is to actually transform our communities and our families. How can we take those lessons and actually not to be entertained by sport, but say here's what's essential in terms of development of humans, feeding of humans, the humans bonding together, being tight, and what we are trying to do is say "here are these essential lessons and bookends, benchmarks for sort of ideal human function." So an example is my wife and I are obsessed with all things Everest. We love Everest documentaries, we love all the Everest movies. I'm never gonna go to Everest, I've been to Everest Base Camp and I've never go up Everest 'cause that's crazy. But what we see is, everyone is really obsessed with which rope we're gonna go up Everest with, what color rope, and if you look at the comments and arguments that we're having in our field, like this crampon is better placed in this position with this ice axe and you need this calorie, meanwhile, no one is at Base Camp. We're arguing about which way up the Khumbu Icefall, but we gotta get people to Base Camp.

So what we've tried to do is say, "Hey, look, here are these 10 vital signs," which is really a base on original conversation I had with Greg Cook, based on a conversation he had with Shirley Sahrmann, about how could we create a reference language so that physios became movement experts and started to create a set of vital signs, movement essentials, minimums for themselves.

If you go to a physician and get a physical, there's nothing physical about it. They don't watch you move, they don't watch you breathe, they don't watch how you get up and down. They don't assess your range of motion. They're like, "oh, your blood pressure looks good. Good job." Meanwhile, we know fall risk, stiffness, center, I like choose something you care about. Number one reason people end up in nursing homes can't get up and down off the ground independently. So how can we sort of recapture and start to establish some movement vital signs and some behavioral vital signs.

It's really disingenuous to say, "Hey, someone's going to come into me as a physical therapist and I'm not going to care about how they eat or how they sleep or do they walk or decongest." The real question is, "When do I have time to deal with those conversations, those real nuanced conversations?" We love to represent that no one gets more time with patients than we do, right? The physician, she's too busy, she gets eight minutes. Physical therapists, we get 30 minutes. I'm like, that's not enough time to really get in. Ultimately, that's really a better view for a coach. So, but physical therapists should quickly be able to identify some movement vital signs. So even if you're coming in for a shoulder pain, we can be talking about your hips or behaviors to maintain your balance. Where is that gonna be done? What we try to do is say, hey, here's a book that's gonna have some reference marks that are evidence-based on literature, based on our performance, performance of sort of keystone events and signature movements that allow us to begin a conversation about this is really what it means to be a human body moving it in this environment so you can occupy a role in your family or your job.

And that's what we've tried to do with this Built to Move book is say, hey, let's take what we've learned, let's go ahead and see if we can level everyone up and begin a conversation about vital signs. And again, not good or bad, hey, we should pay attention to this. Like you haven't gotten up off the ground and you don't have any hip flexion. You wonder why your back hurts? How can we put range of motion and movement at the heart of this conversation in longevity?

Stacey: Excellent. Well, one thing you touched on was climbing Everest. So blazing new trails, blazing new paths. What if there's someone who wants to follow in the path that you've blazed?

Kelly: Oh boy, good luck, don't do that. No. No. I think, you know, one of the greatest things would be being a physical therapist. And I say, if you sit down next to me on an airplane, people will ask me, what do I do? I'm like, I'm a performance coach. But I say I'm classically trained as a physical therapist, which I think is the right way to describe it, 'cause we have a lot of young coaches that are like, hey, how do I do what you wanna do?  I'm like, you need to go to physical therapy school, because you can handle anything. Sprain, ACL, old surgery, hernia, dysl, it doesn't matter what comes through. If you want to coach a person, chances are they have a history and you want to be able to be handled that.

And simultaneously we talked to a lot of young physios and I'm like, could you program basic barbell for a high school? Can you get people to the Olympics? If a runner came in, would you know what to look at? How would you evaluate their program? How would you evaluate their strength and conditioning? So the thing to do if you're interested in this sort of performance field, number one is you've got to become fluent in strength conditioning. I think CrossFit's a great entree in. You need to be able to speak barbell, kettlebell, dumbbell. You need the language of programming. And if you feel like you can't go in and coach a group class, a fitness class, that's a hole in your programming. And again, for the average physio, and there's no average physio, but a physio who's not working in that field, that might not be useful other than they can really understand what someone's needs are.

