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  • Outdated Techniques Including Assessment and Treatment Procedures.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 Many of these machines have now been decalred as outdated, ineffective or simply unnecessary.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[You can read some of the outdated treatments used in physical therapy here!]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

 

 

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

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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:

  •  SFMA/MDT

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.

  •  REPEATED MOTIONS AT END RANGE

 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.

 2. IASTM

Image

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

–          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.

 Conclusion

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.