Old School PT

[Sortho14]

Hi Everyone,

So I am a 3rd year DPT student and I’m currently in a clinical rotation with some PTs who practice with old school antiquated ways of thinking.

Their main approach to pt care is ‘putting the body into alignment’ and ‘correcting asymmetries’. Every patient with LBP has a pelvis that is ‘out of alignment’. They think ultrasound is “really good” for tendinopathy. Everyone has a tight psoas that needs to be “released”… They underdose exercise, of course, most patients are doing clamshells 3x10… And they think that IASTM and theragun lengthens tissue… just to name a few things.

I expressed my concerns to them. But, they’ve “been doing it for 20 years” and they “know it works”..


Am I missing something? Does this way of treatment work? It seems to go against everything barbell medicine preaches for sure.. I don’t know how to navigate this situation…
Any advice would be appreciated.

thank you everyone

[PazStrong]

I absolutely understand what you’re saying and where you’re coming from. I’ve been a PT for over 8 years now and through clinicals and working in multiple clinics, this is commonly how things are typically practiced. There are newer things such as dry needling but it’s really just new, and thus trendy, things that are still along the same lines of the antiquated, passive treatments that provide short term placeboed improvement at best. I am thoroughly convinced that patients don’t truly get better because of these interventions, but rather placebo effect and time as they usually are in for 6 weeks, sometimes longer. I think the most telling things about the “effectiveness” of these treatments are that patients usually have to come in multiple times a week for several weeks for any improvement (if there is any) and a lot of them will repeatedly return over the years for similar issues, so is it really working and providing meaningful improvement? The only way I believe there is truly improvement from these type of interventions is when the patient does not do any form of activity normally and the underdosed exercises actually get them to move and do something.

[Derek Miles]

Yeah, unfortunately this is more the exception to the rule and there are many factors at play here. The evolution to the DPT (with plenty of faults) was partially to try and increase the critical thinking exposure in school. Those who have been out 20 years are likely to not have been exposed to how to read research or may not even have had access. Of course the glut of PT programs emerging in the last 10-15 years has diluted any positive intentions of the DPT IMO. There is no evidence for these interventions "working" but there is a high likelihood that these individuals have honed some soft skills over the years that are worth learning from. Pay attention to how they speak to their patients, I am willing to bet they are confident. This is a skill that increases patient rapport and hedges towards more positive outcomes.

My first CI did a technique called Strain-Counterstrain with 1) no evidential backing 2) not even the slighted physiological feasibility. I was stuck there for 8 weeks but I did learn that he was excellent at communicating with patients, even if what he was saying was complete BS. Often patients need to hear they are going to be okay as much as anything else. It just depends on how much crap we say in messaging that. Communicating that pain is a difficult concept, is often multifactorial, and takes more than just fixing structures is a skill that takes time and effort to develop. It's easier to blame the "cause" on a boogieman diagnosis then offer support and get a result.

This is unfortunately the state of affairs but I would argue these individuals are more forgivable than the clinicians that do read the research and still stick to antiquated rationale. This is a hard profession as we'll never have the answers and we always need to be updating beliefs as new information emerges. It's easier (and more comfortable) to think we have it figured out and blame things like the multifidi, psoas, poor motor control then program movement in homeopathic doses and rely and regression to the mean and natural history to get our patients where they need to go. The issue then is what belief did we expose the patient as the cause of their problems and how substantiated is it. Everyone says they are comfortable being wrong until they find out they are actually wrong. My advice, learn from them what you can in how they communicate. Learn even more from them in how not to end up in the same place they are 20 years from now.