Why doesn’t Physio always fix my problem?

Over the many years I have been practicing the application of exercise, I have run across many physiotherapists and practitioners of other modalities like chiropractic and massage.  Since I don’t want this article to become several dozen pages, today I’m going to discuss the world of physiotherapy and specifically the limitations that I have seen within that system and how it can be helped by a competent trainer.  Like any type of practitioner, even medical ones there are both good and not so good people in the respective industry (including my own).  However, one of the biggest trends that I see with my clients is that more often than not, their experience with physiotherapy results in limited results and often doesn’t cover the whole need for the person involved.  This is what I’m exploring here. 

The format is fairly consistent whenever one of my clients or someone I know sees a physio.  They are evaluated, which can take the form of simply glancing at a person and doing a cursory examination and then diagnosing (and yes, I have seen this) or a full musculoskeletal workup including x-rays.  A diagnosis is given of what the person seems to have affecting their body in the form of painful movement.  Treatment is given, which normally takes the form of a couple of different types of therapeutic modalities (most commonly massage, ultrasound, hot/cold packs and TENS).  Sometimes simple exercises and stretches are prescribed as well depending on the patient.

When I went into some research about some of these modalities, some interesting things came about.  For example, did you know that ultrasound has rarely if ever been proven to actually do anything beneficial for pain reduction?  And, on top of that a recent study published in May of this year in the Ultrasound Journal found that therapists displayed “a lack of knowledge” of the basic physiological effects of ultrasound.  After several hours of searching, most studies I found basically stated that there was little to no difference with most patients in terms of reduction of pain whether they actually received the treatment or had a turned off machine hooked up.  The research on TENS is remarkably the same – there has been little to no evidence that it actually does anything useful in terms of healing or pain reduction.  One statement I found (from an actual physio site) suggested that TENS and acupuncture are essentially the same thing.  But many therapists use these all of the time of all of their patients without even considering if they will be useful.  Don’t even get me started on the various versions of stretching – that’s a whole other kettle of fish I’ll open up another time.  Of all the things that are performed, massage and hot/cold packing is most likely to create some relief, but it does absolutely nothing to address the joint and muscles in question strength wise, which is normally the source of the injury.

Then we head into the exercise area.  Granted, many people who come into clinics like this have quite limited function and simply want to get back to their normal daily sitting on the couch and in their office chair.  However, therapists often don’t even give exercises at all beyond simple joint mobility movements and suggestions like “take a yoga class” or “stop lifting heavy”.  I realize that therapists deal with some very broken people, but to me they should have some solutions in place in order to help the people make sure that these things do not happen on a recurring basis.  Doing rotator cuff rotations with a 2-pound weight isn’t likely to improve the ability of a muscle to maintain tension or generate force, especially if it isn’t even affecting what you think it is (standing dumbbell external rotations anyone?).  Many therapists who prescribe exercise in my experience have little knowledge of how to do it properly in order to maintain joint strength and increase the ability to generate force.  Machines are the devil and “functional movement” is the best thing.  I actually had a therapist months ago – who had been seeing her patient for a YEAR (and the injury happened several years prior) – tell me she should “definitely never do” anything like squatting, lunging or lifting.  Within about three weeks I had her client squatting and lifting without pain and able to at least hold herself on one leg without any problem or loss of control whatsoever.  From what I know of the therapy profession, if something isn’t improving after that amount of time, don’t you think it is time to try something else or stop taking that person’s money and admit you aren’t helping?

The other side of that coin is that patients are not educated and often try after a couple of treatments (thinking they are now reduced pain wise) to go right back to what they were doing before the injury.  They don’t realize that the body takes a while to improve back and they might have to modify their movements for a little while or simply approach their joints in a different way – and it will make little to no difference to the muscles in question.  In fact, by “rotating their tires” most of my clients find that they improve faster and can do more after they have laid off of a specific pattern for a while.  But they need to know what to do and how, and most therapists either don’t have the time for this, or don’t have enough knowledge in that area.  I acknowledge that there are also a lot of PT’s who think they are therapists and massage their clients with sticks and diagnose things they shouldn’t, but they don’t have a big official title and public trust behind their names.

I think that every PT should have to take a therapy based course, if not to get some more knowledge in anatomy and proper movement of joints, then for a very simple reason – to learn how to de-progress somebody to the point of ridiculously low loads that they might need at first.  Through my RTS/MAT knowledge I can do things like remove bodyweight, change the intensity of a load halfway through a movement, change directions of force entirely or even apply forces differently so that the joint can learn to maintain tension.  I realize that not a lot of trainers have this type of knowledge.  I wish that some of my colleagues cared enough to study these things.  I realize the fear that most physios have is the typical “boot camp” trainer who is going to take their client just getting over an injury and hurt them again (if it wasn’t the trainer who did it in the first place).  There are biases on both sides and instead of competing for clients, I often find the best solution is to work together so the client gets the best benefit.  Physio can take you to the point where you can move properly again, but more often than not much, much more needs to happen after that to ensure that nothing happens again, and that’s where someone like me comes in.  Many therapists simply don’t have the tools for what happens after and aren’t trained in them through no fault of their own.

Very recently (Monday last week) I had a client come in after not seeing her for a couple of weeks with pain down her leg which she said had been there for a few days after a weekend of doing things at the cottage.  She was upset because she didn’t know what she did and was worried that it was going to set her back with her running program.  After doing an assessment I found that her problem likely wasn’t anywhere near her leg and seemed like it might be the result of some strain from painting – with her opposite side on her upper body.  Her midsection was also not responding well to muscle testing.  After I applied some simple MAT and movements to those areas, she came in two days later claiming that I was a “wizard” because the next day she was 90% better and pain free.  One of the things I tell my clients constantly is that the body has no rules, and more often than not the source of the pain is not where the pain is.  These are things that a lot of practitioners fail to explore.  I often use the analogy of a person coming in with a headache.  You can give them an aspirin to mask the pain – or try to find the source of the headache and not only stop it completely but also prevent it from coming back.  Using MAT and RTS principles I am able to do this consistently with success.  And, the great thing is that usually they end up stronger as a result over time.

My advice is always the same with any practitioner, including my own industry.  Get referred to one (and please not through someone you don’t trust) and evaluate them while they evaluate you.  Get a sense for what they are trying to do to help you.  Don’t believe anything just because they say it, research and evaluate on your own as well.  Some people will research televisions they are planning to buy more than the person who is going to affect their body in a very fundamental way.  Never assume anything.  And good luck with whatever you are doing to your body today.

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