As we continue to examine how the physical therapy field can better serve the public, we realize that certain treatments are being done that we, as patients, really don’t
need or aren’t effective.
In many cases, specifically in third-party-payer-dependent settings (PT Mills), your insurance company dictates much of your care. While your physical therapist may have some unbelievable manual skills and great clinical judgment to get you back to awesome movement, this pro is most likely handcuffed in the amount of useful service they can provide simply because of the setting in which they operate.
Common PT Treatments That Don't Work
In the PT Mill, the physical therapist might want to give you lots of one-on-one attention and hands-on care, but that would require stringent justification of the treatment(s) to your health insurance. Because of this, the professionals at PT Mills are more likely to perform treatments they KNOW they will be reimbursed for. Unfortunately, this leads to a lot of tired treatment that is rarely what you need to get all the way well.
Here is a short list of the most common PT treatments that we don’t need because they don’t work:
Ultrasound
This is the number one offender, and we’re pretty passionate about this one. It is used as a heating modality. The basic physics makes perfect sense: the device creates ultrasonic waves that move the molecules and produce heat. However, it’s been used in a much more wide arching way for many years. It has been thought to decrease pain by a few different mechanisms. It increases the tissue temperature, increases blood flow, and reduces inflammation. This is not the case; there is little evidence to back it up and quite a bit to refute it.
There is LOTS of literature to support the outright removal of ALL ultrasound units from physical therapy settings. I've included the information below for more research-minded patients and therapists. You should find this interesting yet disturbing, mostly because there isn’t a PT Mill in the country that doesn’t have one or more US units.
A recent study in the Annals of Family Medicine examined the added benefit of ultrasound to a more hands-on approach to treating low back pain. They found NONE.
In a study in Rheumatology International, the researchers found that sham treatment was AS EFFECTIVE AS the “real” thing.
This study in the Journal of International Medical Research also examined the effect of different types of US in treating knee pain. One of the types was sham-US, which, over ten treatments, showed significant improvement in pain. While this study showed that a version of US (pulsed) improved pain more than sham, the fact that the con also provided statistically significant improvements in pain in this group of knee pain patients is very telling. We should all go out and pretend to do US treatments on everyone because their pain WILL decrease.
The list goes on. Worse is that there exists literature that the tissue heating effects of ultrasound are no better and, in many cases, worse than what can be done using simple manual techniques for the same purpose. Good PTs use the most current evidence in practice in combination with best clinical practices and patient values. If I can’t logically explain what I am doing and how this will benefit a client, WE DON’T DO IT!
The Upper Body Ergometer
You will see this one in a lot of Mills. It is simply a bicycle for your arms. Some patients need this equipment because a limitation prevents them from performing cardiovascular exercises with their legs. For example, if you have no use of your lower extremities or the use of them is very painful, this might be a good exercise. However, in these cases, PT occurs in very different settings, and the UBE is appropriate.
That said, the reality is that this vast and expensive piece of equipment is used to get folks out of the way while managing traffic. The UBE is the PT world’s dirty little secret. It’s not there because it’s better than the regular bike or the treadmill. If you are on it, it's because the PT is swamped, and they need a place to put you that isn’t technically “waiting” so they can bill your insurance company for it. After all, if you’re in a Mill, any minute that passes that you’re not charged for something is a wasted opportunity.
Any Passive Heat, Cool, or “ESTIM” Treatment
Electrical Stimulation therapy can be very effective. It comes in different varieties, such as TENS and NMES, to name the most commonly used. ESTIM, for short, is a treatment that is overdone and usually in conjunction with a hot or ice pack. Evidence supports its use in decreasing pain, but the majority of this would dictate that its effectiveness ends when the machine is no longer on. Are we to walk around all day with ESTIM units buckled to our belts? Pain is the signal of some problem. Wearing a 9V battery-operated machine to remove or lessen this signal will NOT improve you.
