Reasons Why Physical Therapy Doesn’t Work Sometimes

We’ve probably heard it said. “Why should I bother going for physical therapy when it doesn’t seem to work?” I had friend whose mother had hip pain. She was about 80 years old but still active and well, except for her recurring hip pain. Her doctor advised her to go for physical therapy but she preferred to use a cane instead. She said it’s just a waste time and money going to PT because it’s not very effective. Indeed there are still many who think that physical therapy is ineffective. And these are not just personal opinions. Some are personal experiences!

So why do some patients have this experience? Why is physical therapy ineffective to some? Or most importantly, when does physical therapy seem ineffective? What makes it inefficient?

Here are a few reason I can think of. These are from me as a practitioner, as well as what patients tell me.

  • Outdated Techniques Including Assessment and Treatment Procedures.

Physical therapy is evolving just like any other branch of medicine. Many traditional treatments have been debunked, thanks to continuing research done to better the profession. Many patients are familiar with physical modalities used in PT clinics like ultrasound, TENS, traction machines, hot and cold packs among others. Many of these machines have now been decalred as outdated, ineffective or simply unnecessary. I do like hot pads for their relaxing effect, and I instruct some of my patients to apply hot pads themselves when they feel sore after doing their home exercises. But in the clinic, unless the muscles are super tensed, I dont use heating pads. There are other hands on techniques that produce better result of relieving muscle spasms; the quicker way. There will be more accomplished in 15-20 minutes with manual and movement therapies than just putting hot pack for the same duration. Just not cost and time efficient!

more to pt than

 

When it comes to assessment, many physical therapists still rely on the old paradigm where postural assessment is standard part of evaluation for various musculosleletal pain. They check for aligment, asymmeties and from there they base their diagnosis and intervention. Postural assessment maybe necessary in some instances but is never enough basis for diagnosing musculoskeletal pains and dysfunctions. A more accurate mode of assessment is movement screens.

[You can read some of the outdated treatments used in physical therapy here!]

  •       More Passive Than Active Treatments. 

Since a more accurate way of assessing musculoskeletal problems are dynamic movements more than the usual static postural assessment and provocative tests, it should follow that treatment should also be dynamic and movement based. Other than the treatments mentioned in the number one reason I gave, there are also newer techniques that physical therapists employ that still fall under passive treatments.

manip

While manual therapy is not really new, its name and use is becoming more and more popular in contemporary practice. So much so that many PTs have made it a panacea in many musculoskeltal and orthopedic problems. These manual therapy techniques can include a variety of techniques ranging from moderately scientific to outright pseudoscientific. In many manual therapy treatments, the patient/client remains a passive recipient of the treatment, whether it’s spinal manipulation, soft tissue works, or joint mobilizations.

This does not mean there is no validity and merit in using passive interventions, but that we need to familiar ourselves with what is effective and promote the patient to move.

In many cases, manual therapy works to decrease muscle tone/spasm, increase joint mobility, and relieve pain. But their effect can be short term if they are not followed by exercises to activate the muscles and restore joint functions.

[You can check some weird manual therapy techniques here!]

  •    Non Compliance with Home Exercise Program

For a successful rehabilitation program, the client or patient must be an active part. That is why a good physical therapist gives the patient home exercises and the patient is expected to do them regularly are prescribed. Equally important is the frequency and duration of the exercises. Just as medications are taken in dosages and frequencies, so are exercises. Some exercises need be done several times a day while some might be done once a day or on alternate days.

Exercises are also progressed while other exercises terminated during the course of rehabilitation. If the same exercises and repetitions are done every session, what is the need for PT? It will be waste of time and resources.

do your exercises

There are some who are pretty compliant but when you ask them to do the exercises again on the next session, you could just shake your head because they got the exercises all wrong… or maybe a little off. That is why I am in the habit of emailing my patients the list of exercises I prescribe them with brief instructions, including repetitions and frequency.

2 weeks

  •     Wrong Exercise Prescription.

