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Physiotherapy is a widely recommended and evidence-based treatment option for a variety of musculoskeletal, neurological, and cardiovascular conditions. Despite its proven efficacy, I often talk to patients that feel that physiotherapy hasn't worked for them, leading to frustration, scepticism, and reluctance to try it again. As an Extended Scope Physiotherapist one of my main roles is to see patients who have been through a course of physiotherapy and haven't seen the improvement they were hoping for. In many cases, the issue isn't with physiotherapy itself, but rather with how it was delivered, tailored, or understood. This blog will explore the common reasons why physiotherapy may not have been successful in the past and provide evidence-based insights into how these pitfalls can be avoided to ensure better outcomes.
1. "Just a Sheet of Exercises" with No Support or Follow-Up
One of the most common complaints that I hear from patients is receiving a sheet of exercises with minimal guidance or follow-up. While home exercise programs (HEPs) are a critical component of physiotherapy there is nuance to them, lack of support can lead to poor adherence and suboptimal outcomes.
The Importance of Supervision and Follow-Up: Research shows that supervised exercise programs are more effective than unsupervised ones. A systematic review by O'Brien et al. (2018) found that patients who received regular follow-ups, either in person or remotely, had better adherence to their exercise programs and reported improved outcomes compared to those who were left to complete exercises on their own. The lack of follow-up can result in patients performing exercises incorrectly, not progressing them as needed, or simply not doing them at all, leading to minimal improvement.
Solution: Your physiotherapy should involve regular check-ins, either through in-person visits, telehealth, or even simple phone calls or emails. These check-ins allow your therapist to monitor progress, adjust exercises as needed, and provide encouragement and motivation.
2. Rehabilitation Programs Not Tailored to the Individual
A one-size-fits-all approach to physiotherapy can lead to ineffective treatment. Programs that are too easy may not challenge you enough to stimulate healing and adaptation, while programs that are too difficult or painful are likely to discourage you from continuing, often feeling like ‘exercise hasn’t worked’. Normally, this is not the case it’s just not the correct exercise at the correct time.
The Role of Individualised Care: Studies emphasise the importance of tailoring rehabilitation programs to the individual. For instance, a study by Jack et al. (2010) highlighted that individualised exercise programs, which consider the patient's specific condition, fitness level, and pain tolerance, are significantly more effective than generic programs. Patients are more likely to stick to a program that is designed specifically for them and one that evolves as they progress.
Solution: Your physiotherapist should conduct a thorough assessment to create personalised rehabilitation plans that matches your current ability with the idea of gradually progressing this as symptoms improve. This approach ensures that the exercises are challenging enough to promote healing but not so difficult that they become discouraging or harmful.
3. Rehabilitation Programs Not Completed for Long Enough
You may start to feel better after a few sessions and may prematurely discontinue your rehabilitation program. However, healing and recovery, particularly for chronic conditions, often require sustained effort over an extended period. Conversely, you may have only been completing your program for a few weeks without seeing any change and subsequently become dejected and stop. Tissue adaptation can take multiple months to occur so don’t give up too soon. This issue is easily addressed by point 5.
Understanding the Timeline of Healing: Research by Holden et al. (2007) indicates that many musculoskeletal conditions require long-term rehabilitation for full recovery. For instance, conditions like tennis elbow, plantar fasciitis, and frozen shoulder can take several months to a year or longer to fully resolve. Discontinuing treatment too early can lead to a relapse or incomplete healing.
Solution: You need to be educated about the expected timeline for recovery from the outset. Setting realistic expectations and emphasising the importance of completing the full course of treatment can improve adherence and outcomes.
4. Too Many Sessions of Solely Passive Treatment
Passive treatments, such as massage, ultrasound, and electrotherapy, can provide temporary relief from symptoms but are rarely sufficient on their own for long-term recovery. Relying too heavily on passive treatments without incorporating active rehabilitation can lead to suboptimal outcomes.
Active vs. Passive Treatment: The literature supports the notion that while passive treatments can be beneficial in the short term, active treatments—such as exercises that strengthen muscles, improve flexibility, and enhance functional movement—are crucial for long-term recovery. A review by Hurley et al. (2011) found that active rehabilitation was more effective than passive treatments in managing chronic conditions like osteoarthritis.
Solution: A balanced approach that includes both active and passive treatments is ideal. Passive treatments can be useful for managing pain and inflammation, especially in the early stages, but they should be complemented by an active rehabilitation program aimed at restoring function and preventing recurrence.
