Ins and Outs of Physical Therapy

Impetus is into its second year now, and owning a PT practice that operates outside of the traditional healthcare system has been a huge learning experience. As many of you might already know, I don't take insurance. I believe that healthcare decisions should be made between patients and clinicians based on research and what's right for the patient, not mathematical calculation of profitability. This has presented some unanticipated challenges, but more on that down below.

One of my proudest achievements is that I have been able to consistently help patients get results in 3-5 visits on average. I don't do this through magic spells, super foods, or trade secrets. Rather, my success emerges from an obsessive attention to detail at every level of patient care and spending adequate time on patient education and independence. I find that when patients have a thorough understanding of their problem, the solution, and their specific role in the rehab process, outcomes are better. Goals are achieved faster. 

The Public Perception of Physical Therapy

Going into my first year, I figured I would spend much of my energy, explaining to potential patients how my clinic was unique within a city full of PT clinics. I was totally wrong. My competition is rarely other PT clinics. To my surprise, I have needed to spend substantially more time promoting the profession as a whole. 

In the world of patient self-referral, my biggest enemy is the unfamiliarity with PT among the public. Their only frame of reference becomes their framework for expectation. This means I often get compared to chiropractors, massage therapists, and personal trainers, not so much other PTs. My biggest challenge: explaining how physical therapy differs from these other services.

The PT profession has gone to great lengths to legitimize itself within the medical community, but at the same time, failed to do so with the general population. When I started PT school, I was surprised to find out that most people in the world are unfamiliar with PT. This is especially a problem for me because patients refer themselves to Impetus: I don't rely on physician referral like other clinics.

What is the difference between physical therapy and chiropractic

Most attempts to differentiate physical therapy from other similar services continues to be a zero sum conversation. Physical therapy, chiropractic, massage therapy, and personal training, each have far too much intraprofessional variability and specialization (especially the former two) to attempt a simple delineation between them. In truth, much of what my clinic provides shares some striking similarity with these other disciplines. In reality, what each of these disciplines provides is actually dictated more by what insurances deem a reimbursable service.

Personal trainers are often sought out for weight-loss, strength, or general wellness. Chiropractors and massage therapists are sought out for different reasons, although not exclusively. Sometimes the goal is pain management or general wellness. Of course, chiropractors are commonly associated with the spine, but I know many who would say that's an oversimplification. The biggest difference between my clinic and these other services is two-fold:

  1. I believe you will more consistently find elements from all four of these disciplines combined in one treatment plan, than from any one other singular discipline.
  2. The need of the patient to be involved in and take responsibility for their own progress is critical to the achievement of goals.

An in-depth analysis of exactly what physical therapy is or is not goes far beyond the scope of this post, but I did want to address five questions that commonly come up in conversation with friends, patients, and family members alike. Speaking in generalities is often dangerous, albeit a good starting-off point for learning about a new topic. I fully acknowledge that nothing in this post is considered a universal truth, and that exceptions can be found in many places.

1. My hip hurts: can you tell me what's wrong?

In short, no. The PTs of today are educated more thoroughly than ever before. They are trained to utilize firsthand reports from patients, medical imaging, lab values, and objective examination findings, among innumerable other tools, to create a complex and scrutinized diagnosis.

Much can be inferred from what we learn from the patient's story, but without a thorough hands-on examination, they would only be guessing. This is irresponsible as things in the medical world are not what they seem. All too often, we see cancer present as 'low back pain,' strokes present as 'sleepiness,' and spine problems present as 'carpal tunnel.' The wrong diagnosis can delay the correct treatment at best.

The implications of treating something incorrectly for 4 weeks can sometimes mean the difference between life or death. If you have a question for a PT about a problem you are having, I encourage you to ask, but don't expect a quick and simple answer. An expert opinion requires hands on examination and will go to great lengths to rule out 2 to 3 more serious possibilities for every 1 likely problem suspected. 

Take home message: if it's worth asking about at a social event or family gathering, it's worth having a PT fully examine it. 

2. Can you just give me some stretches?

This is one of my favorite questions of all time. Interestingly, some physicians still refer patients to PT and tell them that this is what will go down. Stretching is often a part of a treatment plan for some, but I can think of no scenario in which stretching alone will change a person's dysfunction in a meaningful way.

Even in the presence of a progressive or chronic neurological disorder, where stretching may be prescribed as a daily focus, it is almost always a precursor to improve the quality or tolerance of other adjacent therapeutic activities. When stretching is indicated, often strengthening, motor control training, or balance training are also indicated as well, even when it's not particularly obvious to the patient.

Stretching is complex topic. Is the goal to elicit a relaxation response to a tense muscle, or is it to work out some focal muscle knots? Is the goal to improve the range of a particular joint, or to increase the length of the muscle itself? All these things will determine how long you stretch, how you stretch, and how long it will likely take before results are seen.

I find that stretching remains an area of misinformation and ineffective technique, so I continue to educate on this topic as much as possible. There are even circumstances in which stretching consistently actually makes the patient's problem worse, hence blindly assigning stretches to someone without formally assessing them can be problematic and dangerous.

This is something you may see a personal trainer do, but rarely will you see a PT do this. Why? My guess is that it is because trainers work with mostly uninjured, healthy populations, and PTs work mostly with people who have movement dysfunction or pain, and often with multiple problems.

Just remember this: stretching should leave you feeling better than when you started. If this is not the case, then either you aren't stretching what you think you're stretching, or stretching is not the answer.


3. I can just do exercises at the gym, so why should I see a PT? 

This is an excellent question. This may be the quintessential 'why PT' question. I could write on this topic for days and days, but I will try my best to keep it relatively brief. In short, physical exercise is similar to medication: some pills are considered safe for purchase over-the-counter with self-managed dosing. Other medications and/or circumstances require additional instruction and closer supervision by a physician or pharmacist.