The cases that see the best benefit from ESTIM treatments are almost always those who have lost some or all muscle function for one reason or another. NMES is proven effective at maintaining the ability to contract muscles for periods of time until the patient regains full muscular control. Surgery often produces this side effect, and NMES is appropriate. Note that NMES is best when performed with a voluntary CONTRACTION OF MUSCLES, and a good PT will be right there to coach this along. You’d be surprised how difficult it is to get a quadriceps muscle to contract after knee surgery.
So, not all people who get ESTIM ‘treatment’ will see real benefits from it, but you will be hard-pressed to find someone who received treatment in a PT Mill that didn’t have ESTIM.
The issue we have, as movement specialists, is that ESTIM and the associated hot or cold packs are completely passive. Anything the patient can do while immobile, sitting down, and without supervision should be done by themselves. This is not skilled care and a waste of time for the patient and the pro.
If one of these passive treatments is appropriate, we send people home to borrow one of our units. Our most important role as your PT is to spend the one-on-one time in treatment doing what you can’t do to heal yourself.
Massage
Physical therapists are trained to find muscle and tissue problems and treat them directly. While most times this isn’t the most comfortable experience, it’s what the tissues need to be ‘reset’ and allowed to learn the new function that will help relieve your pain. If you are in a Mill and your PT feels more like a massage, GET A MASSAGE. Massage therapists have become very skilled at providing this experience and making you feel nice. They don’t think about soft tissue the way a PT does, like a personal trainer can’t see exercise the way a PT does. It’s simply a matter of perspective gained with advanced formal education.
We at SPARK do lots of soft tissue work when appropriate, but there is a specific goal in mind. We also use a technique called trigger point dry needling. It’s a cutting-edge treatment approach for the manipulation of those same tissues. It uses your body’s own nervous system to release trigger points and to decrease pain both locally and into referred pain patterns. It is very useful in conjunction with our manual techniques. However, this is another technique that takes a LOT of time to learn and then perform. You don’t see this effective technique in many PT Mills.
A Better Approach
If you must be seen in a PT Mill, you can still bring information to your therapist and ask questions. You can help educate your therapist or ask them to help you look for a new therapist. If you are getting a massage at PT, ask your physical therapist, “Why are you massaging there?” A tell-tale sign of a muscular restriction issue is the ability to reproduce the patients’ pain by manipulating these areas. If your PT doesn’t tell you that the muscles they are working on are a muscular restriction (trigger point/knot, etc) for the pain you are experiencing AND can’t accurately reproduce YOUR PAIN, it's probably time to start looking for a new PT.
It is OK to say, “This isn’t working for me, and I want to do it differently?” That is being your own best advocate.
Most patients we see have been to the PT Mills and had that very same realization. As with all the techniques here, it’s just EASIER to go with what has already been approved than it is to climb the mountain of getting a new treatment recognized and paid for, even though it may be more effective. When the ease and reimbursement potential of the treatments you are given become the priority, YOU are no longer the priority. Seek better for yourself.
Dr. Carlos J Berio, PT, DPT, MS, CSCS, CMTPT is a licensed Doctor of Physical Therapy, Certified Strength and Conditioning Specialist, and a Certified Myofascial Trigger Point Therapist. In addition, he holds a Master’s Degree in Clinical Exercise Physiology. He has treated high school, collegiate, recreational, and professional athletes of various sports, including baseball, softball, football, hockey, tennis, swimming, golf, and martial arts. His experience as a collegiate and semi-professional athlete, as well as a professional baseball coach, make him a sought-after resource among elite-level athletes on the field and in the training room. The concept of ‘all the way well’ in his work as a physical therapist and fitness professional is what continues to drive Dr. Berio to be the best movement specialist there is.
Dr. Berio is the founder of SPARK Physiotherapy in Alexandria, Virginia. A clinic and approach designed from the ground up to set the new standard for integrity and patient satisfaction in the PT industry. Carlos remains active in several sports and enjoys agility training, powerlifting, and adventure races. He is an advocate for his patients, clients, and his fellow PT colleagues. He can be reached at [email protected].
