Blog
Words by Andrew Fitzgerald, Integrative Physiotherapist and General Manager
One of the questions we are regularly asked at Zebras is “should I see a physiotherapist or an exercise physiologist?” And the answer is that it depends.
There is a lot of overlap between physiotherapy and exercise physiology. Both professions work with movement and can prescribe exercise. Both can help people improve strength, function and confidence. Both can work with chronic and complex health conditions.
The difference becomes clearer when we look at what we are trying to achieve, what is currently limiting you and how your body responds to activity.
For many people we see at Zebras, it is not a choice between one profession or the other. A common pathway might involve physiotherapy initially to assess symptoms, pain, injury, joint instability or movement problems, establish a starting point for rehabilitation and then exercise physiology to continue developing strength, conditioning and physical capacity over the longer term.
For someone else, exercise physiology may be the right starting point – and for people experiencing significant fatigue, dysautonomia or post-exertional malaise, we may need to think about movement very differently again.
What does a physiotherapist do?
Physiotherapists are trained to assess movement, function, pain, injuries and physical impairments.
That can include:
- Acute or persistent pain
- Joint instability
- Changes in strength or mobility
- Returning to sport, work or everyday activities
- Spinal presentations
- Neurological symptoms
- Balance and coordination
- Joint or muscle injuries
- Rehabilitation following injury or surgery
Exercise is a substantial part of physiotherapy. Depending on the person, treatment may also include education, symptom management strategies, taping, bracing, hands-on treatment and modification of activities.
For people with hypermobility, the assessment component of physiotherapy might be particularly important. If your knee keeps giving way, your shoulder is repeatedly subluxing, your neck has suddenly become painful or you have developed new neurological symptoms, strength training may not be the right starting point – we need to understand what is happening first.
What does an exercise physiologist do?
An Accredited Exercise Physiologist is a university qualified allied health professional with specific training in clinical exercise prescription.
Exercise physiologists use movement and exercise to help improve:
- Strength
- Cardiovascular fitness
- Physical capacity
- Movement confidence
- Balance
- Endurance
- Independence
- Function
- Participation in work, recreation and everyday life
This becomes particularly useful once we understand what we are working with and want to build something sustainable around it. For example, someone may have spent several months working with their physiotherapist on knee stability. Once the knee feels more stable, an exercise physiologist may take that foundation and progressively build lower limb strength, cardiovascular capacity, gym confidence and tolerance for the activities that person wants to return to.
The goal is not simply completing exercises. It is increasing what your body can realistically do.
So, is physiotherapy for injuries and exercise physiology for exercise?
Not quite.
Physiotherapists prescribe exercise every day. Exercise physiologists also work with injuries, pain, disability and complex medical conditions. The better distinction is often the question being asked.
Physiotherapy may initially be asking: “What is limiting this person’s movement or function, and what do we need to address?”
Exercise physiology may continuously be asking: “Given what we know, how can we safely build your physical capacity over time?”
Sometimes both questions need answering simultaneously.
How does this change with HSD and hEDS?
Hypermobility Spectrum Disorder (HSD) and Hypermobile Ehlers Danlos Syndrome (hEDS) can change the way we approach rehabilitation, but they do not automatically mean someone needs to avoid exercise.
In fact, improving strength and movement capacity are often part of the treatment plan for someone with HSD or hEDS. They may experience reduced joint stability, recurrent injuries, altered proprioception, poor movement control or pain associated with repeatedly loading tissues that are struggling to tolerate that load.
A physiotherapist may initially work on understanding the painful or unstable areas and establishing appropriate movement strategies. An exercise physiologist can then help with progressing strength and general physical capacity.
For someone with HSD or hEDS, this might involve:
- Slower progressions
- Lower starting loads
- More attention to technique
- Controlling range where appropriate
- Allowing for longer recovery
- Gradually increasing resistance
- Building confidence with gym-based exercise
The eventual goal does not necessarily need to be gentle exercise forever. Many people with hypermobility can become very strong – but the path towards that may call for more consideration. Exercise and strengthening are recognised components of management for HSD and hEDS, particularly for improving joint stability and movement control.
Fatigue changes the conversation
Fatigue is also common in HSD and hEDS.
That fatigue can have many contributors – pain takes energy. Poor sleep, autonomic dysfunction (including POTS) and repeated injuries take energy. Medications, nutrition, reduced activity, stress and other health conditions may all contribute as well.
Fatigue after exercise does not necessarily point to post-exertional malaise – and that distinction matters enormously.
What is post-exertional malaise?
Post exertional malaise (PEM) is a worsening of symptoms following physical, cognitive, emotional or sometimes social exertion. It is not simply feeling tired after a workout, and it is not being unfit.
A characteristic feature of PEM is that the deterioration can be delayed. Someone may complete an activity and initially feel reasonably well. Later that day, the following day or sometimes even later, symptoms may substantially worsen. This delayed response is one of the reasons why PEM is easily missed or dismissed.
