What to do When Physical Therapy Hurts
As you lie comfortable on your back on a treatment table, your physical therapist turns your head to the right side gently with both hands, telling you to relax and exhale as she approaches the end of your flexibility. As your head is turned all the way to the end of your range of motion, you feel a small “clunk” in your neck that remains very sore for a couple days after treatment. Your physical therapist assures you that nothing is wrong, only that the manual therapy treatment caused significant movement in your neck vertebrae and will take time to resolve.
In the next treatment session, your physical therapist tells you to perform 3 sets of 10 repetitions on a leg extension exercise while she “monitors” from across the room working with another patient. On the 9th repetition of the second set, you feel a sharp pain in your left knee, stop immediately and tell your physical therapist what happened. After examination, your physical therapist tells you that it’s only a small strain and to ice for 15 minutes 3 times per day. Your knee hurts moderately for 3 days and then recovers.
The above examples represent negative experiences in physical therapy, with one more preventable than the other. Manual therapy (i.e., skilled hand treatment used in the first example) and exercise therapy not only require considerable skill to administer, but also major attention to detail. Depending on your condition and treatment, effective physical therapy often will cause mild soreness because “stress” must be applied to various tissues, such as muscles, tendons, ligaments and nerves in order to improve strength, flexibility, endurance and motor control in an effort to reduce pain.
In the first example, the physical therapist was performing manual therapy on your neck to enhance rotation. Should she have been doing this in the first place? If so, should she have gone as far as she did? There’s probably nothing wrong with what she did, but these are questions that must be asked of the physical therapist at the treatment as there are many possible answers.
In the second example, there are two factors that may have caused your knee pain.
First, the leg extension exercise must be done in a specific way to minimize knee joint stress: the lower legs should start at 90 degrees of knee bend and extend only another 40 degrees (JBJS 2009; JOSPT 2005). Most people perform the leg extension exercise through the full range of motion, which dramatically increases forces between the kneecap and thighbone. Did the physical therapist and/or physical therapist aide ensure that the safe range of motion was followed the entire set? Further, did the physical therapist direct you to slightly lift your knees upward during the entire exercise? If not, abnormally high forces may have been imposed on your knee joints that could cause pain.
Second, and most importantly, you should always be carefully monitored during all strengthening exercises to ensure safety and efficiency. Research shows that adequate intensity is the most important factor to improve strength, in which you should work at 60% of maximum or greater (Med Sci Sp Exerc 2006, 2001). The problem is that when you work at this level of intensity, you compensate by changing your body position to make it easier for non-targeted muscles to overcome external loads (e.g., arching your back, moving your head). This compensation increases forces within joints and can cause chronic pain, especially in the low back, shoulder and knee (Arch Phys Med Rehab 2004, 1998). Therefore, constant attention to detail during exercise by your physical therapist is essential to minimize these compensations when adequate intensity is achieved.
The bottom line: always question treatments provided by your physical therapist or other health care provider, especially if they yield unsatisfactory or alarming results. Force them to give you a scientific basis for the care they provide and whether or not research supports its use. Doing so can save time, money and potential hazards to your health.