The Problem with Physical Therapy
Why passive interventions alone leave patients pain-free but not performance-ready — and what it means to put the physical back in rehab
I recently watched a video on social media with a physical therapist describing what he saw as the problem plaguing his profession. In the video he stated: “The problem with physical therapy is that physical therapy is no longer physical.” That seemed like a bold statement — but honestly, in my own way, I agree with him. Since this is such an important topic, I think we should take some time to talk about it.
(And if you saw the same video and remember who it is, I’d love to tag him so he can be credited with sparking my thoughts.)
The physical therapy profession
To begin, I want to make it perfectly clear: by having this conversation I am in no way disparaging physical therapists or the profession as a whole. I am not here to criticize anyone for their style of practice or current beliefs. I am only discussing what the physical therapist said in his own social media video.
Traditionally, physical therapy is performed using exercise to reduce pain and restore function. Exercise has been a hallmark of the profession since its onset — in some instances, physical therapy has become almost synonymous with exercise itself. The physical therapist in the video described a shift he has observed, where more and more professionals are moving away from exercise as their primary intervention and toward modalities like cold laser, dry needling, electrical stimulation, pulsed electromagnetic frequency, or acoustic wave therapy. He also discussed the increased use of joint mobilization, manipulation, and instrument-assisted soft tissue mobilization.
These are all interventions within the scope of practice for physical therapists, and they are commonly used in most physical therapy clinics. The point the PT was making, however, is that many of his colleagues have shifted toward these more passive interventions and away from exercise as the primary active intervention. I think that is an astute observation. I have seen the same trend developing over the last three to five years, and it has been moving in this direction for longer than that.
The professional shift
I agree with the person who made that video. Across many professions that treat musculoskeletal conditions, the pendulum has swung toward passive therapies and technology — and away from exercise and the long-term adaptation it creates. These interventions are being used primarily to reduce pain and, in some cases, restore local function. Using them is not wrong. What we have to understand is the role they are actually designed to play in the rehabilitation process.
There are many reasons this shift is occurring. It is easy to sell continuing education courses built around technology. It is convenient to package a device and sell protocols with it. When providers start getting less than optimal results, their first response is often to enroll in another course and search for a better tool. As I have discussed previously, this is what I call the “tool illusion” — the belief that the right instrument is the answer to every complex clinical situation. The patient has ankle pain: use a laser. Shoulder pain: drop some needles. Foot pain: use shockwave. Tools have become the default response to create quick changes in the subjective perception of pain.
To be clear, I am not saying these interventions are not useful. Quite the contrary. The use of these technologies in the acute management stage, or the use of manual therapy in the foundational kinematics stage, can be quite effective. I have seen meaningful changes in pain and local function through the use of these modalities. But they do not create long-term physiological adaptation. What they do is open neurological windows of opportunity — they create an environment in which we can begin to load tissue in a meaningful way and drive long-term change. That is the entire point. And that is also where the problem begins.
The problem
The problem — and I think this is what the physical therapist in the video was trying to convey — is that clinicians who have made this shift rarely seem to get to the loading part. As I stated above, the only reason we use these interventions in the clinic is to get the patient’s body into a position where we can begin to progress load. Yes, in my model these interventions are their own progressions within the loading continuum — but what we ultimately need to reach is weight-bearing exercise using progressive overload. That is what creates long-term meaningful change. And for many providers who have made this shift, that part never happens.
This has been my complaint for years. In most rehab settings, care ends once the patient is out of pain and local function has been restored. But pain-free does not equal performance-ready. In many of these clinics, the provider uses technological interventions in acute management, performs some form of manual therapy, and then releases the patient once the pain is gone. Going back to the original statement from the social media video — there was nothing physical. No increased effort, no meaningful strain. We need that exaggerated load to increase tissue stress and drive adaptation. This is paramount to the rehabilitation process. The organism only understands stress.
If we have swung the pendulum so far toward the early stages of the rehabilitation continuum that all we are doing is acute management and foundational kinematics, we are creating exactly the problem being described. We never get to the physical part of physical therapy. And by never reaching the actual exercise portion of the process, we leave patients under-prepared for the demands of their life or sport. If we reduce this to basic physiology, it becomes clear: in order to prepare an individual for the necessary demands placed on them, we have to apply the principles of exercise and training. That is what seems to be missing in many modern clinics. That is what the physical therapist was talking about.
Professional criticisms
These problems are not limited to physical therapy. I have the same complaints about my own profession of chiropractic. We get so caught up in the trends of technology — or in those interventions that produce fast changes in pain and help justify our existence to patients and insurance providers — that we skip the part that makes any of it matter: long-term meaningful change.
When describing my own practice, I often say that I am a strength coach who is allowed to treat people in pain or with severe dysfunction. I describe myself that way primarily to set the intention that my goal with every patient is training. My goal is to get everyone in my care to weight-bearing exercise as quickly as possible, because that is where we create long-term physiological change.
