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  • Outdated Techniques Including Assessment and Treatment Procedures.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 Many of these machines have now been decalred as outdated, ineffective or simply unnecessary.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[You can read some of the outdated treatments used in physical therapy here!]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

 

Education and Exercises – The Cornerstone of Physical Therapy

“If your therapist only does a ‘treatment’ to you and misses out the ‘get it moving/ rehab/ graded recovery / functional recovery process – then its my opinion that your therapist is a complete waste of time”

Louis Gifford
Aches and Pains P.159

In his article Chiropractic and Osteopathy – How do they work?, respected physiotherapist from UK, Adam Meakins wrote:

The lines between physiotherapy, chiropractic and osteopathy have become blurred. As physiotherapists we should be giving only education and exercise-based advice. We believe in self-management, giving patients ownership to get themselves better and not looking for repeat business.

Indeed, the past few years we have seen the crossover of practices among many different rehabilitation specialists. While I don’t have anything against chiropractors or osteopaths, there has got to be distinguishing line somewhere. Good thing, there is… Physical therapists are well known in constantly educating their patients and keeping them actively part in the rehabilitation process instead of just keeping them passive, with the practitioner doing all the work.

Education.

A good physical rehabilitation practitioner must be able to educate their clients/patients properly. Education starts with discussing the underlying condition as accurately as possible. What and where is the problem? Why does the problem exist? Many times patients come to physical therapy to have assurance that there is nothing particularly a major problem with their [insert musculoskeletal problem here]… In the discussion, it is important that the clinician uses non-threatening words to make sure that what we tell our  patients won’t cause a nocebo effect. Nocebo is a detrimental effect on health or symptoms produced by psychological or pyschosomatic factors. In rehabilitation medicine, these factors involve mainly the words that we use when discussing with patients their conditions.

nocebo

“A massive fear inducing nocebo” – Ben Cormack, Physiotherapist

Nocebo effect is particularly common in pain management. Even well trained clinicians use inappropriate words that cause more harm than help to pain patients. Sometimes, these inappropriate words are used intentionally to encourage the patient to to sign up for long term treatments. This happens when the patient is made to believe that some things are wrong with their body and they need a regular or at least a long term, repeated fix. Examples of these are: spinal vertebrae being out of place that need some long term adjustments, some muscular imbalances that need repeated correcting, core muscles being weak causing recurring low back pain… the list could go on! [More about this in future blog, but there already numerous articles regarding these issues].

But what is so threatening with these words? In their article, The Nocebo Effect: How Your Power of Suggestion May Harm Your Clients, Matt Danzinger, a personal trainer and Jonathan Fass, an orthopedic physical therapist wrote:

Words like “fat, scrawny, or weak” are words that harm. Words like “damaged” or “broken,” phrases such as “you’re going to be injured,” or “you don’t move right” can destroy what you are trying to build.

Telling a patient they have degenerating discs, bad posture, displaced sacrum, etc. can be perceived as threat by the brain. And when the brain perceives a threat, real or imagined, pain is produced. Imagine if everyday our patients believe that their posture is bad, they have a bulging disc, their knees are degenerating. How would the brain react to these catastrophic thoughts? We know now that pain and tissue damage are not always correlated. Unfortunately, pathologizing posture and movements is very common and rampant in musculoskeletal medicine resulting in fear-avoidance behavior and catastrophic thinking. I’m not saying that discs or joint degenerations are not real, just not causative factors of many recurring or chronic pain conditions. [Again, this topic needs a totally separate article].

In other words, educating patients regarding their condition is essential part of physical therapy practice. But more important still is to say the right words that are more helpful than harmful.

Exercises.

Prescribing appropriate rehabilitative and therapeutic exercises is one of the most important parts of a real physical therapy program. It is prescribed both in the clinic and as part of patient’s daily home program. Very often, they are prescribed as graded movement exposure wherein the exercises prescribed depend on the patient’s capacity and tolerance at the time of treatment. These exercises are also specific to the patient’s underlying problem – acute injury, non-specific pain, or presence of pathological condition.

