Marcus had been off work for 14 months with a shoulder injury. His treatment log showed 97 physiotherapy sessions — mostly ultrasound, heat packs and soft tissue massage. He arrived at each appointment, lay on the table, received his treatment and left. The sessions felt good. They seemed like progress. But when his insurer finally requested an independent review, the assessor noted that Marcus couldn't lift his arm above shoulder height — worse than at injury onset. The passive care had become its own barrier to recovery.

Passive treatment in compensation settings isn't neutral

Across cohort studies and systematic reviews, reliance on passive interventions—ultrasound, electrotherapy, traction, ongoing manual therapy without exercise — is associated with treatment escalation, opioid prescribing and prolonged disability. Healthcare is doing harm.

Insurers face genuine pressures: the need to fund reasonable treatment, manage costs and support recovery. But when passive modalities dominate care plans for months or years, the evidence consistently shows worse outcomes — not despite the treatment, but partly because of it.

By the numbers

The research paints a consistent picture across study designs and populations.

• 2024: Retrospective cohort (US), n=4,827. Workers with greater use of passive interventions had 50 to 220% higher likelihood of escalation-of-care events at one year — including opioid prescriptions, spinal injections and specialist referrals. A 10% higher proportion of passive treatment predicted 5 to 11% higher escalation likelihood. Mechanical traction showed particularly strong associations with poor outcomes (1).
• 2022: Prospective cohort (UK). Shoulder pain patients receiving passive treatment (manual therapy, acupuncture, electrotherapy) experienced equal or more pain and disability at 6 months compared to those who did not receive these interventions (2).
• 2025: Cochrane overview of reviews, 644 trials, n=97,183. 
  Therapeutic ultrasound: low-quality evidence showing ‘little to suggest clinically meaningful benefit’. 
  TENS and interferential: ‘very low-certainty evidence — we cannot make any definite statements on efficacy’. 
  Spinal manipulation as sole treatment: ‘no more effective than inert interventions or sham SMT for acute low back pain’ (3).
• 2020. Cross-sectional survey, n=1,288 orthopaedic manual therapists. 42.5% of orthopaedic manual therapists believed nocebo effects — negative outcomes produced by patient expectations — pervade clinical practice. Yet systematic education on avoiding these effects remains absent from undergraduate training (4).

How passive treatment extends disability

The pathway to dependency 

Passive treatment feels helpful. The warmth, the hands-on contact and the dedicated attention create genuine comfort and attention to their pain validates their condition.  

But comfort and recovery aren't the same thing. When workers receive passive care week after week, they learn that improvement requires a provider. Self-efficacy erodes. The capacity to manage symptoms independently never develops.

A 2024 case analysis documented a worker ‘given passive physiotherapy for much longer than is considered useful alongside ‘overtreating by the psychologist’ at 18 months had no functional improvement, but increasing opioid reliance. The treatment became the problem.

Reinforcement of fear-avoidance 

Passive modalities carry an implicit message that your body needs external intervention to heal. When a physiotherapist applies ultrasound to a ‘damaged’ shoulder or uses traction on a ‘degenerating’ spine, they inadvertently reinforce the belief that active movement is risky. 
Research shows that workers receiving prolonged passive care retain persistent biomedical framings of their conditions — fear-avoidance beliefs well above clinical thresholds — reinforced by their clinicians (5).

A cascade is initiated

Passive treatment rarely stays passive. When ultrasound doesn't resolve symptoms, the next step is often imaging. When imaging shows ‘abnormalities’ (age-typical findings), specialist referral follows. Each step adds time, reinforces the sick role and increases the likelihood of procedures and prescriptions. The Farrokhi study found that traction is particularly associated with these cascades — a modality that clinical guidelines explicitly recommend against.

What the guidelines say — and what happens in practice

The Clinical Framework for the Delivery of Health Services, endorsed nationally and by the Australian Physiotherapy Association, establishes clear principles: measure treatment effectiveness, adopt biopsychosocial approaches, empower workers toward self-management, focus on function and RTW and base treatment on the best available evidence.

Choosing Wisely Australia recommendations for physiotherapy state: ‘Avoid using electrotherapy modalities in the management of patients with low back pain’ and ‘Don't use ongoing physiotherapy in cases where there isn't improvement in measurable patient outcomes’.

Yet implementation research reveals systematic gaps. A 2019 study found that many healthcare professionals were not familiar with, or did not consistently follow, clinical guidelines, with the compensation funding model identified as a key barrier. Only 35% of physiotherapists reported providing guideline-recommended treatments for low back pain. 44% acknowledged they were providing treatments that were explicitly not recommended — rest, acupuncture, traction and external supports (6).

The evidence-practice gap is substantial. When surveyed, only 52% of physiotherapists agreed with the recommendation against electrotherapy for low back pain. One in 4actively disagreed.

The structural drivers

Fee-for-service payment creates documented incentives for overtreatment. In surveys, physicians estimate that 20.6% of overall medical care is unnecessary, with 70.8% believing they are more likely to perform unnecessary procedures when they profit from them (7). 