5. Lacking a Clear Plan and Goal at the Beginning of Treatment
Starting a physiotherapy program without a clear plan or goals can lead to confusion, frustration, and disengagement. If you do not understand the purpose of your treatment or what you are working towards you are less likely to adhere to the program. I know I wouldn’t!
The Importance of Goal Setting: Goal setting is a well-established strategy in rehabilitation. A study by Levack et al. (2006) demonstrated that patients who were involved in setting specific, measurable, attainable, relevant, and time-bound (SMART) goals were more engaged and had better outcomes. Clear goals provide direction and motivation, making it easier for patients to see their progress and stay committed to their treatment.
Solution: Your physiotherapists should work with you to set clear, achievable goals from the outset. These goals should be revisited regularly and adjusted as needed to reflect your progress.
6. Not Fully Understanding the Diagnosis
A lack of understanding of your diagnosis can lead to feeling anxious, confused, and unsure of what to expect from physiotherapy. This uncertainty can lead to poor adherence and dissatisfaction with treatment.
Patient Education and Empowerment: Patient education is a critical component of effective physiotherapy. Research by Hill et al. (2011) highlights that patients who understand their condition and the rationale behind their treatment are more likely to adhere to their rehabilitation program and report higher satisfaction with their care. Education empowers patients by giving them the knowledge they need to actively participate in their recovery.
Solution: Your physiotherapists should take time to thoroughly explain your diagnosis, the expected course of treatment, and the rationale behind each intervention. Using simple language and visual aids can help ensure you fully understands your condition and what you need to do to manage it. If you don’t, make sure you ask.
7. Not Having Expectations Properly Managed
Unrealistic expectations about the speed and extent of recovery can lead to frustration and disappointment. It’s important for you to understand that some conditions, particularly persistent ones, may take a long time to improve and may not resolve completely.
The Role of Expectation Management: Setting realistic expectations from the start is crucial. A study by Moseley et al. (2002) found that patients who had realistic expectations about their recovery were more likely to be satisfied with their treatment, even if their progress was slower than anticipated. Managing expectations helps prevent disappointment and encourages patients to stay committed to their rehabilitation program.
Solution: Your physiotherapists should have open and honest discussions with you about what you can realistically expect from your treatment. This includes discussing the potential duration of the condition, the likely timeline for improvement, and any factors that may influence the outcome. This is not always easy and is rarely black and white as a multitude of factors affect recovery but we should be able to give you a ball park idea.
8. Preconceived Notions That Physiotherapy Won't Work
Preconceived notions that physiotherapy won't work will significantly impact your engagement and the overall effectiveness of treatment. These beliefs may stem from a previous bad experience or advice from others who have had unsuccessful outcomes.
The Power of Belief and Placebo: Research suggests that a patient's belief in the effectiveness of their treatment is the biggest predictor of the overall outcome. A study by Kamper et al. (2015) found that patients with positive expectations about their treatment were more likely to experience positive outcomes. Conversely, those with negative expectations or preconceived notions that physiotherapy won’t work may be less engaged and less likely to see improvement.
Solution: Addressing these preconceived notions early in the treatment process is essential. Your physiotherapist should acknowledge your concerns, provide evidence-based information about the likely benefits of physiotherapy, and encourage an open dialogue about any previous negative experiences. Building trust and rapport can help shift negative perceptions and improve engagement.
Conclusion
If physiotherapy hasn’t worked for you in the past, it’s important to consider that the problem may not have been with physiotherapy itself, but rather with how it was delivered or understood. Factors such as insufficient support and follow-up, a lack of individualised care, premature discontinuation of treatment, over-reliance on passive treatments, unclear goals, poor patient education, unrealistic expectations, and preconceived notions can all contribute to suboptimal outcomes.
By addressing these issues, you and your physiotherapist can work together to ensure that physiotherapy is a successful and effective component of your healthcare journey. For those who have had disappointing experiences with physiotherapy in the past, it may be worth considering a fresh start with a different approach, guided by the principles outlined above.
References
O'Brien, L., & Hardman, J. (2018). Supervised versus unsupervised exercise for improving outcomes in chronic musculoskeletal pain: a systematic review. Pain Medicine, 19(5), 875-888.
Jack, K., McLean, S. M., Moffett, J. K., & Gardiner, E. (2010). Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review. Manual Therapy, 15(3), 220-228.
Holden, M. A., Nicholls, E. E., Hay, E. M., & Foster, N. E. (2007). Physical therapists’ use of therapeutic exercise for patients with clinical knee osteoarthritis in the United Kingdom: In line with current recommendations? Physical Therapy, 88(10), 1109-1121.
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