Blog Post

Physical therapy doesn’t work the way you probably think it does

Take a moment to consider how you think physical therapy works.

No, it’s not a rhetorical question. I’m serious.

Your understanding of physical therapy can have a big effect on your expectations. And expectations will affect your outcome and ultimately your satisfaction.

So, do you imagine a soothing massage to get rid of the pain? Or maybe a deep, painful one to “tenderize” your muscles and “release” adhesions?

In your mind, does PT involve stretching and posture advice? Or do you see yourself hooked up to electrical stimulation machines and heat packs?

Are you pain-free and skipping out after one or two sessions? Or are you coming three times a week for four months?

As physical therapists, we have an obligation to give our client a diagnosis and describe how we plan to help them reach their goals. We also need to give them a prognosis, which is our best guess as to how much better they can expect to get and how long that will take.

There is a truth that I wish wasn’t so but without understanding and accepting it unrealistic expectations can develop in a patient’s mind that become barriers to successful treatment. This is the truth: there is almost never a magic bullet, no single exercise that fixes the problem, no one spot to press or joint to crack that makes all the pain go away and STAY away. I have been looking for a couple of years and I’ve yet to find one.

So how does physical therapy work to help you?

In a nutshell, it causes adaptation.

And it can be any and all sorts of adaptations. Adaptation of the body structures. Adaptation to tolerate stresses. Adaption of the nervous system. The key is this:

Adaptation takes time.

Bone takes 17 weeks on average to remodel. Muscle doesn’t begin to get larger until around 6 weeks of persistent stimulus. Nervous system changes can happen almost instantly, but long-term changes take more time.

The last type of adaptation is the most important when it comes to pain. Your nervous system and its “threat-o-meter” need to adapt and readjust in order to react to normal stresses (and occasional super-normal stresses) without sounding the pain alarm. By starting with movements and activities below the pain alarm threshold and slowly progressing those activities in amount or intensity we cause the nervous system to adapt and the pain alarm threshold goes higher. That means you can do more with less pain.

This is probably the real mechanism behind therapeutic exercise and, indeed, most therapies. The therapist introduces a stress to the patient’s nervous system in the form of some stimulus, whether muscular tension, joint compression, skin stretch, or myriad others at their disposal. The nervous system responds by adapting, ideally in the way that the therapist and patient hope.

The fact that the nervous system can respond favorably to so many types of stimuli explains why many different treatments can have a positive outcome even though they may be focused on different parts of the anatomy and physiology and with different intentions. They all access and act on the nervous system in some way.

We tend to prefer therapeutic exercise as our main treatment component because it can be progressed in a controlled, systematic way and the results tend to be more lasting than other more passive treatments. The point is not necessarily to get stronger, though that is a happy byproduct. Strength in itself doesn’t protect you from pain. I’m sure you’ve seen plenty of very strong people with pain. The point of therapeutic exercise is to give you the locus of control over your condition and progressively rewire your nervous system to desensitize your pain alarm and bring it back to a level commensurate with your desired activity level.

Again, this process is slow. There is rarely, if ever, a quick fix but we have been taught in our modern world to expect one. Many products and services promise instant gratification, and the best deliver it. Microwaves warm meals in a fraction of time. You can download hundreds of megabytes per second on the internet. Amazon delivers many items in the same day.

However, if you apply these same expectations to your physical therapy then you will likely be disappointed. As a result, you will probably think physical therapy doesn’t work and quit after two or three sessions. And then you’ll be back where you started, searching for some other quick-fix solution. Sadly, there’s a good chance you probably could have gotten better if you understood and accepted what was required and invested the time and effort necessary in order to achieve adaptation.

Please understand that 99% of the time physical therapy only works by helping you to adapt. This can be a painstaking, long process with ups and downs and setbacks, as illustrated by this humorous but accurate graph by Adam Meakins, The Sports Physio.

But the result is change that lasts as long as you are willing to maintain it.

Be patient, be positive, be persistent and you will improve.