This can include:
- Profound fatigue
- Brain fog
- Headaches
- Dizziness
- Pain
- Sleep disturbance
- Flu-like symptoms (such as a sore throat)
- Increased sensory sensitivity
- Worsening autonomic symptoms
- Reduced ability to perform normal daily activities
To learn more about this commonly misunderstood symptom, read our blog Unpacking Post-Exertional Malaise (PEM), written by Exercise Physiologist Daisy Welsh.
HSD/hEDS fatigue and PEM are not necessarily the same thing
This is where rehabilitation needs nuance. Someone with HSD or hEDS may exercise on Monday and feel muscularly tired or sore on Tuesday. This does not necessarily mean the exercise was harmful; with appropriate recovery, we may continue gradually progressing their program.
Another person may complete the same session and experience a significant deterioration in fatigue, cognitive function, pain, dizziness and general function for the following three days. That is a completely different response, and may point towards PEM. We should not automatically apply the same progression model to both people.
Fatigue is common in EDS and HSD and can arise from multiple factors including pain, sleep disturbance and reduced activity. PEM, however, requires us to specifically consider the relationship between exertion and delayed systemic symptom worsening.
What about ME/CFS and Long COVID?
PEM is a core feature of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and can also occur in people with long COVID.
When PEM is present, the goal is not to push through symptoms in the hope that fitness will eventually improve. Current ME/CFS guidance advises against exercise programs that prescribe predetermined increases in activity regardless of the person’s symptoms.
Current World Health Organization guidance for long COVID takes a similar approach when post exertional symptom exacerbation is present. Rehabilitation needs to be modified and pacing or energy conservation approaches become important.
The question then changes from:
“How do we progressively increase your exercise?”
to:
“How much activity can your body currently tolerate without causing a meaningful deterioration afterwards?”
What does an exercise physiologist do when PEM is present?
Exercise physiology is still about exercise, but sometimes good exercise physiology means recognising when increasing exercise is not currently the goal.
Early management may involve understanding:
- Current activity levels
- What triggers symptoms
- Delayed responses to activity
- Recovery time
- Physical versus cognitive demands
- Autonomic symptoms
- How everyday activities affect the person’s available energy
- Where movement might comfortably fit within their current capacity
The intervention may involve very small amounts of movement or maintaining current level of function. The first priority may be to reduce the repeated cycle of doing too much on a good day and spending several days recovering from that.
Progression, when appropriate, should be based on the person’s response rather than an arbitrary weekly increase.
What about POTS?
Someone with Postural Orthostatic Tachycardia Syndrome (POTS) may experience exercise intolerance, because being upright places additional demand on the cardiovascular and autonomic systems. For someone with POTS who does not experience PEM, exercise may still be progressively developed.
Early exercise might use more supported or horizontal (supine) positions such as:
- Recumbent cycling
- Seated strengthening
- Floor based strengthening
- Rowing
- Carefully selected resistance training
As tolerance improves, upright activity can gradually be introduced.
But POTS and PEM can co-occur – if someone has POTS and also experiences PEM, we cannot simply assume that a traditional POTS conditioning program is appropriate. The program needs to respect both orthostatic tolerance and the person’s overall energy limits.
What if you have HSD/hEDS, POTS and PEM?
This combination is not unusual in the population we see at Zebras. HSD/hEDS may affect joint stability and load tolerance, POTS may affect upright exercise and cardiovascular tolerance and PEM may limit the physical, cognitive and emotional exertion the person can tolerate.
A program cannot focus on only one of these. A ‘perfect’ strengthening program is not useful if it repeatedly triggers a three-day crash. At the same time, avoiding all movement may contribute to other problems.
The skill is finding a balance. That might mean changing the:
- Exercise
- Position
- Resistance
- Number of repetitions (reps)
- Duration
- Frequency
- Rest periods
- Environment
- Amount of concentration required
Sometimes the best rehabilitation decision is to progress, maintain or reduce.
So, who should you book with?
If you have developed a new injury, significant pain, joint instability or a change in your physical symptoms that needs assessment, physiotherapy is often a useful starting point.
If the main goal is developing strength, cardiovascular conditioning, exercise confidence and longer term physical capacity around an already understood condition, exercise physiology may be the way to go.
For many people, the best pathway involves both. A physiotherapist might help establish what is happening and create the initial rehabilitation framework. An exercise physiologist can then turn that framework into something sustainable that develops strength and physical capacity over months and/or years.
If you live with HSD, hEDS, POTS, long COVID, ME/CFS, significant fatigue or PEM, the answer becomes more individual again.
The profession matters, but understanding how your body responds to movement matters even more.
At Zebras Australia, our physiotherapists and exercise physiologists work together so that care can change as your needs, symptoms and capacity change.