But you have to be able to switch hats quickly. Long time ago I worked with a brilliant physio, and this is 2007 Trish Fong, who is a super badass. She, again, this is so early in this sort of idea, she pulled me aside, and she was like, "You're going to have to decide. Are you a physical therapist? Are you a coach?" And I remember being like, "Whoa!" I don't want to decide. I want to do both. And I think in this exciting field, we're seeing that we have physios. You can't tell if they're a coach, if they're a physio. They're competent in basic sports nutrition. They're competent in basic psychology. They understand sleep and the recovery. And they really start to have a grasp of seeing all of those biopsychosocial components of a human, but we can actually minister to that because we have vital signs and minimums. So it's not this, I'm like, "Hey, do you feel safe in your community?" I'm like, "Hey, you don't walk, you don't get any sunshine." That's why maybe you're not thriving and in this 30 minute session, that's not where we're gonna uncover that. That ends up being a much more interesting conversation about I see this person three to five times a week, they can't tell if I'm their physio or their coach.

Stacey: One of my favorite things about the book, about what your career that I've followed, I'm a crossfitter. I will admit it.

Kelly: I’ve been crossfitting for 20 years.

Stacey: I'm only eight eight years in, Is that I feel like you push boundaries you practice at the top of your license. It's amazing to see What do you see is the future of PT?

Kelly: It's a great great question. I think what's really amazing about this group and and it's actually a problem of this group, is that we are very seemingly disconnected. That if I'm talking to a pelvic health PT potentially, of course we talk about, you know, the pelvic floor stuff with all our athletes, so there's no piece, you can't pull out the neuro, you can't pull out the biological, everyone has all these things. But it's incredible to see how people have taken this education and found a niche that they're passionate about. Again, I think what's great about being a classically trained physical therapist is the last time in your life you get to be a savage generalist. You get to, you know, take peds and wound care and, you know, do all these things you're never going to touch again that really create a classical education. You know, yes, I know reading the classics may not be fun, but you're going to appreciate having that that background. I think the future of PT is we're going to continue to see this sort of opportunity to morph the practice so that it's not in delivered in these little chunks that are reimbursed under these units of time.

We're going to start to see physios at the top of the doctoring profession managing strength coaches and health coaches because they're actually just as competent in delivering clamshells or squats or you know nutrition information or lifestyle information. We're going to see physios sort of become the leaders in in some of these fields because people really it's difficult to encapsulate the whole thing and understand where someone is in their progress and so I think when we start to see physical therapists continue to reshape how they deliver care, who pays for that care, you know, we'll really start to truly embody what's possible in this field. Because, you know, I came through physical therapy as a professional athlete and I was like, oh, you think I'm going to do, I'm never going to do. In fact, I sat down with Liz Sluzar as my advisor at Samuel Merritt a million years ago and she read me the riot act because I told her I was going to do this and she was like,  that doesn't exist. How dare you. You don't even know. And I was like okay I think we're not ready for this conversation yet so Liz thank you I've made it.

Stacey: I was going to say, where is your communication with Liz today?

Kelly: I haven't seen Liz in a minute she's cheering me on she came by the gym after I graduated and I was like this is awesome. But you know I think what we have to do is say it's okay to practice in a whole bunch of different ways and that what is the one thing that unites us all it's being experts truly in movement not in muscles not in soft tissues, in how people use their bodies and really begin to sort of own that in a real way.

Stacey: So since you've been here I've seen you run into lots of people lots of people saying hi what has it been like to reconnect with mentors, fans, friends?

Kelly: Well you know one of the great things of being at CSM is you feel seen. Everyone here survived physical therapy school. Everyone knows what it's like to be crushed by student loan debt. Everyone understands what it's like to be a hyper-local PT trying to solve the problems in your community. So there's a level up where you're like, I see you, I know you. And I think that feels really good. I had a complicated relationship with the industry of physical therapy when I started, you know.

Stacey: Do you mind touching on that a little bit more?

Kelly: You know, I very quickly realized that the clinic where I wanted to work, they struggled with this gym and performance side. Even the language of physio has traditionally been rooted in corrective exercise, which is valid and totally appropriate. But, in sports and performance,  that corrective exercise model ends up being sort of less useful, less having less utility. Because what we see is that athletes will come in and they'll get a set of exercises that are a PT language that may work for the general population. Everyone's special, I get it. But hard to scale clam shells up indefinitely, right? Hard to scale some of our exercises. And what we see is that if we can sort of take the formal language of strength and conditioning and use it as a diagnostic tool, suddenly we have a way of communicating with every sport. I've taught on every continent except Antarctica, I've taught in weird places with translators. I've seen a lot of stuff. Everyone knows what a deadlift is, everyone knows what a pushup is, so why aren't we using that language to help people and then to be of better service to these communities instead of saying, "Hey, here's my language of Esperanto or classic Greek that you're going to use for a while and then never use. Now suddenly people are going to scale up and scale down.

