The PT Treatments You Don't Need Because They Don't Work

As we continue to examine the ways in which the physical therapy field can better serve the public, we realized that certain treatments are being done that we as patients really don’t need and/or really aren’t effective.

In many cases, most specifically in third-party-payer-dependent settings (the PT Mills), your insurance company is dictating a lot of your care. While your physical therapist may have some unbelievable manual skills and great clinical judgement 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.

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 the person who is paying the bills, everyones' buddy, your health insurance (tongue firmly in cheek). 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 almost NEVER 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:
The number one offender and we're pretty passionate about this one. It is used as a heating modality. The basic physics make perfect sense: the device creates ultrasonic waves that move the molecules and create 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, increase blood flow and reduce inflammation. This is simply not the case and 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. For the more research minded patients and therapists, read below. 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.

Here a recent study in the Annals of Family Medicine, examined the added benefit of US to a more hands on approach to treating low back pain. They found NONE.

Here in a study in Rheumatology International, the researchers found that sham (read: fake, phony, intended to give the impression of the treatment) was AS EFFECTIVE AS the "real" thing. Ridiculous.

In this study in the Journal of International Medical Research, they also examined the effect of different types of US in treatment of knee pain. One of the types was sham-US which, over 10 treatments showed significant improvement of pain. While this study did show that a version of  US (pulsed) did improve pain more than sham, the fact that the sham 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 US 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!

This evidence isn't hidden anywhere. I just picked the most recent relevant articles and listed them here. So why are we still arguing the use of this modality? OOOOOHH, I remember, it's because your insurance company will pay for it, no questions asked. I guess if you've purchased one of these machines (about $2000-$3000 each!), you'll get your money back soon enough and save your staff some time having to defend it.

The Upper Body Ergometer (aka: the hand bike, the UBE):

This model: "The Time Waster PLUS"

You will see this one in a lot of Mills. It is simply a bicycle for your arms. There are some patients who need this piece of equipment because a limitation prevents them from performing cardiovascular exercise 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 takes places in very different settings and the UBE is appropriate.

That said, the reality is that this huge and expensive piece of equipment is used to get folks out of the way while managing traffic. The UBE is the PT worlds' dirty little secret. It's not there because it's better than the regular bike or the treadmill. If you are on it, its because the PT is swamped and they need a place to put you that isn't technically "waiting", oh, and they can bill your insurance company for it. After all, if you're in a Mill, any minute that passes that you're not be charged for something is a wasted opportunity.

ANY PASSIVE heat, cool or "ESTIM" Treatment:
Electrical Stimulation therapy can be very effective. It comes in some different varieties such as TENS and NMES to name the most commonly used. ESTIM for short, it is a treatment that is over done and usually in conjunction with a hot or ice pack. There is evidence to support it's use in decreasing pain but the majority of this would dictate that it's 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 is NOT going to make you better.

"You know. That thing that makes your muscles tingle. That's what they did for me at PT" smh

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 full muscular control is regained by the patient. Lots of times, surgery will produce this side effect and NMES is appropriate. Note, NMES is best when performed WITH 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 a knee surgery.

So not all people who get ESTIM 'treatment' will see real benefit 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 pack (inside secret: they need to be 'bundled' together in order for your insurance to pay for it so you'll almost never get one without the other in a Mill even if you don't need the hot or cold pack) are completely passive. Anything that the patient can do while immobile, sitting down, without supervision should be just that, 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 but our most important role as your PT is to spend the one-on-one time in treatment doing the things that 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, then go 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 just like a personal trainer can't see exercise the way a PT does. It's simply a matter of perspective gained with the advanced formal education.

We at SPARK do lots of soft tissue work when it’s 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 very useful in conjunction with our manual techniques. However, this is another technique that takes a LOT of time to learn and then perform. That is the main reason you don’t see this effective technique done in many PT Mills.

Trigger Point Dry Needling performed on a trigger point in the upper trapezius muscle

What to do?
If you must be seen in a PT Mill (you should be realizing that don't have to settle for it) you can still bring information to your therapist and also ask questions. You can help educate your therapist or ask them to help you start looking 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, its 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. The majority of 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 the 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, power lifting and adventure races. He is an advocate for his patients, clients and his fellow PT colleagues. He can be reached at cjberio@sparkphysio.com.