My Biggest Gripes in Rehab (A mildly bitter – but evidence-based – rant)

By James Shute, Exercise Physiologist

Welcome to the clinic of miracle machines and common-sense amnesia
You come in sore. You leave poorer. Somewhere in between, you’re told the solution
involves a machine that looks like it belongs on the International Space Station.

Meanwhile, you’re sleeping five hours a night, skipping meals and barely moving outside
your appointments. Let’s talk about the three rehab myths that refuse to die – with
science and a little sarcasm.

Gripe 1 – Fancy tools and equipment don’t magically improve outcomes

There’s a persistent belief that better rehab requires more equipment. The research,
however, is far less impressed.

Multiple studies comparing low-resource or home-based rehabilitation programs with
equipment-heavy, gym-based programs show similar improvements in function and
capacity when exercise dose and progression are matched (1,2). In other words, it’s the
program design, not the machine, doing the heavy lifting.

Even in tech-heavy fields like robotic neurorehabilitation, systematic reviews show no
clear superiority of one device over another, with improvements largely driven by task-
specific practice and repetition, not the hardware itself (3).

Clinical reality:

If the exercise stimulus is appropriate, progressive and adhered to – a resistance band
can be just as powerful as a $40,000 machine.

The machine may look cooler on Instagram, though.

Gripe 2 – Fear-based messaging is not “being realistic”

“You’ll never play tennis again.”
“If you lift like that you’ll destroy your spine.”
Ah yes — the classics.

Fear-based language has been consistently linked to increased pain, disability and
avoidance behaviours, particularly through mechanisms like catastrophizing and fear-
avoidance (4,5). Rather than motivating patients, these messages often reduce
confidence, movement exposure and long-term outcomes.

Evidence from pain science and rehabilitation psychology shows that positive yet honest
communication, education and graded exposure to movement improve outcomes far
more than doom-laden predictions (6,7).

Clinical reality:

Telling someone they’re fragile doesn’t protect them — it teaches them to stop moving.

Gripe 3 – Passive therapies are over-prescribed while basics are ignored

Heat, ice, needles, infrared, cupping – the rehab snack pack.

Systematic reviews and Cochrane analyses consistently show that thermal modalities
(heat and cold) may provide short-term symptom relief, but have little impact on long-term
pain or functional outcomes when used alone (8,9).

Similarly, many passive treatments show small, short-term effects at best – particularly
when compared with active rehabilitation approaches, which demonstrate superior
improvements in pain, function and return to activity across musculoskeletal conditions
(10,11).

Meanwhile, foundational recovery factors like sleep, nutrition and overall physical activity
have strong, well-established links to tissue healing, pain modulation and injury risk – yet
are often under-addressed in clinical settings (12,13).

Clinical reality:

If someone isn’t sleeping, eating or moving enough, adding another passive modality is
rearranging deck chairs on the Titanic.

Practical takeaways (for patients and clinicians)

• Exercise beats equipment: Spend time on load, volume and progression before
  spending money on machines (1-3).
• Language matters: Fear increases disability; education and graded exposure
  reduce it (4-7).
• Passive ≠ useless, but secondary: Use modalities as short-term symptom
  modifiers — not centrepieces of rehab (8-11).
• Fix the basics first: Sleep, nutrition and movement are non-negotiable pillars of
  recovery (12,13).

Final thought (because this is still a gripe)

If a rehab plan contains more machines than movement, more fear than clarity, and
more needles than sleep advice – it’s time to ask better questions.

Rehab doesn’t need to be fancy.

It needs to be progressive, human and honest.

References

1. Holland AE, et al. Home-based rehabilitation for chronic disease: systematic review. Thorax. 2017;72(8):755–763.
2. Maltais F, et al. Home-based pulmonary rehabilitation versus hospital-based
   programs. Am J Respir Crit Care Med. 2008;178(5):440–447.
3. Mehrholz J, et al. Electromechanical-assisted training for walking after stroke.
   Cochrane Database Syst Rev. 2020;(10):CD006185.
4. Vlaeyen JWS, Linton SJ. Fear-avoidance model of chronic pain. Pain. 2000;85(3):317–
   332.
5. Leeuw M, et al. The fear-avoidance model: updated state of the art. Pain. 2007;132(1–
   2):77–94.
6. Moseley GL, Butler DS. Explain Pain. Noigroup Publications. 2015.
7. Pincus T, et al. Communication and chronic pain outcomes. Pain. 2013;154(11):2394–
   2403.
8. French SD, et al. Superficial heat or cold for low back pain. Cochrane Database Syst
   Rev. 2006;(1):CD004750.
9. Nadler SF, et al. Therapeutic modalities in musculoskeletal rehabilitation. Arch Phys
   Med Rehabil. 2004;85(3 Suppl 1):S36–S43.
10. Hayden JA, et al. Exercise therapy for chronic low back pain. Ann Intern Med.
    2005;142(9):776–785.
11. Fransen M, McConnell S. Exercise for osteoarthritis of the knee. Cochrane Database
    Syst Rev. 2015;(1):CD004376.
12. Simpson NS, et al. Sleep and pain: clinical implications. Sleep Med Rev. 2017;32:61–
    70.
13. Walsh NP, et al. Position statement: nutrition and recovery. Br J Sports Med.
    2011;45(12):905–912.