And I think when we started this thing initially, my family thought it was crazy. I would start my own practice so early in my gym. And my table was one foot away from the squat rack.  And that really confused people. And then the other thing I think that initially was that I really felt that we were delivering a lot of unskilled care. That because the internet didn't exist, you didn't know about all these low-level rehab exercises that the industrial fitness complex has seized on and claimed, right? The average personal trainer is an expert in corrective exercise now. And that means great, I don't have to teach you this low-level stuff anymore. I get to actually teach the high-level stuff. And I think those people, some of the people who are unsure of how strength and conditioning scaled and fit, they thought it was sort of a sideshow and that we should stick sort of these traditional models. So I think initially really felt like I was like I don't really think this is there's something here and there's something here about shifting the burden of simple pain problems, simple range of motion problems back to the athlete and coach. So that the Venn diagram, because people were really worried that like hey, "Are you making these coaches physical therapists?" I was like never. They're never gonna be a physical therapist but we can get them to sort of bring their practice closer to ours so we have better continuity of care.

Stacey: So the lines are blurring. We don't need to be so siloed.

Kelly: Yeah, and again, I think that's a feature of every institution institutionalism is that we create these, there are experts here that are so good at their job. But simultaneously, I think when we're talking about, remember, I think I had someone said, interdisciplinary care a thousand times at graduate school, right? And really, it's okay, I think a better model is that we have a performance director sort of at the top, and with that performance director is the athlete. And at different times, that person may need to go see a nutritionist, may need to work with a massage therapist, may need to work with a physio, may need to work with a strength coach. But at different times, that person may need to go see a nutritionist, may need to work with a strength coach. But at different times, that person may need to work with a strength coach people take different leads. I think that physio is the right person to sort of be able to see all of those things. And again, what's the unifying language here? Biomotor output. Really, there's only two things we can, I can ever truly measure and make objective. One is your range of motion, 'cause that's why Norkin and White has burned into my brain forever, right? And you made me memorize the L Rancho Gate Cycle for some reason. And so range of motion matters. But what I'll tell you is what really matters is the expression of the human being. One of the things that I think we can do a better job of as an industry is reach into the master coaches in the world and really understand what they're doing. There's a coach, a Dutch coach named Frans Bosch who has a great saying. And the saying is there's more variation in waltzing than there is in sprinting. And that at low level, low load low speed, low force, doesn't matter, human beings are pretty durable. You can walk like a duck, pick up the pillow, but at higher speeds, higher forces, we start to see that the brain and the body and all coaches and all movement specialists start to aggregate and become a little bit more unified in how they move, which tells us about sort of what the highest expression of the human function is. So, I think we might as well be teaching and working towards teaching people this highest expression of human movement with the most movement choice, the most movement solutions available to them, that's range of motion and then showing me, proving it in wattage output. You've got to prove to me that it's better. Your subjective feelings of your pain and comfort, those things aren't important.

Stacey: Amazing Kelly, you're so passionate and you're so knowledgeable and it's just a pleasure listening to you. Is there anything that you want to leave the attendees and nonattendees of CSM 2024 with?

Kelly: Yeah, look, I think it's easy to sit back and say to complain. It's easy to complain about the education if you're taking on young students and my push back always is what are you doing to change it?  How are you working? What are you going to pull out of physio school? How are you volunteering? Where are you taking on this generation? I just talked, I've talked to two or three friends who now have sports residencies here and they're like, hey, we recognize that we get people through graduate school and that's the beginning of the conversation. And what I think is it's easy sometimes in our field particularly, we have tall poppy. We like to cut down that tall poppy, hammer down that nail and what we need to do is sort of recognize that there's so much agency and power you have.

APTA is yours, and it's an expression of what you wanna do. And we're at a place now as an organization with the senior leadership, what's going on, how Justin and Drew, how they're thinking about these things, where the boundaries of physical therapy have expanded enough to wrap our arms around the strange stepchildren of the human performance, of lifestyle medicine, of these things. And so it's up to you. If you want to be represented and have the advocacy, you're going to have to be part of the conversation. And we're inviting people back to become part of this conversation.

Stacey: Amazing.

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