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The Fatal Flaw of (most) Physical Therapy

By Austin Baraki, MD, SSC

This past week I was alerted to a new article in the journal Physical Therapy by Falvey et al. titled “Rethinking Hospital-Acquired Deconditioning: Proposed Paradigm Shift” (abstract, thanks to Dr. Scotty Butcher for the tip). It is an excellent piece in one of the leading Physical Therapy journals that provides evidence-based practice recommendations, and is worth the read if you have journal access. Many of the concepts in today’s discussion were previously covered in the sarcopenia article series on this site (starting here), but I’d like to re-iterate some of the points made in this important article, particularly for those who don’t have institutional journal access.

The authors begin by noting that on average, acutely hospitalized adults spend about 83% of their time in bed and about 12% of time in a chair. This means that 95% of their hospitalization time is sedentary, and this prolonged immobilization has a cascade of negative effects, particularly in the setting of acute illness. Recall from the sarcopenia series that in healthy individuals there exists an physiologic balance between muscle protein synthesis (MPS) and muscle protein breakdown (MPB). Acute (and chronic) illness strongly tips this balance in favor of MPB, and immobilization further exacerbates this MPB imbalance. On the MPS side of the equation, we routinely apply suboptimal nutrition strategies in the hospital (in particular, the use of continuous tube feedings – see here and the sarcopenia article series for details). Furthermore, this article suggests that standard physical therapy approaches are also suboptimal for stimulating MPS and, as a consequence, suboptimal for generating a physical adaptation. Since we’re all familiar with emojis, perhaps this will help:

Stress-Recovery Adaptation Cycle

It should be clear why this MPS/MPB imbalance results in significant declines in muscle strength and mass that weaken physiologic reserves and impair physical function post-hospitalization. Many of these patients are already chronically frail, and hover precariously over the tipping point between functional independence and dependence. A single acute illness or hospitalization is often enough to leave them physically unable to return home and care for themselves. I deal with this type of situation on a daily basis in my hospitalized patients who are literally “too weak to go home”.

Recognition of this problem has led to increased utilization of “post-acute care” for rehabilitation of this so-called “Hospital-acquired deconditioning” (HAD). Although the field of Physical Therapy has recognized the problem, it has yet to establish clear practice guidelines for effective treatment of HAD. This is evidenced by these patients’ poorer prognosis, above-average rates of re-hospitalization, and lower rates of eventual discharge home when compared to patients with a clear diagnosis for rehabilitation such as acute hip fracture.

As part of the Choosing Wisely Campaign which promotes evidence-based measures for cost-effective care, the American Physical Therapy Association warns: “Don’t prescribe under-dosed strength training programs for older adults. Instead, match the frequency, intensity and duration of exercise to the individual’s abilities and goals.” It is interesting that physiotherapists, who often claim to be THE experts in exercise prescription, so commonly give inadequate and inappropriate prescriptions that the APTA made it one of the top 5 most important recommendations to change clinical practice. In contrast, this fundamental concept is applied every single day in the practice of Starting Strength Coaches all over the country, and is so ingrained that any SSC can explain the principles at play here in excruciating detail (and did so, in order to earn their credential). Frustratingly, this idea has been painfully slow to take root in clinical practice.

There are a multitude of studies of “usual” physical therapy interventions for various conditions, including HAD, showing suboptimal or sometimes even insignificant effects on outcomes (think on that for a second…). For example, here is one randomized trial from last week’s JAMA showing no apparent benefit of physical therapy after ankle fractures (though criticisms of that study might require a separate article). Now, many in the healthcare field might interpret such results as “Well, the evidence suggests that physical therapy has no difference on outcome in this situation, so there is no need for it here because it is a waste of resources.”  I would vehemently disagree in just about every situation, and instead argue that these results are NOT due to the ineffectiveness of physical therapy per se, but rather the ineffectiveness of “underdosed” physical therapy interventions that do not apply specific, targeted interventions of sufficient intensity to elicit adaptation.

A few damning quotes from the paper read:

There is a paucity of literature supporting current rehabilitation approaches as intense enough to even return older adults with HAD to the threshold of independence, much less increase functional reserve

Physical therapy in this population has been described in a recent review as “almost exclusively based on historical tradition rather than rigorous scientific evaluation or evidence-based medicine,” with lower extremity resistance training in particular, described as a supplement to basic transfer and gait training instead of a foundational treatment.”

