You have been going for six weeks. You have done the home exercises most days. You have not missed an appointment.
And you still cannot honestly say whether any of it is helping.
That question is an uncomfortable one to sit with, and most people sit with it alone. Nobody handed you a yardstick on day one. So you have no fair way to tell the difference between slow progress and no progress.
This guide is the yardstick. It covers what a real change actually looks like, what to expect at week 2, week 4 and week 6, the five honest reasons a course of therapy stalls, and the exact words to use when you want to raise it.
One disclosure first. We are a physical therapy clinic. That means we have an obvious interest in what you decide, so we have written this to be useful whether you stay exactly where you are or not. You will notice there is no list of warning signs of a bad therapist in here. That is deliberate.
If you take one thing from this page, take this. The most frequent way a course of physical therapy fails is that the person quits before the treatment had a fair chance to work.
Musculoskeletal problems in your 50s, 60s and 70s do not resolve on a two-week clock. The published response windows for most common problems are measured in weeks to months, and we will go through them below.
Six weeks of feeling like nothing is happening is not, by itself, evidence that nothing is happening. It is usually the point at which you should start asking better questions, not the point at which you should walk away.
So everything that follows is built in that order. Measure first. Talk second. Change something third. Leaving is the last option, not the first.
Here is the reframe that changes everything, and it comes from a real idea in clinical research called the minimal clinically important difference.
Researchers noticed a problem. A treatment could shift a score on a questionnaire by an amount that was statistically real but so small that no patient would ever notice it in their life. So in 1989, Jaeschke, Singer and Guyatt built an approach that compared changes in score against patients' own ratings of whether they felt better. That gave a threshold: the smallest change that a patient would actually call an improvement.
Translated into your kitchen: progress is not "the pain is gone". Progress is a change big enough that you would notice it without being asked.
That threshold has been estimated for pain. In a study of 2,724 people across ten placebo-controlled drug trials in chronic pain conditions, Farrar and colleagues found that on the 0 to 10 pain scale, "a reduction of approximately two points or a reduction of approximately 30%" represented a clinically important difference.
Two caveats belong with that number. It was measured in drug trials, not in physical therapy, so treat it as a yardstick for the scale rather than for any one treatment. And the same paper notes that people who start with higher pain scores need a larger raw change to reach the same meaning.
So if you started at 8 out of 10 and you are now at 6, that is not nothing. That is roughly the size of change researchers use to define a real improvement.
Here is a concrete version, for anyone whose problem affects how they get around.
Perera and colleagues ran a secondary analysis of three groups of older adults: 100 people with mobility disabilities in a strength training trial, 100 subacute stroke survivors, and 492 community-dwelling older people. Their conclusion was that "best initial estimates of small meaningful change are near 0.05 m/s for gait speed" and of substantial change "near 0.10 m/s."
Note their own hedge. These are best initial estimates, not a fixed rule. They were also built in older adults with mobility problems, so they tell you what meaningful change looks like for walking and getting around. They are not the yardstick for a shoulder or a wrist.
What they do hand you is a very good question to ask at your next visit: "Are you measuring my walking speed, and has it changed since week one?"
These thresholds are estimates, not laws. Copay and colleagues took 454 lumbar spine surgery patients and calculated the threshold several accepted ways. The answers varied "fivefold for ODI, PCS, and leg pain, 10-fold for back pain."
Their final figure for the Oswestry Disability Index, a common back questionnaire, was 12.8 points in that lumbar spine surgery population. Use these as rough yardsticks for a conversation. Do not treat them as a pass mark.
This matters more than most people realize. Your pain score and your ability score are tracked separately, and they do not move together.
The 2021 Cochrane review of exercise for chronic low back pain pulled together 249 randomized trials. Against no treatment, usual care or placebo, exercise moved pain by 15.2 points on a 100-point scale, which the reviewers described as clinically important. It moved function by 6.8 points, which did not meet that threshold. Both findings were moderate certainty.
Notice the direction: in that review, pain improved more than function did. In other people, the opposite happens, and daily life gets easier while the ache stays put.
The practical point is not which one moves first. It is that if you are judging your therapy by pain alone, you may be missing a real gain that is showing up somewhere else.
The table below is a general expectation for a common musculoskeletal problem in an adult over 50. It is not a guarantee and it is not condition specific. Some problems run faster and some run considerably slower.
| Point in care | What should be true by now | What is still normal | The question to ask yourself |
|---|---|---|---|
| Week 2 | You know your working diagnosis in plain words. You have goals written in specific, functional terms. You have a home program you understand. Baseline measurements were taken. | Little or no change in pain. Some soreness in the day or two after sessions. Feeling unsure it is working. | Do I actually know what we are treating and what we are aiming for? |
| Week 4 | Your program has been progressed at least once, because it got easier. You can name at least one small thing that is different. Your therapist has checked something against your baseline. | Pain that fluctuates, good days and bad days, no clean downward line. | Has anything about my plan changed since week one, or am I doing the same sheet? |
| Week 6 | A measurable change on at least one thing that was measured at the start. A conversation about where this is going. | Not being back to normal. Real gains that are still small. | If nothing has moved on any measure, has anyone formally reassessed me? |
Why six weeks and not four or ten? It is not a magic number, and it is worth knowing where it comes from.