While other specialists may administer mainly passive treatment to “fix” the client’s problem/s, physical therapists make use of the therapeutic effects of exercises to relieve pain, increase range of motion, strengthen muscles and improve movement. That’s right, graded movement exposure can actually help relieve pain. So no need to avoid movement altogether. Furthermore, exercises can promote tissue repair after tissue injury, or surgical repair of damaged tissues in the musculoskeletal system through a mechanism termed as mechanotherapy.

I am not in anyway saying that these so called passive treatments like heat, ultrasound, massages, manipulations, joint and soft tissue mobilizations, even kinesio taping have no place in physical therapy. Although evidences of the therapeutic effects of these modalities are weak at best, they can be in some cases they can be helpful. [Ok, so more and more orthopedic physical therapists are discarding their ultrasound machine, and for good reason]. I do spend a great deal of time doing hands-on therapy on my clients or patients prior to giving exercises. They can produce neurophysiological changes in the tissues to make movement drills easier and tolerable. For example, soft tissue work and joint mobilizations can help decrease pain, decrease muscle guarding, and increase range of movements. Exercises are then carried out to help maintain these improvements though activating the nervous system. That is why a good home exercise program, and adherence to these exercises are essential in the over all success of a physical therapy program.

So the next time your physiotherapist gives you only passive treatment without giving you exercises to do in the clinic and to do at home, you are hereby advised that you find another therapist.

gangnam

 

 

References:

A meta-analytic review of the hypoalgesic effects of exercise. Kelly M. Naugle, Roger B. Fillingim and Joseph L. Riley. 2012

Exercise as medicine – evidence for prescribing exercises as therapy in 26 different chronic diseases. B.K. Pedersen and B. Saltin. 2015

Mechanotherapy: how physical therapists’ prescription of exercises promotes tissue healing. K.M. Khan, A. Scott. 2009

Further Readings:

Placebo and nocebo effects in the neurological practice.

 

 

Physical Therapy Approach to Pain and Injury Rehabilitation

When I write “Physical therapy approach to pain and injury rehabilitation,” I mean my personal approach in managing various musculoskeletal conditions. And my approach is mostly based on the works of Erson Religioso’s “Ecclectic Approach”, Greg Lehman’s  “Reconciling Biomechanics and Pain Science”, and some of Gray Cook’s “Functional Movement” principles. No, I don’t utilize nor promote Cook’s FMS screens. I only follow how he manages musculoskeletal problems where he starts with mobility and stability and concludes with strengthening. Following all these pattern and principles make it easier for me to treat injuries at a minimum amount of time, and with high success rate. I am not going to talk about specific techniques here but rather the flow of my treatment protocols. Specific techniques will be discussed separately some other time.

So here are the areas I work on when working on patients and clients with pain and/or injuries.

  • Pain Relief

Relief of pain would obviously be the most immediate immediate concern of most clients or patients with musculoskeletal conditions that come for physical therapy. They are in pain and as a result making them less functional and less productive. Treatment to relieve pain will depend on many factors including the stage of the underlying condition [whether acute, sub acute or chronic], the intensity and frequency of pain [constant or intermittent], accompanying symptoms, trigger factors, patient’s general lifestyle among many others. So generally I start my treatment with pain science education. Pain science education is winning half the battle in treating patients with musculoskeletal pain. It helps clients understand how pain works, how the treatments I do can help, and lessen their anxiety and fear avoidance.

no-pain

Next I do some manual techniques. Touch in itself has calming effects. It can decrease soft tissue tone and relieve spasm. It can stimulate mechanoreceptors in the skin and underlying tissues [nerve, fascia, muscles] that bring about neurophysiological changes in the brain that help desensitize the painful area. [Please note that I did not say release fascia, loosen scars, or break myofascial nodules and any therapist who tells you that has not evolved with the new evidences yet or tricking you with the skills they thought they have].

