When you visit a physiotherapist, you can expect to receive safe and effective treatment that is supported by research. A physiotherapy care plan may include a variety of treatments including exercises, hands-on therapy and the use of various machines, sometimes referred to as passive physiotherapy.
What is passive physiotherapy?
Passive physiotherapy is a treatment that someone or something does to you. Examples of passive treatments include the use of heat or ice packs or the application of a TENS (Transcutaneous Electrical Nerve Stimulator) machine or other types of electrical modalities. Treatments performed by a physiotherapist such as deep tissue massage, needling or joint manipulation and mobilization are also considered passive in nature.
Passive treatments can be useful. However, physiotherapists should use these techniques to help patients participate in an active care plan.1
What do we mean by active physiotherapy?
Active physiotherapy requires you to participate in the treatment and is considered a key component of an effective physiotherapy program. Active interventions should be the focus of treatment and should take up a significant part of the time you spend with your physiotherapist. Examples of some active physiotherapy interventions you may receive are:
- Therapeutic exercise
Research suggests that exercise and increased physical activity lead to better health outcomes and quality of life.2 Your physiotherapist should recommend and teach exercises early in your program and modify them as your condition changes. Exercises should be matched to your abilities and goals, and you should expect to continue with these exercises after your physiotherapy program has finished.
- Active manual therapy approaches
At times, your physiotherapist may provide a hands-on treatment that requires you to work with them. They may ask you to actively assist or resist a movement they are doing as a way to increase strength or flexibility.
- Education and self-management strategies
Your physiotherapist should provide you with education related to your injury or condition, when and how to re-introduce activity and how to return to the level of activity you desire. You should be taught ways you can effectively manage your care when you are away from the clinic to allow you more control of your own recovery. 3, 4
Why are we talking about this?
As a consumer, it is reasonable to expect to get the most out of the time and dollars you spend on physiotherapy. Whether you are accessing physiotherapy through the public health system or seeing a physiotherapist in a private clinic, there may be limits placed on the number of visits you can receive. If your treatment isn’t helping with your symptoms and ability to manage your injury or condition, continuing with the same program is a waste of time and money. This may ultimately result in delayed recovery and delayed return to the activities you enjoy. Research tells us that when passive treatments are the only treatments a person receives, it often leads to these delays.5
When do passive physiotherapy treatments make sense?
Home remedies such as heat, ice or some rented or privately purchased machines can make you feel more comfortable in the early stages of an injury. Your physiotherapist may suggest using these passive treatments until things have settled a bit. Once your injury is less acute it is recommended that you start a more active physiotherapy program and/or receive information on how you can resume activities on your own.
Similarly, heat and ice may be applied during your physiotherapy appointment. Physiotherapists often apply heat or ice to provide a short-term decrease of pain and/or swelling. This may make it easier for you to participate in your exercise program or may be used after a more aggressive treatment session to settle the joints or muscles the treatment focused on.
The use of various electrical modalities may also provide some relief of pain or help manage inflammation. However, as with all passive treatments, these machines should not be offered as the primary treatment and should only be used as part of an active physiotherapy program.
A basic rule of thumb for physiotherapists is, if a joint is not moving as it should be, using passive techniques to move the joint may help. These are hands-on techniques that a physiotherapist may use to get stiff joints moving again. Again, the goal of these techniques is to help you move more and make participation in your active treatment easier. When combined with exercise, research suggests they may provide additional treatment benefits.6
A physiotherapist may utilize dry-needling treatments such as acupuncture or intramuscular stimulation (IMS) to facilitate pain relief or to decrease muscle spasm in an affected limb. More high-quality research is needed to support the effectiveness of needling; however, some research suggests that the use of dry needling can be effective when combined with active treatment.7
When do passive physiotherapy treatments not make sense?
