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  • Outdated Techniques Including Assessment and Treatment Procedures.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 Many of these machines have now been decalred as outdated, ineffective or simply unnecessary.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[You can read some of the outdated treatments used in physical therapy here!]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

 

Advertisements

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.

 

 

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.