But pain can be tricky. Much of the pain we experience is an output from the brain and thus there are times the site of pain is not always the site in question. And so adjoining joints and tissues are also checked for any pathology, dysfunction or restrictions. Painful neck, check the shoulders. Painful back, check the thoracic or the hips, painful knee check the hips and ankles… The manual techniques I use depend on the problems I find in the assessments. And they are pretty simple. There are many manual therapy techniques out there that are unnecessary and only help the therapist look cool and seemingly more qualified.

  • Improving Mobility
ankle mobility exercise

Ankle Mobility Exercise

Pain and mobility are usually correlated. In the presence of pain, range of motion is decreased sometimes just owing to the fact that the person in pain will tend to guard the joint, to protect it from triggering more pain, or to avoid causing more harm. When pain is decreased, muscle guarding is decreased and joint range of motion is improved.

But mobility is not just about joint range of motion. In fact in many cases, textbook range of motion in some joints are not necessary for functional activities. The point of mobility drills is not how far you can go but how easily and smoothly you move. Movement patterns and joint proprioception are altered in the presence of pain or injury. Mobility drills have something to do with sending sensory information to the nervous system that can bring about change in movement and perception and improve joint proprioception.

  • Improving Stability

As mobility is improved, stability training comes next. Truth is, stability and movement co-exist in the human body kinetic chain. Mobility and stability are the cornerstone of movement. That is why they come first in many musculoskeletal rehabilitaion. Joint stability refers to the ability of the muscles to maintain or control joint movement or position. It’s training the  muscles and surrounding tissues of the joint to function in coordinated actions under the control of the nervous system. Just like mobility, satbility drills are neurophsyiological. Stability exercises aim to let the nervous system have the musculoskeletal units move in coordinated fashion producing efficient and smooth movements.

core - bird dog

Bird-dog Exercise for Trunk and Lower Back Stability

  • Improving Movement

Efficient movement is constant balance between mobility. After basic mobility and stability training, more dynamic, functional movements are introduced. Speed is increased as needed, and directions are varied. While I introduce mobility and stability initially in single planes, transverse planes and diagonal movement patterns are added.

Walking Lunge with Twist as Movement Retraining

Walking Lunge with Twist as Movement Retraining

Movement retraining follows functional movements, and are modified depending on the person’s daily, recreational and sporting activities. Movement retraining will help break the abnormal movement pattern the injured person has developed as a result of pain, muscle guarding and fear avoidance.

  • Strength and Conditioning

Injury and pain does not only affect mobility, motor control and movement but also strength and endurance and thus affect the body’s overall performance. Resistance exercises with the use of everything from body weight, to resistance bands, to free weights, to compound machines will not only strengthen and recondition the muscles, ligaments, tendons and bones but also help promote further healing.

Yes, we use weights in physical therapy!

Yes, we use weights in physical therapy!

Prof Karim Khan of the British Journal of Medicine explains in an interview podcast that exercise-based rehabilitation relies on the cells of the injured tissue sensing the exercises stimulus, converting the signal to protein synthesis, and repairing tissue. This is why rest doesn’t work.

In the event that my client would need a more vigorous strength, conditioning and functional training, I refer them to a more qualified strength and conditioning professional.

  • Return to Performance
voleyball pt meme

Do the things you love,,, pain free!

The highest goal of any kind of rehabilitation is for the injured person to get back to doing what they love – whether it’s running, or dancing, or sporting activities, or playing with the children. In some cases I go and supervise my clients start their sporting program again. I have had a client who’s been indoor rock climbing for five years. He’s had medial epicondylitis [yes, it’s acute] and pain around muscle guarding. After few sessions with him, I joined him at the indoor rock climbing site as he attempted to start climbing again. I’ve done the same thing with my client who is a professional contemporary dancer.

Don’t let pain and injury stop you… Physical therapy can help in more ways that you realize. A good physical therapist can help you in every step of the way – from your recovery to return to performance.