A 2012 meta-analysis in the Canadian Medical Association Journal pooled 33 inception cohort studies and 11,166 people with low back pain. It found that "patients who presented with acute or persistent low-back pain improved markedly in the first six weeks. After that time improvement slowed."
That describes the natural course of low back pain, not the effect of treatment. But it is a fair reason to treat around six weeks as a checkpoint for a conversation. The same study also found that low to moderate pain and disability were often still present at one year, which is a useful reality check in the other direction.
Every timeline below comes with the population it was measured in. Do not stretch one to cover a different problem.
Knee or hip osteoarthritis. GLA:D is one of the better studied structured programs for this. In the 2017 paper describing it, Skou and Roos set it out as "three sessions of patient education delivered over 2 weeks and 12 sessions of supervised neuromuscular exercise delivered twice weekly for 6 weeks."
That is a useful dose picture for arthritis of the knee or hip, and only for the knee or hip. On effect size, the 2015 Cochrane review of 54 knee osteoarthritis studies found exercise reduced pain by about 12 points on a 100-point scale immediately after treatment. Worth knowing: only 19 of those 54 studies reported adequate randomization and allocation methods, so the true effect could be smaller.
Low back pain. See the six-week finding above. Marked improvement in the first six weeks, then a slower grade after that.
Rotator cuff related shoulder pain. StatPearls states plainly that for patients who do respond to non-surgical care, they "will do so in 6 to 12 weeks." The American Academy of Orthopaedic Surgeons reports that "in about 80 to 85% of patients, nonsurgical treatment relieves pain and improves function in the shoulder." If your shoulder is the problem and week 4 feels like nothing, that is within the expected window. Our shoulder symptom sorter goes into what is likely to be driving it.
Neck pain that runs down the arm. For acute cervical radiculopathy, meaning nerve pain from the neck into the arm, StatPearls reports that "over 85% of acute cervical radiculopathy resolves without any specific treatments within 8 to 12 weeks." That figure describes acute cases and describes natural recovery, not a therapy result. Longer-standing neck problems behave differently.
If your underlying question is really "how many visits should this take," that is a different question and we answered it separately in how many physical therapy sessions you actually need.
Keep an eye on these. They are the changes people forget to count.
Every one of these is a functional change, and functional change is exactly what a physical therapy plan of care is supposed to target. APTA's documentation standards require that goals be written in functional, measurable terms.
Write these down as they happen. Six weeks from now you will not remember which week the laundry basket got easier, and that detail is genuinely useful at a reassessment.
Some of these sit with the plan. Some sit with the patient. A fair account has to include both.
This is the most common one and the least dramatic. Two sessions a week with a home program is a different treatment from one session every other week with a sheet you glance at.
Strength and balance work in particular depend on doing enough, often enough, at a hard enough level. If your exercises have felt comfortable and unchanged for a month, the dose is probably the issue.
It helps to know what the research doses actually look like. The GLA:D knee and hip program described above is twelve supervised sessions, delivered twice a week, across six weeks. If you are getting one supervised session every other week and no home program, you are not receiving anything close to the dose that evidence was built on.
That is a comparison, not an accusation. Schedules get built around availability, travel, work and a dozen other real constraints. But it is a fair thing to put on the table, because sometimes it is the whole explanation.
This one is worth handling carefully, because the evidence here is messier than most clinics admit.
Jack and colleagues reviewed 20 high-quality studies of musculoskeletal outpatients. They found strong evidence that poor adherence was associated with seven things:
Note that word: associated. These are observational findings.
And the picture is not settled. A 2024 secondary analysis looked at 173 low back pain patients across 58 physiotherapy practices. Adherence was scored at every single session. It found "no significant associations between adherence to [home-based exercise] recommendations and clinical outcome changes."
The authors flagged real limitations. The subgroups were small. The confidence intervals were wide. The adherence data was collected by the treating therapists.
So the honest version is this. Doing your program consistently is the sensible bet, and it is what the plan assumes. But nobody has proven that adherence causes recovery, and the relationship may partly run backwards, because people who are recovering find it easier to keep exercising.
If the program is not happening, say so out loud rather than quietly. A therapist who knows you have managed twice a week can build a plan around twice a week. A therapist who thinks you did it daily will keep progressing a program you never got to.
Sometimes the treatment is right for the diagnosis and the diagnosis needs another look. That is not a failure, and good guidelines build it in.
The UK's NICE guideline on low back pain opens with exactly this instruction: "Think about alternative diagnoses when examining or reviewing people with low back pain, particularly if they develop new or changed symptoms."