Passive modalities fit easily into high-volume practice. They require less clinical reasoning, less patient education and less time than active rehabilitation. They are a routine, simple pathway in a busy practice with a full patient load.

Canadian research found that workers' compensation reimbursement rates — often lower than private insurance — create ‘inequality of care’ where ‘treatments provided to compensated injured workers markedly differ from those provided to other patients receiving physiotherapy care at the same clinic (8). Providers reported being placed in ‘uncomfortable positions where they cannot always do what they believe to be best for their patients’.

Australian regulators have responded. SIRA NSW's 2024 Value-Based Healthcare Progress Report documented compliance letters sent to 49 psychologists and 42 physiotherapists demonstrating ‘atypical billing practices’, with conditions imposed on 10 workplace rehabilitation providers. WorkSafe Victoria's Clinical Panel actively reviews ‘outlier provider performance’.

But regulatory action addresses symptoms, not causes. The underlying payment structures that incentivise volume over value remain largely intact.

What we've known — and what we overlook

Passive modalities have their place. Manual therapy combined with exercise shows benefit. Short-term use of electrotherapy may facilitate engagement with active programs. The problem isn't passive treatment itself — it's passive treatment as the dominant mode of care, continuing beyond any reasonable expectation of benefit.

We've known for decades that active approaches — exercise, graded activity, self-management education — produce better outcomes than passive modalities. The Cochrane evidence is clear. The guidelines are explicit. Yet in compensation settings, passive care persists because it's comfortable for everyone: workers feel cared for, providers fill appointment books and claims continue without confrontation.

Why this matters for schemes

WorkSafe Victoria data shows that physiotherapy use above the 90th percentile — more than 125 sessions over 4 years — accounted for 41% of all physiotherapy use despite representing only 10% of claimants (9). These aren't workers with complex injuries receiving intensive rehabilitation. They're workers receiving ongoing passive care that produces no measurable improvement.

Each session represents scheme expenditure without corresponding functional gain. More importantly, each session represents a worker whose recovery has stalled — whose confidence has eroded, whose identity has shifted from ‘person recovering’ to ‘patient requiring treatment’.

The comfortable path leads to chronicity. And we fund it.

Questions for discussion

• What outcome measures should trigger mandatory review of ongoing passive treatment — and at what session thresholds?
• How could payment models shift from rewarding volume to rewarding functional improvement and return to work?
• What training and support would help providers transition from passive-dominant practice to guideline-concordant care?
• How should schemes publicly report provider-level data on treatment patterns and outcomes to drive improvement?

References

1. Farrokhi S, Bechard L, Gorczynski S, et al. The influence of active, passive, and manual therapy interventions for low back pain on opioid prescription and health care utilization. Phys Ther. 2024;104(3):pzad173. https://doi.org/10.1093/ptj/pzad173

2. Rugg B, Khondoker M, Chester R. Shoulder pain: Is the outcome of manual therapy, acupuncture and electrotherapy different for people with high compared to low pain self-efficacy? Shoulder Elbow. 2022;15(6):680–688. https://doi.org/10.1177/17585732221105562

3. Rizzo RRN, Cashin AG, Wand BM, et al. Non-pharmacological and non-surgical treatments for low back pain in adults: an overview of Cochrane reviews. Cochrane Database Syst Rev. 2025;3(3):CD014691. https://doi.org/10.1002/14651858.CD014691.pub2

4. Rossettini G, Geri T, Palese A, et al. What physiotherapists specialized in orthopedic manual therapy know about nocebo-related effects and contextual factors: findings from a national survey. Front Psychol. 2020;11:582174. https://doi.org/10.3389/fpsyg.2020.582174

5. Kühn L, Kleist L, Weißenstein F, Choi KA. Biomedical dogmas still influence the delivery of exercise therapy in chronic low back pain management: mixed-methods study. Patient Prefer Adherence. 2024;18:1493–1507. https://doi.org/10.2147/PPA.S462689

6. Zadro J, Peek AL, Dodd RH, McCaffery K, Maher C. Physiotherapists’ views on the Australian Physiotherapy Association’s Choosing Wisely recommendations: a content analysis. BMJ Open. 2019;9(9):e031360. https://doi.org/10.1136/bmjopen-2019-031360

7. Lyu H, Xu T, Brotman D, et al. Overtreatment in the United States. PLoS One. 2017;12(9):e0181970. https://doi.org/10.1371/journal.pone.0181970

8. Hudon A, Hunt M, Ehrmann Feldman D. Physiotherapy for injured workers in Canada: are insurers’ and clinics’ policies threatening good quality and equity of care? BMC Health Serv Res. 2018;18(1):682. https://doi.org/10.1186/s12913-018-3491-1

9. Berecki-Gisolf J, Collie A, McClure RJ. Determinants of physical therapy use by compensated workers with musculoskeletal disorders. J Occup Rehabil. 2013;23(1):63–73. https://doi.org/10.1007/s10926-012-9382-0