Welcome to Part 2 of The College of Physiotherapists of Alberta’s series reflecting on The Choosing Wisely Campaign. You can read Part 1 on diagnostic imaging here. This follow-up article will focus on the use of both passive and active treatments by physiotherapists.
Passive treatments are defined as those interventions applied to a patient with no active participation by the patient. These treatments can include manual therapy, acupuncture or dry needling, heat, cold, and various machines.1
It’s safe to say that most people think of physiotherapy as a hands-on profession and that care received can include passive treatments. There is nothing wrong with receiving any of these treatments but, there is a limit to their usefulness in achieving a full recovery from your injury. It is worthwhile to know why your physiotherapist is using passive treatments or how they fit into achieving your goals.
Physiotherapy Goal: Reduce Pain
You just hurt your back and you can’t straighten up due to pain. Lower back pain has many different causes, and the treatments can vary widely in what could be effective for you.
At the start of your care passive treatments can be a useful first step to help get your pain levels under control and help you start moving better. Initially when you see your physiotherapist, the pain might be limiting the amount you feel you can move or do things. At this point your physiotherapist may suggest heat, some gentle manual therapy or other passive treatments to reduce the pain that you are in and allow you to move more. Passive treatments can be used as a bridge so that you are able to participate in more active treatments or to start self-managing your back pain.
As you improve and your back pain decreases, you should see your treatment change where more focus or time is spent on exercise and you becoming a more active participant in your sessions. Typically, back pain will improve to the point that it is no longer a concern, and you can expect to be discharged with recommendations for continued strength training and to increase your activity levels to maintain the health of your back.
Physiotherapy Goal: Return to Sport or Work
Unfortunately, you just suffered a serious shoulder injury after crashing your mountain bike. The emergency room doctor evaluated your shoulder and told you that physiotherapy is the way to go so you’ve booked your first appointment. Your physiotherapist spent time assessing you and then talked about what you need to do over the next four months to successfully return to your job as an electrician and your weekends mountain biking.
Your start to physiotherapy includes passive treatments using electrotherapeutic devices like interferential current (IFC), an electrical device used to help temporarily reduce your pain levels. The physiotherapist has also started taking your arm gently through different movements. As time goes on you notice the sessions start to change and they begin taking you through more exercises in clinic, educating you on how to activate certain muscles and strategies to avoid painful positions. They start discussing return to work strategies like modified hours or duties and you even get to start riding your bike around town.
By the last few months of your recovery, you haven’t really seen an electrotherapeutic device and most of the time spent in physiotherapy is dedicated to exercises and education on how to progress back to work and mountain biking safely.
As you can see in this scenario the physiotherapist and patient got to a point where the usefulness of passive treatments had run its course. Pain became less of an issue, and both agreed there was no need to continue to use those things that were helpful at the start of treatment.
Physiotherapy Goal: Post-surgery Recovery
You just went to your first physiotherapy appointment after surgery to repair a torn muscle. Like the last scenario you start with passive treatments such as ice, ultrasound, and the use of electrodes to help stimulate the muscle to contract. Initially recovery is going well but you feel after some time that you are hitting a plateau and the treatments are all the same. You talk to your physiotherapist about whether you should change what you are doing but it doesn’t seem like much is changing and treatments continue to be mostly passive.
A couple different things could be going on as to why your care hasn’t changed. First it could be you just aren’t ready to start more active treatment. For some surgical repairs, there are surgical protocols to follow with structured timelines and specific goals to achieve before moving on to the next stage. Or potentially you may have a medical condition like diabetes that can slow the healing process and your medical team is being cautious of the surgical site. Or maybe you are the type of person that operates at 100km/hr 100% of the time and they want to ensure you are ready for the next stage. There are many clinical reasons to sometimes delay the next step in your recovery, its best to ask your physiotherapist to give them a chance to explain.
Secondly, there is change but it is being done gradually and progressively under your physiotherapist’s guidance. It is ok to be impatient to get better and see progress but, there should be an explanation by your physiotherapist on how this occurs and reasoning as to why they are taking this course of action. It is important that you have a positive therapeutic relationship with your physiotherapist and can communicate effectively with them regarding your care. It is also important to acknowledge that if you are unhappy with your care, you can seek a second opinion from another physiotherapist on your perceived lack of progress.
Physiotherapy Goal: Dealing with Chronic Pain
You experience chronic low back pain, and it has been 10 years that you have been coping with the persistent pain. Most days you manage to go to work and be there for your family. Unfortunately, you are in the middle of a flare up and have had to miss the last two days of work. You decide its time to book in with a physiotherapist to get some help.
The physiotherapist asks questions regarding your back pain and suggests that due to the nature of your pain they would like to do a few things during your treatment sessions. In the first session they spend some time working on your back and use some electrotherapeutic device that feels nice, they also spend quite a bit of time discussing chronic pain, provide you with some educational resources on managing chronic pain and refer you to a mental health therapist to discuss coping strategies. Then they take you through some gentle movements and talk about how you can get through the next few days and what you should be doing at home. Over the next couple sessions, the flare up settles down, but you are still back to your normal chronic back pain.
Should you keep going to receive passive modalities since they may have helped you through your flare up? There is extensive research that shows passive modalities have poor effectiveness in improving the quality of life or functional capabilities of people with chronic pain.2 Knowing this, your physiotherapist should be discussing more helpful long-term strategies to improve your overall activity levels and quality of life, which do not involve passive modalities. Although passive modalities can be used from time to time to help manage acute pain or more intense episodes of pain, the focus should be on the things that can be more effective in the long term.
Conclusion
It is important to remember that as a patient you need to be clear about what you want to achieve with your physiotherapist. Goals range between people and your goals might differ from those around you.
Passive treatments can be a part of your physiotherapy care but generally are not a part of a longer-term treatment strategy and should be offered in conjunction with active treatments. Passive and active treatment can be offered in a variety of ways and across multiple health conditions, but the overall goal is to use a treatment plan that is helping you to recover to your potential.
Take the time to learn about treatment options and be clear about your goals and why they matter to you. If you have questions its ok to ask and its ok to be an advocate for your care or the care of someone you love.
- https://choosingwiselycanada.org/
- Dennis C Turk, Hilary D Wilson, Alex Cahana. Treatment of chronic non-cancer pain. The Lancet 2011;337(9784):2226-2235.
To ensure safe, effective and quality care, anyone using the title physiotherapist, physical therapist or P.T. in Alberta must be registered with the College of Physiotherapists of Alberta. Use our Verify a Physiotherapist feature to confirm you're receiving treatment from a registered physiotherapist.