Apply this analogy to gym time. Most healthy adults can go to the gym and with simple instruction, guide their own strength program. Now consider atypical circumstances. How does the workout need to be modified when someone sprains an ankle, has a heart valve replacement, or starts 3 new medications in one week? Should these people even be at the gym?

I have a friend, who 30+ years ago injured his knee, and subsequently had his meniscus removed (very common in the 1980's.) Over the following 30 years, he had remained an avid cyclist and soccer player, but like so many others who'd had this surgery, he had developed progressive arthritis in the knee and it was finally time to opt for joint replacement.

He underwent surgery, and attended PT for 3 or 4 treatment sessions, but was convinced he could do the rest on his own at the gym. He decided to discharge himself to save some cash and took the bull by the horns. In truth, I blame the PT for this. I find that when we fail to explain the 'why' of what we do with patients, we also fail to demonstrate the value of PT.

A year later, he still had significant joint swelling, lacked strength, and could barely bend his knee. He regretted his decision and was on his way back to PT once again to resolve these issues. This was a full year of continued dysfunction, unable to ride his road bike or walk long distances as he likely would have been. This was an unfortunate scenario wherein better explanation to the patient may have helped avoid months of dysfunction. Among everything else, PTs are always serving to monitor progress, and are on the lookout for signs that something is going wrong.

The biggest principle of exercise physiology is that physiological adaptation and response is dose dependent. This makes sense to most people at a macro level: "I haven't run in a while, so running will now be hard." In PT, we're always looking for the "sweet spot": how much stimulus can the patient tolerate in a productive way.

If the prescription is not aggressive enough, few significant gains will be made and progress will take longer. If too much is prescribed, injury or pain can become worse. As a PT, I rely heavily on patient feedback to determine the right amount of exercise to prescribe. This takes some time for trial and error, but requires regular check-in's with patients. I could easily prescribe a super safe amount of exercise for everyone, but it would really be a waste of time for many.

4. Why does PT require so many visits?

I think this is an implicit question more than anything. A minority of patients show up and expect an immediate fix at the first visit. I understand the desire for this to happen, especially in a world where things mysteriously feel better after a single visit to another similar practitioner, but it's simply not practical. The body does not work this way.

Take spinal manipulation for example. This is the hallmark of chiropractic treatment, sometimes referred to as an 'adjustment.' I hear often from patients that they regularly go to have this done, and feel better initially, but the pain returns within a couple days. This tendency is fairly well established from my experience as a clinician, after all PTs perform spinal manipulation too. But what's going on here?

If you follow the research in this area, it's become clear that spinal manipulation does not do what we as clinicians have thought it was doing for years. Some of what we now know is that:

  1. Manipulation changes the way the nervous system functions at the level of the spinal cord
  2. Manipulation changes the way the nervous system functions at the level of the brain.

This is great news! With a quick procedure, manipulation is able to improve the quality of muscle firing, the perception of pain, and improve functional mobility. The downside is that these changes (mostly neurological) are not permanent, and require compliance to other activities such as strengthening or stretching for long term benefit. There is no evidence in the research to support any long lasting tissue length changes from a singular session of spinal manipulation, however it does create a small window of opportunity where things like strengthening, stretching, and daily activity are more well tolerated.

If you have ever joined a gym and noticed how long it takes to make changes in strength or weight loss, you can understand why PT takes more than 1 to 2 visits. Real changes in strength, flexibility, and tissue length take time, and that's IF you are doing everything correctly. Neurological changes like gross motor control, balance, or fine motor coordination can happen more quickly, but still require lots and lots of practice. Think about how long it took for you to perfect your free-throw, learn piano, or write legibly in cursive.

With new patients, sometimes I am able to make huge differences on the first visit with activity modification. If we can identify what exactly exacerbates the problem, then we can problem solve to find ways to modify that activity so that it can be performed in a way that is more tolerable or even pain free. Even in this case, there may still be weeks of work required to address any associated tissue healing, weakness, or postural abnormalities associated with the original problem. Chose not to do the work, and the problem is almost certain to come back.

5. PT always works great for my (mom/dad/etc.) but as soon as it stops, they just go right back to where they started. 

I get this from concerned adult children of chronically ill patients or elderly patients with some low to moderate level dementia. These patients have often taken PT 2-3 times in the past several years, with noticeable benefit, but demonstrate a slow and steady decline after therapy concludes. This phenomenon is almost always specific to patients who are sedentary at baseline, whether due to physical limitations or a lack of motivation.

In PT schools, frequently is said that "physical therapy is not a passive modality." In essence this means that PT is not something done TO someone, but something done WITH someone. If a patient is unwilling or unable to participate, results with be nil. The goal of therapy is to provide enough education and strategy that eventually the patient (and/or caregiver) is able to become independent in their own rehabilitation and wellness.

Teamwork makes the dream work!

Teamwork makes the dream work!

Patients at Impetus are far more independent than patients at most other clinics. My patients understand that compliance to a home program is critical, sometime for extended periods, but the eventual goal is to progress isolated and targeted exercises to their meaningful task, sport, or functional activities. If a patient is still using elastic bands 6 months after they were discharged from PT, I would not anticipate much benefit to emerge.

Patients must be engaged in their rehab for real, actual, long-term results. Education should be given early on explaining the arc of treatment and regularly to connect weekly rehab activities to long-term goals. Prior to completing therapy, patients need explicit instruction in continuing to drive progress and solidifying that last 10% of recovery. This is how PT is supposed to work. Real results take time, hard-work, and patience. Its takes teamwork between the patient and therapist to get the job done.  

Thanks for reading! Until next time: keep moving!