Yes, there are physical therapists who prescribe almost the same exercises during the course of rehabilitation. Same exercises for every back pain. Same exercises for every shoulder problem. Same exercises for every knee pain. Sometimes it works. Sometimes it doesn’t. Exercises should be individualized based on assessment and patient’s functionality [Is that even a word”]. And equally important is timing of when to prescribe the exercises. We call it graded movement exposure.

empty can

Another thing that is a bit off with many therapist’s exercise prescription is the intensity. Some therapists are afraid to challenge their patients for fear of aggrevating their problem. So they stick with minimal resistance using the mildest theraband, maybe lightweight dumbbells and ankle weights, and never challenging their patients.

[Some weird and outdated exercises given by some physical therapists here!]

  •     Premature Discharge from Physical Therapy.

finally

This mostly falls on the clients themselves. There are some clients who stop rehab so soon. While I dont believe patients/clients should be kept for a long period of repeated sessions, they should not be discharged so sooner either. Sometimes patients decide to stop having physiotherapy once they feel better and see some improvements. But pain relief is not the only goal for rehabilitation or else we might as well just prescribe analgesics. The most important goal of rehabilitation is return to usual, daily activities without the risk of relapse or re-injury.

And then there are those who give up quickly when they don’t see immediate result. Some patients think that going for physical therapy is like going to a doctor or dentist where certain medication is prescribed, or certain procedure is done and everything goes fine. But rehabilitation of any kind takes time.

i dont always

Patients must remember that at the initial stage of rehabilitation, there will be ups and downs. The patient may feel fine after couple of sessions, depending on the severity of the injury or problem, but then some triggers may cause the symptoms to reappear, even in the absence of real injury or pathology. In some cases, pain may no longer be present but the surrounding tissues [muscles, tendons, ligaments] are still not ready for some specific, complex tasks. That’s the reason why in the later stages of rehabilitation, more challenging movements and exercises are prescribed. And sometimes patients may need to be referred to a strength and conditioning coach or a personal trainer to ensure the patient is ready to return to usual activities.

Get PT 1st.

So these are some of the most common reasons why physical therapy doesn’t seem to work. These are based on clinical experiences as well from experiences of clients themselves. Surely there are cases when other factors are involved and would need additional consult with another professional like a medical doctor [when a damaged tissue need repair] or maybe a psychologist [when experience of pain includes other psychosocial factors]. That’s why it’s always wise to get PT first.

So next time you feel like physical therapy is not working for you or for your significant others, check these reasons first. There are cases when we go see other doctors and dentists for second opinions. It is also wise to go see another physical therapist before you give up.

Wishing you all free, painless, functional movements!

What are other reasons you can add to my list?

Further readings:

Dinosaurs in Physical Therapy- Will a Comet Ever Wipe Them Out?

5 physical therapy treatments you probably don’t need.

Does Therapeutic Ultrasound Work?

Note: Many of the memes used here are from The Awesome Physical Therapist.

 

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5 thoughts on “Reasons Why Physical Therapy Doesn’t Work Sometimes

  1. Pingback: Reasons Why Physical Therapy Doesn’t Work Sometimes – The Manual OT

  2. I’m not having much luck with physiotherapy myself. Severe shoulder pain for about 3 and a half years now. Didn’t start with an injury, just began as a unpleasant ache one day for no obvious reason, then suddenly got worse (downright crippling for a couple of months) then mostly went back to an intense ache when walking any sort of distance.

    Took an age to even get referred to anyone, but been doing exercises for good part of a year now and they don’t seem to make any difference at all.

    In fact as of a month ago have now given up doing them as they seem to be making things worse. it has gone back to the point where it was years ago, where I can’t sleep because of the intense pain, and have limited movement in the arm.

    One problem is every time I see the physio (every couple of months) they show me some exercises and then within minutes of leaving I find I can’t remember half of them. I have asked for diagrams or something but they say they don’t have any to give me. So I end up just doing the ones I can actually remember.