This assertion is starting to become more and more supported by the strong evidence showing that even the most frail elderly can respond to resistance training with improvements in strength and, as a consequence, a multitude of other functional parameters such as balance, mobility, and stamina. Fortunately, resistance training is now recommended as a first line intervention for frailty by the American Geriatrics Society and the American College of Sports Medicine. The only caveat is that older individuals show a dose-dependent response that requires higher relative intensities to overcome anabolic resistance (a concept discussed in detail in the sarcopenia article series).

Despite this conclusively demonstrated phenomenon, most practitioners continue to prescribe “General Conditioning Activities” as the foundation of rehabilitation methods. These include such activities as walking down the hallway, “supine bed exercises” or “nonspecific active range of motion exercises” with little to no application of the principles of progressive overload. This is frequently done because of a misguided perception that low-intensity work is safer, particularly in patients with other comorbid conditions. Not only does the evidence show this dose to be woefully subtherapeutic, but has also consistently shown that supervised higher-intensity resistance training is well-tolerated and elicits robust adaptations in conditions including heart failure, chronic kidney disease, chronic obstructive pulmonary disease, and cardiovascular disease (among many others we’ve discussed before).

Again from the article, read carefully:

“Older adults with frailty typically respond more robustly to RT than to aerobic training in the early stages of an exercise program, especially in the presence of significant sarcopenia. There is minimal evidence that aerobic training alone substantially improves functional performance or disability in older adults who are frail.

There is no evidence that [General Conditioning Activities] impart substantial short-term or long-term functional benefits in older adults with frailty; thus, these activities that lack the formal components of exercise [e.g. intensity, duration, frequency, specificity] should be included sparingly in rehabilitation programs for older adults with HAD.”

Obviously, no one is suggesting to throw 300 lbs on the backs of acutely hospitalized patients and tell them to squat a set of five, but rather to appropriately dose a stress for the individual patient, and systematically overload them to continue eliciting adaptation even in the post-hospital period. The General Adaptation Syndrome (consisting of the stress-adaptation-recovery cycle) occurs in all people, 24 hours a day, no matter how old or frail or sick, and it never stops until you take your last breath. It is therefore a simple and universal fact that, no matter the person, the initial stress must elicit an adaptation, and the subsequent stressors must get harder over time.

I see this principle failing to be applied with patients on a daily basis; many therapists do the same silly exercises day after day, whether it be passive knee flexion in bed (an utterly useless exercise) or standing active knee flexion (which likely fails to elicit any further strength adaptation beyond the first day even in the most frail of patients). In addition, I guarantee that every outpatient provider can attest to hearing the following phrase from a patient, as I have on more occasions than I can count: “I stopped going to physical therapy after a couple weeks because we did the same exact exercises every time, and I could do them myself at home just as easily for free.” I think our friend Brian Jones can attest to this as well (see here).

In short, this refreshing journal article applies the most recent evidence to recommend re-shuffling the rehabilitation “hierarchy” from focusing on ineffective “general conditioning activities” to applying progressively overloaded, high-intensity resistance training as the first-line intervention before anything else. This is an idea that Starting Strength Coaches have been endorsing and successfully applying with clients for years (for example HERE). We say “GET STRONG FIRST,” it’s about damn time the medical establishment started catching up.


 

Dr. Baraki is an internal medicine resident based in San Antonio, Texas . He came to the sport of powerlifting after 15 years of experience competing in and coaching competitive swimming through the collegiate level. Since transitioning to powerlifting he has achieved personal best lifts of a 530 lb squat, 400 lb bench press, and a 600lb deadlift. He has a passion for coaching, teaching, preventive medicine, a nice rare steak, and making gainzZz™

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Join the discussion 6 Comments

  • Michael Mash says:

    What a great point you have made! I am a physical therapy student in Pittsburgh, PA and I just finished my acute care rotation at a major hospital. I was on the Level 1 Trauma unit and saw various debilitating conditions resulting from MVCs, strokes, falls, GSWs, etc. While in THEORY it makes complete sense to put an emphasis on high intensity resistance training in the acute care setting….how feasible is it? There are many variables at hand here including, patient motivation, adherence, and compliance. Sometimes it takes a whole lot of convincing just to get these patients to sit on the side of the bed. It’s a good day in the acute care setting if you can even convince someone to stand up and take a few steps. How does resistance training fit in to this? Where I DO believe as a profession we are underdosing strength exercises is in the outpatient setting. These older adults are walking into the clinic JUST FINE and are getting sets of 30 of thera-band isolation exercises…THIS is a MAJOR problem. So I will definitely be sure to make grandma do her squats when she walks into my outpatient clinic, but how are we going to convince someone who has two chest tubes, a NG tube, multiple IVs, multiple orthopedic precautions, or orthostatic hypotension, to do anything more than sit on the edge of the bed or take a few steps?

