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  • Outdated Techniques Including Assessment and Treatment Procedures.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 Many of these machines have now been decalred as outdated, ineffective or simply unnecessary.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[You can read some of the outdated treatments used in physical therapy here!]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.


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.


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.



Keeping Up With The “Trends” in Physical Therapy Treatment

hot not

Trends can be a good thing or bad thing. It’s a good thing if we define trend as an update or upgrade. Old things are abandoned as new paradigm shift is welcomed. In science, it means that new studies present a more scientific fact nullifying those that have been previously believed and taught. Or trend can be a bad thing when it is described as fashion or fad. Here today, gone tomorrow because they don’t have scientific studies to back them up. In physical therapy, there had been numerous techniques once used and now being abandoned. That’s fine too. Which medical science does not evolve and advance, and still use same method of diagnosis or treatment for decades?

I am happy to be in the bandwagon in this journey of new trends in my profession. Some therapists just want to stick to what they are used to in their practice but I am not some therapists. I refuse to be left behind. Thanks to all of those practitioners who constantly push researches and studies so that physical therapy and physical rehabilitation practices will truly be evidence based and treatments based on psuedosciences be contained or minimized. Thanks to clinicians and researchers who are bold enough to call out and challenge the charlatans who provide training and products with unproven effectiveness as a way of monetizing the practice.

I am forever grateful to everyone who keep supplying oceans of new information to the community of PTs around the globe through facebook, twitter, and online forums. Not only from physical therapists but also from related professions like atheltic trainers, strength and conditioning coaches and massage therapists.  There’s always going to be arguments from different groups with different paradigms in the practice, Overtime, as I read discussions and sometimes join in these discussions, I have learned which side to choose. Yes, sad to say, there have been some inevitable divisions among physical therapists. But of course, we can all disagree with respect! Everybody is entitled to voice their opinions. At the end of the day, science wins by landslide.

So, over the years of following various clinicians and researchers, balancing the views of each one, I have come to embrace these trends in the practice, which form much of how I work on my clients and patients now – from assessment to explaining the what, why and how of my interventions.

1. Manual Therapy

Now, manual therapy is really not a new thing. It has been around for quite a while. Many manual therapy techniques are shared by a number of rehab professionals which includes osteopaths, chiropractors, physical therapists and massage therapists. Since manual therapy is simply the use of the therapist’s hands in treating various musculoskeletal conditions like soft tissue pain and injury, many have used these hand techniques in so many ways, some good and some plain ridiculous. I am not the one to point out which ones I think are unscientific but you can read some of them here!. Also, many manual therapists have given big claims on how can manual therapy works wonders, in which no substantial study to back them up. Stuffs like releases fascia, corrects malalignment, boost the immune system, among many others. How one can break up scar tissues and fascia when a surgeon needs to use an scalpel to do so?

I can say that if there’s anything new with manual therapy is it’s how we understand how it works. Manual therapy does not deform fascia, put back an out of place sacro-iliac, or release trigger points. Most of the effects of manual therapy are neural not mechanical or structural. We cannot mechanically deform fascia with hand forces but instead we stimulate skin mechanoreceptors which sends signal to the brain to allow a tensed muscle or soft tissue to “relax”. Most of the time it’s not the techniques that are flawed but how the mechanism of the techniques is explained [i.e., based on purely biomechanical models].

myofascial release

Also,  manual therapy has been made a panacea in MSK [musculoskeletal] physical therapy by many practitioners. But manual therapy is really just a means to an end. Manual therapy as a tretment is mostly passive and thus can make the patient dependent on the therapist all the time. That is why many manual therapists in other disciplines like chiropratic can keep their patients/clients for years or even a lifetime. I also know some physios who became osteopaths who tell me that they don’t prescribe exercises anymore. But the goal of pain and injury rehabilitation is to make the patient/client functionally independent and be able to mange their symptoms. That is why I don’t stop with manual therapy in treating my patients. I use manual techniques to address symptoms of pain, stiffness and limited joint motion, after which I proceed to what physical therapists are known for – movement!

