There’s been a quiet revolution taking place in the field of physical therapy. In the early 2000s, you could go to five different physical therapists for an injury and receive five different treatment plans. Some would have advised targeted exercises to strengthen muscles or classic treatments, like heat and cold packs.
Others might have relied on “voodoo treatments” like ultrasound, lasers and electrotherapy, despite the fact that experts weren’t really sure how — or even if — they worked. Today, many of those techniques have been set aside as the science has slowly accumulated that they don’t accelerate healing. You may still find them in some offices, however, as the field has struggled with a lack of uniformity and a lingering reputation for pseudoscience, leaving patients unsure whom to trust.
Take ultrasound, for instance. The technique has been used in physical therapy since the 1950s to treat everything from back pain to ankle sprains using high-frequency sound waves to speed the healing process. As early as the 1990s, ultrasound’s efficacy started to be debunked, with few studies showing any clinical benefit, but it’s taken over 20 years for the technique to finally fall out of favor with practitioners.
“There’s very little, if any, evidence that ultrasound does anything at all,” said Bruce Greenfield, a professor in the department of rehabilitation medicine at Emory University. “But P.T.s are using it, and they’re charging for it, and they’re getting reimbursed for it — basically for a technique that’s not effective. Is that fraud? I don’t know.”
Over the last 15 years, leaders in the physical therapy field have worked to shed this reputation, improving standards and consistency. They’ve developed systems to diagnose and classify injuries and turned to scientific research to create evidence-backed treatment guidelines.
“That’s how you change the face of the profession,” said David Wert, an associate professor of physical therapy at the University of Pittsburgh. “Using evidence and applying interventions for folks that are meaningful.”
A Shift From Passive to Active Treatment
Originally, physical therapy was largely based on the use of treatments like heat and ice to ease people’s pain and aid healing. Practitioners have also been quick to adopt technologies like laser therapy, which purportedly travels through skin and cells to increase energy production in mitochondria (the powerhouse of the cell) to accelerate recovery. But a treatment’s effect on a cell in a petri dish doesn’t necessarily translate to a patient in the clinic. The most recent — and some say most definitive — study on the technique shows no benefit over a placebo.
Over the past two decades, studies and meta-analyses (like the one conducted on ultrasound) have revealed that these types of passive treatments, where patients lie down on a table and have a therapy performed on them, actually do very little. And in some cases, they can even slow down recovery.
For example, ice has long been used to reduce swelling after an injury by constricting blood vessels in the area, which prevents blood and inflammatory cells from reaching the damaged tissue. But those blood and inflammatory cells are also a necessary part of the healing process, and restricting them with a cold pack or ice bath can delay or even prevent recovery.
When compared head-to-head, active exercise-based therapies are both less expensive and more effective than passive ones. In some instances, exercise is even as effective as surgery. In one study of 350 patients who had meniscal tears, there was no difference after six months between the patients who’d had surgery and those who’d used active physical therapy. Other research is currently exploring whether the same might be true for partial rotator cuff tears.
Instead, what’s emerged from decades of research as a clear winner — whether it’s used to treat low back pain or frozen shoulder or knee ligament injuries — is good old-fashioned exercise.
“We have gotten quite a bit more evidence for the effectiveness of exercise in both facilitating recovery and also protecting people from different kinds of injuries or diseases,” said James Gordon, chair of the division of biokinesiology and physical therapy at the University of Southern California.
Marilyn Moffat, a professor of physical therapy at New York University, agreed, saying that for every type of patient seen by physical therapists, “whether it’s patients with cardiovascular disease, whether it’s patients with diabetes, whether it’s patients with orthopedic problems or fibromyalgia or neuromuscular disorders or falls or frailty or obesity, the literature out there in terms of exercise interventions is so strong for every single one.”
Changing the Field, Slowly
These days, most physical therapists recognize that treatments should consist of exercises that improve strength and flexibility, as well as ergonomic adjustments to people’s work or workout routines to prevent future injuries. However, some practitioners argue that passive treatments still have their place and they are still taught in physical therapy doctorate programs.
James Irrgang, chair of the physical therapy department at the University of Pittsburgh, said he wasn’t surprised there is still a gap between what evidence shows is effective and what some clinical practices do. Across medicine, it traditionally takes 17 years for research to make its way to the clinic. As a result, Dr. Irrgang said that much of the emphasis in physical therapy now is on implementation: “How do we get the clinicians to adhere to the best available evidence?”
He hope the answer is through education. In 2006, Dr. Irrgang — who at the time was the president of the Academy of Orthopaedic Physical Therapy — helped develop guidelines in the form of a report card for diagnostic and treatment techniques commonly used by physical therapists, based on the best scientific evidence.
What to Look for in a Physical Therapist
So how can you tell if your P.T. is relying on the best science? During your first visit, the physical therapist will evaluate your symptoms, level of pain, how you move and your limitations for range of motion, strength and balance. That will become the basis of a diagnosis. This is not a medical diagnosis; the physical therapist wants to know what is limiting the function of, say, your knee, via muscle weakness or joint stiffness.
Dr. Moffat said that this initial appointment is a good time to decide whether you want to work with the physical therapist. “The most important thing is what the therapist does with their initial exam,” she said. “Do they really take the time initially to examine what’s going on and then determine what’s most appropriate for that patient?”
After the evaluation, the treatment they recommend should be evidence-based, drawing from the clinical practice guidelines, but it should also be tailored to your individual limitations and goals. It should also be active, incorporating strengthening and stretching exercises.
It’s important for the physical therapist to be empathetic and honest about what your course of treatment will entail, because the process can be painful. Whether or not you like your practitioner can also make a big difference in how you see the outcome. According to one meta-analysis, patients consistently rated their physical therapists based on how much they liked them as people, not on whether or not they got better.
And if you find yourself in a clinic where passive therapies like heat packs or ultrasound seem to be the main approach to treatment, “Find another place to go,” Dr. Gordon said. Those treatments may be useful for temporarily reducing pain or inflammation, “but they are not therapeutic in and of themselves. They are adjuncts to treatment.”
This approach to physical therapy may not use lasers or cryocompression pants or whatever the hot new toy is, and it requires work on the patient’s part, but it does work.
“I think we are improving what we do, but I think it’s an evolution,” said Dr. Gordon, who’s been practicing physical therapy for over 40 years. Incremental, evidence-based advances are “having an impact, but it’s not sexy. It’s not a new robotic thing. It’s hard to put it on the seven o’clock news. But it is truly a revolution in health care.”