    • Jordan Feigenbaum says:

      The premise of this piece still applies in the acute care setting in my opinion. Instead of letting our patients suffer from critical illness myopathy (CIM) and get really detrained, we need to have them do something that is relatively challenging to them in that given setting. That’s unlikely to be squats, for instance, for everyone- but if sitting up in the bed or taking a few steps is not challenging at all then it is, by definition, useless outside of preventing bedsores.

    • Bryce says:

      I’m also a PT student in an acute care clinical setting. I think the point is less about the modality we choose, and more about how we dose our interventions. My clinical instructor, for example, is loathe to ever let a patient’s heart rate exceed 140. For a severly deconditioned patient, with little reserve capacity (cardiovascularly/metabolically), deliberately avoiding even moderately an even moderately elevated heart rate is a sure way to maintain the deconditioned status of your patient.

      If my CI’s avoidance of high heart rates was based on years of experience, I’d be willing to consider that I’m missing something. But she only graduated last year, and thus her thinking is likely based more on whatever doctrine she learned in school, coupled with the powerful risk aversion we also have instilled in us in school.

      The point of the article is, in my opinion, valid. Challenge your patients, not just in terms of what activities they can tolerate, but also in terms of how much volume they can tolerate, how short of a rest break they can tolerate, etc. If you want to stimulate an adaptation, ask them to do something their body simply doesn’t like!~

  • Walter White, PTA says:

    As a PTA, I feel that majority of my colleagues DO NOT understand the concept described in this article. Adaptation, in order for the body to change we must provide an adequate challenge, we must ask it to change…In my teens and twenties I lifted weights, and I changed my body by making it change. I went from bench pressing 115 lbs to 350 lbs in a few years. Weight lifters, who know what they are doing, understand that we strive to get to complete muscle failure at the end of each set. When I was in PTA school, I asked the Instructor, if and when I should take the patient to complete muscle failure…She had never heard of the term or the concept. As I got further into my career, I was shocked at how little patient’s were appopriately challanged. I understand most therapist were doing little to improve their patient’s physical performance. Which is the entire point of the profession, you know the therapist that hardly ever get anyone better have successful careers. The patient’s think they are friendly, they never get sore or even slightly out of breath, they don’t improve but functional improvement from Rehab Providers is NOT the goal!!! It is keep them happy, let them continue to allow the Provider to bill Medicare…The therapist that challenge patient’s because that is in everyone’s best interests tend to get more complaints because a patient will occasionally get sore or you have a lazy that doesn’t want to improve so they complain. Functional improvement is not financially rewarding, in fact, it is the opposite. The quicker the patient becomes independent the less money the provider gets to bill Medicare…That is the ONLY and #1 goal of Rehab Providers…$$$$$….

  • Landen Wolever says:

    Walter White’s comment leaves a bad feeling in my stomach because of how true I think this is; the last part said about all about money.

    I have graduated with a BS in Exercise Science and couldn’t decide what i wanted to do between PA and PT. So, I took an office job for 6 months and am now quitting to pursue PT school because I know I love exercise, fitness, muscles, etc… BUT, I am so skeptical of the long run career because of this exact thing about making money and how patients AND therapists sometimes dont really understand the big picture… If you do the same thing everyday nothing will change. I have shadowed some PT clinics and i see patients in there for over an hour doing SIMPLE exercises that can easily be done alone at home with little or no supervision…. like PT is so much more a psychological/emotional therapy than most even realize; such as patients continually to come in for the attention they get rather than the actual end goal.

    Don’t get me wrong, I think PT profession is great and I believe I want to pursue it and will enjoy it. But, like Jordan, I want to change it. I want to be revolutionary and REALLY make a difference in how the average Joe looks at resistance training, fitness, and health in general. If that is through treating patients in a hospital/clinic as a PT and equipping them with the tools to help themselves and leave themselves and their wallets at home, than so be it. It just honestly blows my mind how little the vast majority of people know about health and the common EVERYDAY habits that are slowly killing/damaging his/her QOL…

    Sorry for the rant just passionate I guess.

    • Matt says:

      1st year PT student here. I share many of your concerns with the profession I have resolved to pursue. All I can say from my obviously limited experience is that my professors have tried to make it clear that progressive overload is the only way to derive adaptation. They also feel that too many of their colleagues fail to grasp this concept.

      With critical thinking, hard work, and a little luck, hopefully we will make for GOOD Physical Therapists some day!

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