Here’s an excellent article by Greg Lehman on fascial treatment fallacy.

2. Functional Movement Therapy

Physical therapy is the engineering of human body.

Physical therapy is the engineering of the human body.

Like I mentioned, manual therapy is not main intervention in many physical therapy treatment. Movement is. The goal in injury rehabilitation is not only to relieve pain but to improve movement. Injury, if not managed by movement therapy will impose risks of re-injury. Pain might be relieved but the abnormal movement patterns adapted thru the presence of pain or injury are not addressed. Thus, slight deviation in future tasks may trigger central sensitization causing pain to recur. Also injury not rehabbed properly has a higher change of re-injury. Proper rehabilitation cannot be done with manual therapy alone.

Movement, like manual therapy, is not a new thing. In fact it is as old as the physio profession itself. Physical therapy by definition, is all about movement. Just that movement had just got the attention it deserves in the recent past. Movement goes beyond prescription of therapeutic exercises to certain conditions [i.e., 3 best exercises for back pain, neck pain, etc]. They should be functional and diverse, addressing the specific goal of the patient/client – to continue with sporting activities, to be able to get back to dancing, to be able to carry out household chores pain free… the list goes on.

My movement therapy intervention starts with graded movement exposure. This process addresses patient’s fear avoidance of movement. Much of the rationale for graded movement has something to do wit pain neuroscience, which third but possibly most important in the list.

Once the patient/client has gained more confidence in movement, more complex movement patterns are taught and prescribed as next home exercise program. Movement matrices [movements in different planes and combination of planes], increased speed of movement, movement with resistances are developed and taught. For clients who have more active lifestyle or are involved in sporting activities plyometrics may be the final phase of movement therapy

3. Pain Neuroscience

no brain no pain

Understanding pain neuroscience makes pain and injury management becomes so much simpler and easier. Instead of coming up with ridiculous and unscientific biomechanical paradigm like postural pain, muscle imbalances, spinal units called vertebrae and disc going out of place, increased anterior pelvic tilts, unequal leg lengths, and many other fear mongering biomachanical phrases which can cause more anxiety to the already suffering pain patient, explaining pain in the context of neuroscience gives a better assurance to the clients that their condition is not that bad. It may take time to “heal” but with excellent prognosis. Pain science paradigm is also cost effective as it eliminates, in most cases, the need for expensive scans and imaging like X-rays and MRI.

In a nutshell [as condensed from words by Jason Silvernail], pain neuroscience is grounded in the notion that pain is a conscious feeling that motivates protective behaviour, not a discrete biological event that occurs when tissue is truly in danger. Thus, the relationship between true danger and perceived danger is modulated by the sensitivity of our protective system. Meaning that pain and injury are more not necessaruly correlated. Understanding these things decreases perceived danger and therefore pain, and positions a biopsychosocial approach to rehabilitation as the best approach to rehabilitation.

Read this primer on pain science here.

4. Preventative Healthcare

To some, physical therapy as preventative healthcare is something new. Many still see Physios as go to professionals if someone has serous injury, physically handicapped or has neurological problems. But physical therapists, sometimes in collaboration with personal trainers and nutritionists can help in prevention of many chronic conditions like stroke, diabetes, osteoporosis, falls and fractures in the elderly, and obesity, among many others. Proper physical therapy assessment and training can also help prevent or minimize injuries in young and professional athletes, weekend warriors, performing artists and other active lifestyles.

exercise is healthcare

Exercise is medicine…

Office workers and those whose jobs require them to either sit or stand for long hours can also benefit from the services of physical therapists. Moreover, children nowadays lack physical activity as they spend more time texting and playing computer games. Physical therapists can provide education and activity prescriptions to inactive populace, either children or adults.