Although passive techniques may have a role to play in reducing inflammation or discomfort and/or enabling movement, you should be wary if they are the only treatment provided or if the use of one or more of these passive treatments takes up more of your physiotherapy visit than time spent in active exercise or treatment.8 Using passive treatments as the focus of physiotherapy is discouraged because only having therapy done to you may reinforce feelings of powerlessness and places the responsibility for recovery solely in the hands of your physiotherapist.5 If you do not learn how and when to move, you may continue to be anxious about becoming more physically active in spite of evidence that shows movement as the best treatment for many conditions.
Continuing to pay for sessions that include only passive treatments such as heat, ice, electric modalities, manipulations, or needling is likely a waste of money and time.
It may help to think of passive and active treatment on a continuum. Starting with passive treatments at home or in the clinic to provide short-term relief of pain may be appropriate early on in your recovery. You should then transition to a combination of passive and active treatments as your condition improves with the goal of having a set of home exercises or an activity program to follow by the end of your treatment sessions. This allows you to continue to manage your condition at home and/or prevent future injuries or flares.5
What should you do?
Take control. If you feel you are not being asked to participate in your physiotherapy program or your sessions continue to involve mainly passive treatments, ask questions about the treatment plan and find out what you can do to become more active in your recovery.
Expect good practice and effective care. If you are paying for treatment sessions but are not seeing meaningful progress towards your goals within a few visits, either ask that something changes in the treatment plan or look for a different therapist or clinic. If you don’t spend more time working than you spend having a machine, hot pack or needle applied to you, you are likely not receiving quality physiotherapy.8
A physiotherapist’s role is to restore, maintain and maximize movement, function, and quality of life. It makes sense that you can’t restore or maximize movement without moving! Although passive techniques may have a role to play in reducing inflammation or discomfort and/or making movement easier, they should not be the focus of your physiotherapy. There is considerable evidence that exercise is the treatment of choice for a multitude of health concerns that physiotherapists treat. When passive treatment approaches are combined with exercise, they can help to improve outcomes.
- American Physical Therapy Association. Choosing Wisely: APTA Releases list of procedures that PTs and patients should question. PT in Motion News. September 15, 2014. Available from: http://www.apta.org/PTinMotion/News/2014/9/15/ChoosingWiselyRelease Accessed January 21, 2020.
- Penedo F, Dahn J. Exercise and well-being: a review of mental and physical health benefits associated with physical activity. Curr Opin Psychiatry. 2005 Mar; 18(2):189-193. Accessed Jan 21, 2020
- Chatzitheodorou D, Kabitsis C, Malliou P, Mougios V, A Pilot Study of the Effects of High-Intensity Aerobic Exercise Versus Passive Interventions on Pain, Disability, Psychological Strain, and Serum Cortisol Concentrations in People With Chronic Low Back Pain, Physical Therapy, Volume 87, Issue 3, 1 March 2007, Pages 304–312, https://doi.org/10.2522/ptj.20060080 Accessed Jan 21, 2020
- Almeida M, Saragiotto B, Richards B, Maher CG. (2018) Primary care management of non‐specific low back pain: key messages from recent clinical guidelines. Med J Aust 2018; 208(6) ll doi:10.5694/mja17.01152 https://www.mja.com.au/journal/2018/208/6/primary-care-management-non-specific-low-back-pain-key-messages-recent-clinical Accessed Jan 21, 2020
- Cosio D, Lin E. Role of Active Versus Passive Complementary and Integrative Health Approaches in Pain Management. Glob Adv Health Med. 2018; 7: 2164956118768492. doi: 10.1177/2164956118768492 Accessed Jan 21, 2020
- Green S, Buchbinder R, Hetrick SE. Physiotherapy interventions for shoulder pain. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD004258. DOI: 10.1002/14651858.CD004258.
- Furlan AD, van Tulder MW, Cherkin D, Tsukayama H, Lao L, Koes BW, Berman BM. Acupuncture and dry-needling for low back pain. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD001351. DOI: 10.1002/14651858.CD001351.pub2.
- Choosing Wisely. Physical Therapy: five treatments you probably don’t need. Available at http://www.choosingwisely.org/patient-resources/physical-therapy/ Accessed Jan 21, 2020