To some this may look like glorified personal training. But no one can argue with the evidence behind exercise as an intervention for health, rehabilitation, and human performance. It is one of the most studied subjects in the history of medicine.
Shouldn’t getting the patient to exercise be the primary goal — not just reducing pain, but getting their body into a position where we can progress load and affect not only their musculoskeletal function, but their overall health as well?
It does not matter whether you are a physical therapist, athletic trainer, or chiropractor. If you are not using exercise as a primary intervention, you are setting your patients up for failure.
Shifting perspectives
The original problem that prompted this discussion is real — and it is one of the main reasons we see high re-injury rates in active and athletic populations. For many people in the general population, getting out of pain and restoring local function is sufficient to return to simple daily activity. But it does nothing to prepare them for higher-threshold demands. It does nothing to increase work capacity so that tissues have greater tolerance to load. And that is why the problem exists in the first place.
To put it plainly: injury is not the problem. The capacity mismatch is. If a mismatch in capacity is what drives injury, why are we not getting physical in order to build that capacity? Exercise and training are the only means of doing so, and they should therefore be the goal in every patient case we encounter.
If we bring this back to the model I have been describing — and specifically to the stages of care on the rehabilitation continuum — it begins to make more sense. Those stages include acute management, foundational kinematics, motor control, functional integration, progressive kinetics, and fundamental capacity. If many providers have shifted toward passive therapies and technology, it means they are operating primarily within acute management and foundational kinematics. In some cases we also see providers working through the motor control stage. A patient who has moved through all three of those stages should be pain-free, have local function restored, and be capable of very basic activities of daily living.
But the problem is that almost none of these providers move forward into functional integration — which is where general physical preparation begins. That is training. That is where exercise creates long-term change. Without progressive overload, that outcome is not achievable. This is what the physical therapist meant when he said physical therapy is no longer physical. He was saying we are no longer using exercise as our primary intervention.
I have often said that rehab prepares your body for training, and training prepares your body for the demands of life or sport.
The shift we need to make is to start with the end in mind and work backwards. Begin with the understanding that the patient is going to be training — then define the specific physical qualities they need by performing a needs analysis. From there, perform an examination to determine current dysfunction, deficiencies, and load tolerances. Then build a plan to move the patient from Point A (current competency) to Point B (desired capacity). That plan has to move beyond the first three stages of the rehabilitation continuum into the right side of the loading progression, where high-threshold exposure to progressive overload is the standard. This is the only way to build capacity and reduce the risk of re-injury.
This is why I often say the professional shift we need to make is from pain relievers to load managers. That shift ensures we place load at the center of every patient interaction and begin with training in mind.
When the only goal is pain relief, the threshold for success is low — because pain, as I have said before, is the last thing to show up and the first thing to go away. When pain is the metric, treatment ends when pain ends. We wave the magic wand over the painful area, the patient feels better, and they never transition to exercise. The provider looks like a magician. The patient is no more prepared for their life than they were before.
But when we act as load managers, the patient understands from the beginning that exercise and training are the goal. Load managers apply the appropriate load at the right time to elicit specific adaptations. That is the SAID principle. That is the essence of exercise. That is what it means to be physical. Load managers are managing load to induce long-term change — and the key word is progressive overload, which can only be achieved through exercise. The physical therapist who made that video was right. We need to put the physical back into rehab.
Practical application
In order to put the physical back into therapy, we need to do the following:
1. Utilize a systematic model with a unified operating system.
2. Make sure this model centers load as the universal language.
3. Centering load will shift us from acting as pain relievers to load managers.
4. As load managers, we need to start with the intention of training.
5. Training is the only way to increase capacity and reduce recurrence of injury.
6. Start with the end in mind and work backwards.
7. Perform a needs analysis to determine the necessary physical qualities.
8. Perform a patient exam to determine dysfunction, deficiencies, and load tolerances.
9. Build a plan that moves the patient from Point A to Point B.
10. Understand that progressive overload is the only way to create long-term adaptation.
The physical therapist in that video wasn’t wrong — and neither is the discomfort his observation raised. Every profession that touches musculoskeletal care has drifted toward interventions that feel productive because they change pain quickly and look sophisticated on a treatment plan. But quick relief was never the finish line. It was always meant to be the doorway into the harder, slower work of building capacity. When we stop at the doorway, we hand patients a body that no longer hurts but still isn’t ready for the life it has to return to.
The fix isn’t complicated, even if it asks more of us. Every patient who walks through the door should be treated with the end already in mind — not just the absence of pain, but the presence of capacity. That means using our tools as the on-ramp they were designed to be, not the destination, and holding ourselves accountable to progressive overload as the true measure of recovery. When we make that shift — from pain relievers to load managers — we stop setting people up for re-injury and start preparing them for whatever comes next.
That is what makes physical therapy physical again.
At what point in the rehabilitation process do you introduce progressive loading — and what usually determines that timing in your practice?
If the shift from pain reliever to load manager is one you want to make in your own practice, my new Language of Human Performance Guide lays out the full framework.