So these are what comprise my approach in my physical therapy practice. In the past, I have been impressed with so many techniques my colleagues teach and use. I have tried to learn some of them. I felt sorry for the things that i couldn’t afford to learn. either through lack of money or lack of availability of the training. In some classes I attended, I was even taught a watered down version of what evidence-based practice is, just so they can justify the things they teach and do which lacks solid and strong scientific evidences.

As I stay within the scope of evidenced based practice, not only my interventions have become simpler but I have been seeing higher success rate, and happier, more satisfied clients and patients.

The Eclectic Approach to Upper and Lower Quadrants by Dr. Erson, DPT


The Eclectic Approach to UE/LE in Manila, Philippines with Dr. Erson

I am totally hyped to finally meet and learn from one of the gurus of manual physical therapy, Dr. Erson Religioso III, DPT, MSPT, FAAOMPT. I have been one of the many followers of his works, blogs, videos, and practice.

Dr. E, as he is widely known is the developer and owner of The Eclectic Approach to Upper and Lower Quadrant. His approach to manual therapy includes assessment of movements, manual therapy, and home exercise program. Assessment is mostly SFMA [Selective Functional Movement Assessment], while treatment and HEP’s are MDT based, with combination of other treatment techniques like tissue works with IASTM, Mulligan’s Mobilization of Movement [MWM], and PNF [Proprioceptive Neuromuscular Facilitation].

The Eclectic Approach uses mainly evidenced-based approach, meaning assessments and treatments that are backed up by research and studies. The approach follows the ARC sequence of Assessment, Reset, and Crystallization [or locking in the progress attained].

The Assessment:


The Eclectic Approach utilizes SFMA and FMS for movement screening. But since FMS is primarily used with athletes, only SFMA is introduced. Only pertinent movements consisting of seven parts are introduced, just enough to cover the whole kinetic chain from cervical to the ankle and foot. Repeated motions and overpressure are then performed for which is mainly part of MDT.

These are the seven SFMA movements used in The Eclectic Approach screening:

1. Cervical flexion/extension, side bending, rotation with retraction, and chin to shoulder

2. Shoulder external and internal rotations

3. Multisegmental rotation

4. Side gliding

5. Multisegmental flexion/extension

6. Unilateral standing

7. Squats

  • Neurodynamics

– Peripheral nerves like joints and muscles need to move freely and unrestricted. Neurodynamics is used to assess the mobility of the peripheral nerve.

– Dr. Erson said that he uses neurodynamics now as part of evaluation [and reevaluation] but not as treatment as he uses tissue work for treatment.

Other considerations during assessments are as follows:

–          Movements are done both actively and passively. Overpressure is applied where limited motion is noted.

–          Asymmetry in movements is also noted. If asymmetry is only present in active movement, motor control is most likely the problem. If the asymmetry is noted in both passive and active movement, the problem is within the joint and/or tissues.

–          Movement is either pass or fail. Pass is when there is no pain, no limitation, and no asymmetry.

–          The directional preference is determined. More often than not, the DP is toward the pain. This DP will be the basis of further treatment.

–          Palpations as taught in PT school and done by so many therapists, osteopaths, and chiropractors are not recommended. Palpation is unreliable as there are many variations of the skeletal make up in each individual. This is something that I read a lot on twitter and I’m so glad to hear Dr E validate it.

 The Treatment

Here is another thing that I appreciate with the Eclectic Approach. The treatment is simplistic, evidence based and no magical or mystical. For rapid responders, which is like 80% of patients we see in the clinic, you can see immediate progress in just few visits.

Here is the sequence of treatment as I understood it. In clinical setting I’m sure there are going to be some variations and overlaps.


 While repeated motions to end range is a part of the assessment initially, they can be done periodically to see if the pain diminishes, centralizes, don’t change, or peripheralizes.

