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  • Outdated Techniques Including Assessment and Treatment Procedures.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 Many of these machines have now been decalred as outdated, ineffective or simply unnecessary.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[You can read some of the outdated treatments used in physical therapy here!]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

Repetitive stress injury [RSI], or now commonly, Overused or Overload Injury is collective term used to describe physical pains caused by excessive strain on the muscles, tendons, nerves and fascia from repetitive movements. Repetitive microtrauma or repeated strain overload overtime results in structural weakening, or fatigue breakdown, of connective tissue.

repetitive_stress_injury

In a nutshell, this is how it happens… When connective tissue is injured, it goes through a reparative process. However, in connective tissue that is repetitively stressed beyond the ability to repair itself, the inflammatory process is perpetuated. Proliferation of fibroblasts with increased collagen production and degradation of mature collagen leads to a predominance of immature collagen. This has on overall weakening effect on the tissue.

Initial signs and symptoms of inflammation such as pain, redness, swelling and limited movement may be observed. Initially, the inflammatory response from the microtrauma is subthreshold but eventually builds to the point of pain and resulting dysfunction. The type of pain may show the stage or extent of the injury. There are stages for repetitive stress injury:

  •  Phase 1 – Pain is localized and is easily relieved when rested.
  •  Phase 2 – Pain radiates out to other parts of the body. Pain appears more quickly and disappears more slowly.
  •  Phase 3 – Pain is almost always present and can limit function.

Since RSI is a progressive condition, the longer you wait for treatment, the longer the period of recovery takes.

Repetitive stress injuries can occur anywhere in the body where there are repetitive and forceful movements. It is more common in the upper body including the neck, shoulders, elbows, wrists and hands. Overuse injury can be simple muscle tensions with recurring aching pain to involvement of other soft tissues like nerves, ligaments and tendons.

The following are the more serious types of repetitive stress injuries.

Thoracic Outlet Syndrome 

thoracic outlet

Thoracic outlet syndrome [TOS] is a term used to describe symptoms of pain and discomfort in the neck, shoulders and arms which can be associated with numbness especially in the fingers. The symptoms are cause by entrapment or impingement of the nerve bundle and/or blood vessels [artery or vein] as they pass through the scalene muscles in the neck, the first rib, or the clavicle [collar bone]. For a more detailed description check out my previous blog on this topic.

Lateral Epicondylitis [Tennis elbow]

tennis elbow

Pain in the common origin wrist extensor muscles along the lateral epicondyle and radiohumeral joint on gripping activities. Activities requiring repeated wrist extension such as the backhand stroke in tennis [thus, the term “tennis elbow”], computer keyboarding, pulling weeds in the garden can stress the musculotendinous [muscle and tendon] unit and cause pain.

Carpal Tunnel Syndrome

carpal tunnel

Carpal Tunnel Syndrome is an irritation of the median nerve as it passes through the carpal tunnel. The carpal tunnel is the tight space located in the wrist formed by fibrous bands and the carpal [wrist] bones. Any condition that causes swelling or change in position of the tissues within the carpal tunnel can cause irritation of the median nerve which results in tingling and numbness in the thumb, index and middle fingers which receive innervation from the median nerve.

Management:

The best way to manage RSI is through prevention. Avoid prolonged used of your joints by talking micro breaks every 30 minutes during working hours. Take some time to loosen your neck, shoulders, elbows, wrists, and fingers by moving and stretching them. A physical therapist can teach you the right mobility and reset drills that you can do few times throughout the day while at work.

In cases where you feel any recurring pain, numbness, tingling sensation, and limited joint range of motion in the neck, shoulder, and arms, conservative physical therapy is also the ideal first line of treatment.

Remember for aching and bothersome body pains, physical therapy is your initial option. This is cost effective as many medications, injections and imaging are unnecessary.

Get PT 1st.