    I also have bad knee pain, which started for no obvious reason at the same time as the shoulder, but that has improved over time (still hurts and feels weak, but no longer gets to the point where I can’t walk – when walking it will twinge at some point, and then recover). While I am not convinced that has much to do with the knee exercises I do (from a different physiotherapist), the thing is, those exercises make a lot more sense to me than do the shoulder ones.

    The knee exercises aren’t painful the way the shoulder ones are, and I can actually feel that they are improving muscle strength (whether or not that is relevant to the knee pain, it seems like a good thing in itself), whereas I really don’t see what the arm/shoulder exercises are supposed to achieve – they hurt a lot while not seeming to be doing anything useful. They just don’t _feel_ relevant to the problem.

    Hence I feel much more motivated to carry on with the knee exercises than the shoulder ones (which are now too painful to do in any case).

    Is physio-therapy even a science? It seems more like a craft to me, it just seems very “suck-it-and-see”.

    I’m not convinced the (shoulder) physio knows what they are doing. I have little confidence in them or the whole discipline – I mean, if they don’t actually know what’s causing the pain in the first place (they can’t see inside the shoulder after all), how can they know how to fix it?

    • Hi Michael! Thanks for your comment. Sorry to hear about your shoulder and how your rehabilitation did not seem to help. Like you’ve read from the article, there are many factors why that happens. Modesty aside, I have pretty good success in treating shoulder pains and therefore has become one of my favorite conditions to treat. My patients also seem to respond quicker than say back or knee conditions.

      Yes, physiotherapy is a science. Assessments, treatments, and interventions are scrutinized by research but some practitioners chase after other treatments and interventions that are fancy but unproven treatments except for some anecdotal testimony that such intervention works for some. That’s the thing with physiotherapy… Doctors prescribe medications that are proven effective through clinical trials. Since physiotherapy use physical means to treat like body work [manual therapy] and exercises, so many come up with BS treatment and use it as marketing tool or even to give at weekend certifications. But know that there are many of us who follow the latest evidence and are as indignant of practitioners who promote quackery.

      I notice youre from UK. I have so many progressive physio colleagues there. Check out Adam Meakins [whose specialty is shoulders], Ben Cormack or James Morgan on social media. Maybe google them. I hope you find the right physio fr your shoulders. I fee your disappointment and pain.

      Dion, PT

  3. 3 months ago I had a treadmill accident and suffered injuries to both knees. I have not had a pain free day since. I am at a place now where after about 8 pt sessions (after about 1 month of waiting for stitches to heal) where I did stop them because I felt like I was not making any progress and decided to get a 2nd opinion from another doctor. He prescribed lymhadema and occupational therapy along with pool therapy. I am wearing wraps to deal with some still significant swelling from the injuries (particularly a large hemotoma which I believe is the source of almost all of the pain I still endure). I guess I am frustrated, not at the physical therapist- he in fact was one of the most helpful people for me in theses last few months. But, I know my body and self better than anyone, and am tired of the inference that the pain is in my head. No ! The pain is in my knee and thigh where the hemotoma is. I feel just fine inside but am limited by these injuries. I think that maybe sometimes a person should be more closely examined before getting a standard , go to physical therapy prescription.

    • Hi Mary. First off, thanks for your feedback and secondly, sorry to hear about your injury. I dont know where you heard that pain is only in your brain because it is not. If I ever said that in the post, I would gladly edit it as this was written more than a year ago and my understanding of pain science has so much improved since then but I just dont have time to write anymore and many others of my colleagues write the about same issues and are much better at it. 😉 I never tell any of my clients or patients that pain is just in their head. it’s dismissive and not any helpful at all. Pain however is mediated by the nervous system and the issue is not always about the amount of tissue damage but is governed by the sensitivity of the nervous system which is in turne influenced by other biopsychosocial facotrs. Pain is multifactorial but this is an altogether different topic. Suffice to affirm you that pain is definitely not just in your brain. Even if we, pain professionals, understand what it actually means by context, lay people get the meaning differently and so I never ever use that phrase. I wish you all the best in your recocery.

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