Physical Therapy 2.0
As in any profession, physical therapy has seen growth and change as more research and evidence calls for an updated approach to treatment. There is less and less reliance on passive treatments, such as modalities using ice, heat, and TENS, which are now only being used to complement treatment rather than playing the larger role of the past. The new rehab approach that has become standard care focuses on not just reducing pain in the short-term, but preparing patients for the demands of daily life, sport, or any other personalized goals, as well as reducing risk for further pain or injury. Our goal is to always set the bar high for the quality of care for each patient who walks in the door, adjusting our treatment to challenge them according to their individual needs.
With passive treatment and table-only exercises (sitting/laying exercises) being a thing of the past, the end goal of PT is preparing each patient to get fit for life – whether young or old, physical therapy is appropriate for everyone. However, the end goal of physical therapy involves doing more than the bare minimum, just enough to get out of pain and doing daily activities without pain. It involves strengthening, correcting movement patterns, and loading the injured tissues appropriately to prepare a patient for the future so they are less likely to become injured again, and hopefully get each individual to the point of being even better than where they were before the pain.
So what does this improved approach to rehab look like?
It will look a little different for each person, but the end goal is the same: progressive loading. The starting point will look the most different, depending on someone’s pain levels, level of irritability, or whether they are post-surgical or not. High irritability means more acute and significant levels of pain are present, and rehab starts with lower level exercises that are tolerable and will help reduce the pain. With low irritability, the patient is able to tolerate more activities with lower levels of pain, so exercises that involve greater loading can be the starting point in treatment. In either case, both will gradually increase their load (amount of weight/resistance, exercise difficulty) so that one’s capacity for activity improves.
The end goal of PT is achieving functional strength, such as squatting, deadlifting, overhead pressing, etc. While for some people, these exercises may feel unrealistic, they can be modified, and it may not seem as impossible if thought about as more familiar movements: standing up from a chair is the same movement as squatting, picking up your laundry basket is like a deadlift. These are basic and fundamental movement patterns. Lifting and performing these functional exercises in rehab produce longer lasting strength and abilities. Strength is protective against further future injury. For example, quad strength is protective against development of degenerative knee arthritis. Not only will this focused PT approach challenge general strength, but it also incorporates whole body health and includes building aerobic capacity. Muscles do not produce the same forces, and injury risks are higher when they are fatigued. In addition, submaximal aerobic exercise has even been shown to produce global pain relief.
Load causes mechanical adaptations to the tissues so that they are stronger and more resilient to the demands of whatever activity patients need to be able to do. Bone, tendons, ligaments, and muscles are meant to take load and are strengthened by loading them. With loading, just as anything in life, too much of a good thing can become bad. There are two ends of the spectrum: underloading and overloading. Both can lead to injury. Without being physically active, tissues weaken and their capacity to tolerate load decreases so that eventually daily activities or something that used to seem easy, now may cause injury. On the other hand, overloading a tissue too much can also cause injuries, usually seen as overuse injuries. The tissues did not have the capacity to perform that volume of activity. The overloaded tissues need just as much progressive loading as the underloaded but a more gradual increase and starting out with lower loads/volumes. The answer to both overloaded and underloaded tissues is loading them in a gradual and systematic process. Exercise is medicine, and just like medicine, must be dosed appropriately.