Physical Therapy (PT); a bunch of massage, ultrasound and e-stim (those pads that give you that tingly feeling), and 3 sets of 10 with a yellow theraband for 6 weeks without any progression in resistance. This is unfortunately a good portion of PT clinics and these types of clinics are providing sub par care, to put it lightly. I hope that after reading this, the people of Santa Cruz and San Jose can see what good, progressive, evidence informed physical therapist actually is.
When I meet somebody for the first time, let’s say, at a party, dinner, at the gym, the conversation often goes like this:
Joe: Hi, i’m Joe.
Me: Hi, I’m Nathan.
Joe: Nice to meet you Nathan. The weather is gorgeous out isn’t it?
Me: Yep, sure is…
Joe: SO… WHAT DO YOU DO?
Me: Oh I help people move better.
Joe: Oh so like a personal trainer, a physical therapist?
Me: Yea, a physical therapist.
Joe: OHHH i’ve been to PT before!
Me: Yea, what for?
Joe: Well I had this (insert XYZ injury).
Me: Ah, I see, what did you all do for it?
Joe: Well, the PT did a lot of massage, we did some ultrasound, worked with those bands; what are they called again?
Facepalm meme (check out this meme, it captures my facial expression)
While I listen to the description of physical therapy from this individual, I cringe on the inside. I want so badly to tell them that’s only a SMALL portion of what we do as PT’s, but alas, they had a good experience, recovered from their injury, and now they’re back on the tennis court, hiking, and walking with friends.
PT’s work in tons of different settings. (even more than what’s listed)
As you can see, PTs work in TONS of different settings with many different populations. They also use a variety of different interventions to accomplish the goals of the person in front of them. Ultimately if we are talking about the musculoskeletal physical therapist the main focus is (or should be) on educating, teaching and progressing exercise, and acting as a coach, carefully monitoring progress.
I think most people view physical therapy as a “thing” that is done to them, rather than an entire profession. Physical therapy is a profession and not an intervention. Exercise is an intervention. Massage is an intervention. An adjustment is an intervention. PT is not something that is “tried.” Many people ask the question have you “tried physical therapy.” Do people “try” their MD? I’m not too keen on this phrase. Maybe the exercises you’ve been doing have not been appropriately dosed and you don’t trust the PT you’re working with. Is it possible that this is contributing to your condition not improving?
It’s certainly possible that someone will go through the course of physical therapy with a good practitioner who is listening, educating, prescribing appropriate exercise and appropriate load and will still require surgery or some sort of more invasive type care. This, however, is the exception and not the rule. Heck... I just read an article titled:
"What happens to patients when we do not repair their cuff tears? Five-year rotator cuff quality-of-life index outcomes following nonoperative treatment of patients with full-thickness rotator cuff tears"
Guess what this article found? That over the course of 5 years, those in the non-operative group had the same outcomes as those who received the surgery. Crazy. So, I restate my point, surgery is likely the exception and not the rule in musculoskeletal injury and pain management.
At this point i’m probably sounding a bit frustrated; it’s because I am. Many PTs have presented themselves to the public in a light that portrays us as an intervention and not a profession, and that the only thing we do is massage, perform some modalities (ice, heat, e-stim) and some exercise. I’m frustrated by this portrayal and by the PTs that rely heavily on passive treatments (massage and modalities). It prevents many people from getting the help they actually need that leads to long term resilience. It doesn’t allow others to spread important facts about pain. And, worst of all, it leaves people thinking that in order to take ownership of their health, all they need is a magic technique that is passively received.
With all of this said, most people who come in to see a physical therapist are going to leave feeling better than they came in no matter what the provider does. The reason for this is that people book an appointment when their pain and disability is highest. There is nowhere for the pain and discomfort to go but down, so naturally, people get better. Or, as the saying goes “the body will heal itself.” This is called regression to the mean.
This does not mean that there are not specific issues like a tendinopathy, fracture, post-surgical rehab that require more specific approaches, but, in the vast majority of cases, we are going to improve without an ultra-specific corrective exercise program. Don’t worry, your glutes don’t need to be activated. If you’re walking and standing up from a chair and didn’t have a spinal cord injury, chances are your glutes are “firing” just fine.
This is all coming from a guy (me) who used to train people to “fire” their glutes “better.” I learned in school that if people had tight hamstrings all you had to do was focus on firing the glutes better to make them less “hamstring dominant.” What I now know is that this doesn’t actually occur and the premise of this while it “sounds good,” doesn’t hold up when weighed against the evidence.
What is a good physical therapist going to
do for you?
Hint: They probably won’t throw an ice pack and e-stim on you every visit.
Over the past 2 decades, or maybe even longer than that, we have had TONS of research published in the area of pain, and pain management. There are entire journals related to pain, and blogs from Jarod Hall, Paul Ingraham, Lorimer Moseley, and Ben Cormack to name a few. I strongly recommend you check out these blogs if you want to have a better understanding of your body and to challenge any biases around pain that you might have.
First and foremost your physical therapist, chiropractor, physician, or whoever is working with you should listen to you. They should listen to your story. This means that they are allowing you to share with them about what’s bothering you, what it’s stopping you from doing and asking thoughtful questions along the way. The thing that likely has the greatest effect of whether someone will improve is do they trust who they are working with. Can this provider instill confidence in the person and is there enough trust built up between the two parties.
Second, after they’ve listened to your story and asked appropriate follow up questions they should come up with a plan with you. This plan should include how long the course of care will last for (two, three, maybe ten visits), what types of exercises will be utilized and what to expect throughout the sessions. Exercise progression or progressive overload is a key principle in physical therapy which means that as time goes on, a few things should change. Either the weight should go up, the number of sets should increase, the number of reps should increase, or a variation of those three.
If you are doing the same weight or the same number of reps as you were 6 weeks ago, chances are your therapist is being lazy or doesn’t know how to progress your exercises.
Here’s the core of a good healthcare provider:
As you can see, this stuff isn’t complicated. What is complicated is the interaction that you and your healthcare provider will have. What is also complicated is knowing when there is a more serious pathology to deal with. This is where a trained professional like a physician, physical therapist, or chiropractor comes into play to assess differential diagnoses. A personal trainer does not have the training or medical knowledge to safely or accurately provide you with this health information.
Here is a list of providers and groups of providers that I trust and who put out consistently excellent content on health, wellness, fitness, pain, injury management, and much more:
These are just a few of the excellent providers out there. I’ll be updating this list some more in the future.
At the end of the day you want providers with these qualities in regards to a musculoskeletal injury or pain:
The next time you need to consult with someone about a nagging pain or injury make sure they do these things! These are non-negotiable.