What’s Wrong with Physical Therapy (& how to do it better)
As I’ve made the transition into purely virtual physical therapy and coaching, I’ve done a lot of reflection on what good rehab entails, and how I approach both the exercise prescription (rehab program) and education (rehab mindset) parts of PT with my clients. I’m still learning every day, but I’ve been doing this long enough and seen enough results that I’d like to think I have a general idea of what I’m doing. And I want to share my thoughts with you.
Everything viral on social media over the past few years (and even still today) seems to hinge around finding the “right exercise” for your pain, as if there’s some special movement buried deep in an ancient manual that you have to excavate to eliminate your pain.
99% of the time, this isn’t how it works. Rarely is pain due to a single factor, and rarely is it simple enough to be cured with a single arbitrary exercise.
But if you look at popular PT posts on Instagram, and if you didn’t know any better, it would be reallllllll easy to think that this is how it works. And as a result, there’s a lot of confusion surrounding pain and PT.
I’ll start by saying that pain isn’t simple. Even if your injury was caused by a single, identifiable incident (for example, twisting your knee in a freak accident while going for a hike), there are lots of factors that will influence your pain experience afterwards: stress, sleep, nutrition, physiological factors, etc. And when there ISN’T a clear inciting incident (the pain feels like it came on overnight/out of nowhere), the picture can become even more muddled, because there are lots MORE factors that potentially influenced why the pain began: mobility, strength, tissue capacity, motor control, etc.
Not to mention your brain’s response to that pain, which often goes something like this:
“Oh F&$%. I’m broken. What happened? It must have been because I squatted last week. I should stop exercising because I don’t want to make things worse.” The torrential downpour of catastrophizing and negative thoughts can be overwhelming. While your conscious mind spins out of control, your unconscious mind and nervous system go into damage control mode: muscle guarding to “protect” the painful area, offloading/disuse of the painful area, altered movement patterns, etc.
And somehow, in response to all of this, 3 main options have become normalized to bridge the gap between you limping through your day and you getting back to heavy lifting and dynamic activity:
finding a single stretch on social media that will supposedly solve everything
resting, icing, and stopping all activity, OR
going to a PT clinic where the standard of care is doing some low level exercises with a band while a 15 year old tech watches you, then throwing some ice and electrical stimulation on your painful knee for 20 minutes as a cherry on top?
We can do better than this. Rehab can be more than this. It IS MORE, if it’s done right.
So what does that look like?
First of all, there is no one-size-fits-all solution to pain. That might sound dispiriting, but it’s not.
I’ll give you an example.
Over half of my clients right now have low back pain. That’s 20+ people under the umbrella of “low back pain”, yet their pain experiences are all different and individual to them. While there will be common threads and exercises across each of their programs, every person has their own specific limitations, histories, goals, and CONTEXTS that will dictate what their program looks like and how it progresses. So to give them all a single stretch or exercise to “fix” their pain (or the same exact program) would be ridiculous.
Instead, what threads these clients together (and most people in pain), is a simple equation of PREPARATION.
Stress and capacity.
Here’s how it goes.
If the stress placed on your body exceeds your capacity to recover, you’re going to be more likely to experience pain, because you’re being OVERLOADED in a way that you can’t consistently recover from.
If your capacity to RECOVER or withstand stress exceeds the stress being placed on your body, though, odds are you’re in good shape, because your body is overprepared for the demands of your life and activities. Your tissues are strong and able to recover adequately between bouts of activity.
Reductionist? Maybe, but I don’t think that’s a bad thing. At the most base level, some version of this equation is present in every pain experience.
Good rehab will increase the capacity of your body to withstand and recover from stress. Poor rehab will not; even if your standard physical therapy treatment helped the pain go away, it probably didn’t help you build back up to the level of FUNCTION and PREPARATION needed to fully return to your activities. It only took you half of the way (if that).
Let’s say your knee started hurting after skiing. You stop skiing, get a referral for 6-8 weeks of PT, do some clamshells and air squats in a clinic for 2 months, the pain dies down, and you’re discharged. [feel free to sub 6-8 weeks of PT for doing some tib raises you saw on IG, or RICE-ing your knee for a month]. Does that absence of pain mean that you’re immediately ready to get back on the slopes?
Not at all. There’s a HUGE gap between where you’re at, and the level of preparation required for you to withstand the stresses of skiing without pain coming back. You didn’t do nearly enough to address those deficits in readiness.
You’re still underprepared.
What you need to be…is OVERprepared.
So how do I bridge the gap from pain to overpreparation with my clients?
First, a program. Not a printout of 3 exercises with a 3x10 prescription for 3 months. A holistic TRAINING program that both addresses relevant deficits (things like mobility, strength, control, etc.) with the goal of building back to temporarily painful movements/activities, AND that trains the rest of your body so that you continue to feel strong and confident with non-painful movement. A good program will build the QUALITIES that you need in order to do the thing you love, and get you to a point where your body is OVERprepared for the demands of your sport/activity. A point where your stress/capacity equation isn’t teetering in favor of stress—it’s heavily weighted in favor of CAPACITY.
Second, with frameworks and education. My goal with all of my clients is to make myself obsolete—I want every client to leave our time working together with a diverse toolkit and an understanding of a number of things:
what likely contributed to their pain beginning
why we did what we did to address their pain
why it worked
how to integrate what I’ve taught them into their future training
how to view pain and cultivate a long-game mindset for both working through pain and achieving fitness goals
how to make good decisions surrounding training and activity preparation moving forward
how to manage any potential flare-ups in the future
This needs to be the standard of physical therapy. People deserve better than what’s become the norm for “care.”
I sense that I’m about to take this train way off the tracks into true rant territory, so I’ll wrap it up with a (hopefully helpful, but maybe questionable) analogy:
Good rehab isn’t just slapping duct tape on a flat tire and giving the car a green light to drive again. It’s fixing the tire and addressing the entire car so that the WHOLE VEHICLE is ready to kick ass.
I just threw a lot at you, but my hope is that all of this brain vomit at least gives you some food for thought if you’re experiencing pain and have been stuck in social media/RICE/physical therapy clinic purgatory for too long.
If you have questions or comments, send me a message on Instagram or via email! I’d love to chat.
