The Problem with Physical Therapy — Part 2

On licensing exams, educational gaps, and why exercise keeps getting treated as an afterthought

Last week I wrote about a physical therapist who posted on social media that “the problem with physical therapy is that physical therapy is no longer physical.” I discussed how I have observed a similar shift — away from exercise as a primary intervention and toward passive, technology-driven therapies — and why I think that trend is a problem. The post generated a lot of interesting responses, with some readers agreeing and others pushing back.

This week I came across another post on the same theme. Dr. Justin Farnsworth, DPT, made the following observation: “Therapeutic exercise isn’t named once on the PT licensing exam blueprint. But ultrasound is. E-stim and traction are named, with guaranteed questions. The best-supported intervention in orthopedics has no guaranteed spot on our own boards — and it’s literally in our name.”

Because his post builds so directly on last week’s conversation, I think it’s worth continuing the discussion.

Therapeutic exercise

Dr. Farnsworth went on to note that interventions across every body system combined make up roughly 29% of the NPTE exam, with the remaining 71% covering diagnosis, tests and measures, and non-clinical content like safety, ethics, and billing. Therapeutic exercise, he pointed out, isn’t named within that intervention slice either — it’s an unlabeled fraction sharing space with manual therapy, gait training, and wound care. Meanwhile, passive modalities aren’t competing inside that 29% at all. Ultrasound, e-stim, thermal agents, and traction have their own separate, named, weighted section — with their own guaranteed questions.

His conclusion was direct: “When the exam, the curriculum, and the clinical rotations all treat loading as an afterthought, you get exactly what we have — excellent diagnosticians who were never required to master the thing that most changes outcomes. We need to make capacity as the treatment something you can actually deliver. That should be the standard.”

I can start by saying: yes. Yes, yes, yes, and yes — times a thousand. I am not a physical therapist and I won’t opine on the specifics of the PT profession — I’ll leave that to people like Dr. Farnsworth. But I will make a broader observation. Across the fields that encompass rehabilitation — athletic training, chiropractic, and physical therapy — the trend toward passive modalities is real. And what Dr. Farnsworth is describing helps explain why. What gets tested gets managed. If physical therapists are not being evaluated on the intervention their profession has historically been built around, it is difficult to expect them to prioritize it in patient care.

Starting with education

Dr. Farnsworth makes a point about clinical rotations that resonates: “You are buried under 15 to 20 patients per day, and nobody has time to teach you how to actually load someone. The person supervising you came up under the same testing blueprint. Their exercise knowledge is thin for the same reasons as yours. The gap doesn’t get closed during clinicals — it gets passed down.”

He also notes how skill transfer actually works: “Special tests, manual therapy techniques, palpation — someone stood next to you, watched you do it wrong, and fixed your hands. That is how skill transfers. And that is what we are missing with exercise.”

I agree with both observations. If loading and exercise are not made a priority during professional education, clinicians are not going to prioritize them in patient care. If we do not center load as the language that unifies our operating system, we produce clinicians who consider care finished after pain relief. That was the point I was trying to make last week.

Regardless of professional designation, if loading and exercise were not adequately covered in your training, the responsibility falls on each of us to seek that education independently. Some of the best education I have had on exercise came from a licensed physical therapist. The professional label on the door matters less than the quality of the knowledge behind it. If your formal education left gaps around exercise and loading, find the people who can close them.

Why do we see this problem?

A reader from last week’s post asked a reasonable question: why is this trend happening? I think there are two main reasons.

The first is patient demand. People want quick pain relief, not long-term physiological adaptation. As I have often said, pain is the last thing to show up and the first thing to go away. Passive therapies — low-level laser, dry needling, electrical stimulation, electromagnetic therapy, diathermy, acoustic wave — are well-established for making fast changes in neurological sensitivity and pain modulation. Patients feel better faster. The problem is that pain-free does not equal performance-ready. Just because the pain is gone does not mean capacity has been restored or that the individual is ready for the demands of their sport or daily life.

The second reason is insurance reimbursement. Some clinicians have suggested they can bill at higher rates for passive interventions than for codes related to therapeutic exercise. I cannot speak to this directly, but I understand it may influence clinical decision-making. Rehabilitation professionals are in business to help people — but also to sustain a practice. If the financial incentives favor passive modalities, it is not difficult to see how that shapes treatment selection over time.

In the end, it may be a combination of both — patient preference for quick relief and financial disincentives for exercise — that sustains this trend. The underlying cause matters less than the consequence.

Clarifications and misconceptions

Given some of the responses to last week’s post, a few clarifications are worth making.

First, the post was not an attack on physical therapists. The title came directly from the social media post I was referencing. A physical therapist said there was a problem within his own profession. I was discussing his words, not making my own indictment of the field.

Second, some readers took away that I was dismissing passive therapeutic interventions. Quite the opposite. Anyone who has followed my work knows that I discuss these interventions regularly in both writing and teaching. Passive therapies are used in the acute management stage of the rehabilitation continuum specifically because reducing pain, inflammation, and tissue sensitivity is the prerequisite for everything that follows. I use them. I recommend them. The concern is not their use — it is stopping there.

The acute management stage exists to open neurological windows of opportunity so that movement and loading can become successful. Foundational kinematics cannot happen without first completing acute management. Motor control cannot happen without foundational kinematics. Functional integration, progressive kinetics, and fundamental capacity cannot happen without the stages that precede them. None of it is possible without laying the groundwork. The issue is not using passive therapies — it is using them and then calling it done.

Third, no one is suggesting exercise is the answer to every musculoskeletal problem in every situation. One intervention cannot be all things to all people. Exercise needs to be used at the right time, for the right person, and under the right conditions.

What I am arguing is that it should be a tool every clinician has, uses fluently, and progresses deliberately — because without it, the back half of the rehabilitation process simply does not happen.

Why is this important?

The point of this two-week conversation is simple: load — and specifically exercise — should be the goal of every patient interaction.

High-threshold loading strategies are the only mechanism that improves capacity and produces long-term physiological adaptation. And improving capacity is the only way to meaningfully reduce the risk of re-injury. Injury is not the problem. The capacity mismatch is. Load has exceeded tissue tolerance. The remedy is not pain relief — it is restoring and building tissue tolerance to the point where the demands of life or sport no longer exceed it. Exercise is the most researched tool we have for doing that.

When I discuss rehabilitation programs with chiropractic colleagues, my rough estimate is that around 20% use exercise in a meaningful, consistent, and appropriate way. That number concerns me — because it means a large percentage of patients are having their pain managed temporarily, not their capacity restored. They will return when the next incident occurs, because the mismatch was never addressed.

My clinical goal with every patient is resilience, durability, and appropriate tolerance to stress. The only way I can build that is with load. I often say that my goal is to clinically work myself out of a job. The maintenance care in my practice has always been exercise — not passive therapy on an ongoing basis.

The conversation over these two weeks, sparked by two separate social media posts, points to the same problem from different angles. The physical part of rehabilitation is being diminished — not just in physical therapy, but across the musculoskeletal professions. If we can recenter load and exercise in our conversations about patient care, we have a chance to put the physical back into rehabilitation. And when that happens, our patients are better for it.

Where did you actually learn to load patients — in your formal education, in clinical rotations, or somewhere else entirely?

If you want to understand what a practice that centers load from day one actually looks like — from acute management through fundamental capacity — the The Language of Human Performance guide lays out the full framework.