Here are what The Ecelctic Approach utilizes to get to the end range:

 1. Manipulation/Mobilization

–          Dr. E’s use of spinal manipulation is very simple. He follows non-specific spinal level principle which I have also read in another’s work before, as backed up by research. Biomechanically, if one level of spine is manipulated or mobilized at least 6 levels above and below it also moves thus specificity in manip is not really important.

–          Spinal mobilization and trust manipulation have the same effect according to research. Manipulation is simply quicker and less painful.



The Edge Tool for IASTM

–          Instrument assisted soft tissue mobilization with the use of The Edge tool which is designed by Dr. Erson himself is an effective way to diminish muscle tone and relieve pain by activating the mechanoreceptors in the skin.

–          Unlike similar techniques like AYSTM and Graston which uses aggressive forces, IASTM is very gentle. Fascia and scar tissue are very strong  and need at least 100 lbs load to deform it. Or might as well use a scalpel to break it down.

3. MWM [Mobilization With Movement]

–          Brian Mulligan’s concept of Mobilization with Motion on the extremities and Sustained Natural Apophyseal Glides [SNAGS] in the spine where the joint is taken to its pain-free end range and mobilized.

 4. PNF

–          Glad to hear Dr. E say that PNF is not only for neuro rehab, meaning patients with stroke, SCI, etc. But the again, orthopedic patients are also neuro patients in that pain is mediated by neural pathway.

–          MET which is an osteopath technique is actually similar to PNF in that resistance is applied to while muscle is contracting. The difference is the very light force used. That’s why Dr. E fondly calls MET a fancy PNF.

–          I was at another seminar and a clinician next to me hears of MET for the first time. When the techniques is demonstrated he whispered to me “Just like PNF!”

 5. Diaphragmatic Breathing

–          Diaphragmatic breathing is used simultaneously with resets. You’d be surprised how movement improves when diaphragmatic breathing is executed properly while doing repeated motions.

–          Diaphragmatic breathing activates the pelvic floor. The PF when inhibited recruits surrounding muscles like the piriformis, glutes, and hamstrings thus causing limited hip motions.


–          Resets are exercises performed to get a joint to end range, improve ROM, improve  function and improve motor control.

–          Resets include the following parameters: repetitions, end range, and holding the position for some time, say a minute or two.

–          His you tube channels are full of sample videos of resets of various muscles and joints.

  •  The HEP [Home Exercise Program]

–          HEP prescriptions are also very simple. Mostly repeated motions at end range using the DP.

–          HEP is only limited to 1-2 exercises to make the patient compliant and to easily assess which exercises is not working.

–          Exercises are done initially 10 reps every hour. If pain limits motion, 3-5 times every 30 minutes or so is recommended.

–          Patients are educated to do their HEP as prescribed to lock in the progress attained during treatment sessions.


This is just summary of what I’ve learned from the course. There are so many things to say but would be long and difficult to put them into writing. Suffice to say that the assessment and treatment approach to orthopedic manual therapy by Dr. Erson’s The Eclectic Approach is simplistic, doable and evidenced based. There are many clinicians  that I follow on facebook, twitter and the blogsphere who like to complicate the physical therapy practice I have often wondered if I can be even just half as good as them. It’s refreshing to hear somebody introduce something simplistic yet highly effective.

As already a follower of his works through his blog and forum, I have more or less used a couple of his technique in treatment [but not assessment since I haven’t really had training in movement-based assessment before].  As I hear him teach face to face, with lots of interactions with him, I have finally come to understand the things that I could hardly understand just by reading his blog and watching his short videos.

I’m also so glad that somebody has yet validated the fact that palpation as an assessment is unreliable. I’ve been studying movement as primary means of orthopedic assessment, and I hope to write a blog about it.

After this course, I know what succeeding courses, workshops and seminars to focus on. I’ve always wanted to take an in-depth courses in MDT and SFMA but it’s almost impossible to find one in Asia. I just have to pray harder…

And since it’s called an eclectic approach, one can still incorporate other treatment techniques that we are already accustomed with. Treatments that we have already been using and found to be effective.