New symptoms, symptoms moving to a new place, or a pattern that does not fit are all legitimate reasons to reopen the question.
Pain and function do not happen in a vacuum. Another health condition, a medication change, or a fall you never mentioned can all hold a recovery flat. So can a job or a caregiving role that loads the same tissue for eight hours a day, or a long stretch of low mood.
None of that is a character flaw and none of it makes therapy pointless. It usually means the plan needs to account for something it currently does not.
Exercises are supposed to get harder as you get stronger. If you are still on the sheet you were given in week one, and it now feels easy, the plan has stopped asking anything of you.
This is often the fastest fix on the whole list, and it usually takes one conversation.
In this order. Skipping to step three is how people end up starting over from scratch with a new therapist and no continuity.
Most stalled care is fixed by a conversation, not a switch. Your therapist genuinely cannot see what happens between visits unless you tell them.
Try one of these:
"I want to be straight with you. I am six weeks in and I cannot tell whether this is working. Can we look at where I started and where I am now?"
"Which measures did you take at my first visit? Can we repeat them today so I can see the numbers?"
"The home program has been the same for a month and it feels easy now. Should it be harder?"
"I have only been managing this twice a week, not daily. Can we build a plan around what I will actually do?"
Asking what is being measured is a completely normal request. Standardized outcome measures, as APTA describes them, "provide a common language with which to evaluate the success of physical therapy interventions."
They are also not universal. In a 2009 survey of 1,000 randomly selected APTA members, 48 percent reported using standardized outcome measures. More than 90 percent of those who did use them believed the measures "enhanced communication with patients and helped direct the plan of care."
That survey was self-reported, used an unvalidated instrument, and was limited to APTA members. Read it as a signal, not a current national figure. The practical takeaway still stands: it is entirely reasonable to ask what is being tracked.
If the conversation does not produce a change, ask for a reassessment by name. This is a standard part of practice, not a complaint.
APTA's documentation guidance states that a reexamination should occur "whenever there is an unanticipated change in the individual's status, a failure to respond to physical therapist intervention as expected, the need for a new plan of care." Not responding as expected is, in writing, a reason to reassess.
It also states that "one of the most important objectives of the reexamination is to determine the patient's or client's progress or lack of progress toward the established goals and prognosis."
Words to use:
"I would like to schedule a formal reassessment. I have not responded the way we expected and I want to see the plan updated based on where I actually am."
If you have raised it, had a reassessment, and the plan still has not changed or still is not working, a second opinion is a reasonable next step. Not a betrayal, and not an emergency.
Take your records with you. Bring your original measurements, your current ones, and the list of what you have already tried. A second clinician who can see six weeks of data starts far ahead of one who is starting from zero.
In Oregon you do not need a physician's referral to see a physical therapist. Oregon administrative rule 848-040-0117 states that "a physical therapist may initiate and provide physical therapy to a patient who is either self-referred or referred by a 'provider of care.'"
So you can recognize one when it happens. A reassessment should include most of the following:
If walking is part of your problem, the gait speed figures above are the scale to think in. That is the level of precision available when someone is actually measuring rather than asking how you feel.
Some symptoms are not a sign that therapy needs adjusting. They are a sign that you need a medical assessment, and pushing through is the wrong response.
Contact your doctor promptly, or go to urgent or emergency care, if you develop:
Loss of bladder or bowel control combined with numbness in the saddle area or worsening leg symptoms can indicate cauda equina syndrome, which the American Academy of Orthopaedic Surgeons describes as "a surgical emergency." Untreated it risks permanent paralysis and lasting bladder and bowel problems. That one is an emergency room visit, not a phone call.
Two honest notes on this list. First, these are reasons to be checked, not diagnoses. Most people with night pain do not have anything sinister. Second, this field is less settled than it looks. A 2016 review of 16 low back pain guidelines from 15 countries found 46 different red flags in use, a "lack of consensus between guidelines for which red flags to endorse," and that diagnostic accuracy data "was rarely provided."
It is also worth knowing that your physical therapist carries a legal duty here. Oregon statute 688.132 requires a physical therapist to refer you to a physician when your symptoms require medical diagnosis or treatment, when physical therapy is contraindicated, or when the problem is outside physical therapy's scope. A therapist sending you to a doctor is the system working.
Separately, if the question underneath all of this is whether you should be considering an operation, we covered the evidence on that in do I need surgery, or can physical therapy fix this, and it is a different decision from this one.
You are trying to judge a course of care you have never seen, based on what your mother or father tells you on the phone. That is hard, and "how's therapy going" gets you "oh, fine" every time.
Ask better questions instead:
Watch the function, not the pain report. Older adults very often under-report pain and over-report coping. Notice whether they are getting out of the chair more easily, whether they have stopped avoiding a room in the house, whether they are still doing the shopping.
Two more things worth doing. Offer to attend one appointment, in person or by phone, because a second set of ears at a reassessment changes the conversation. And keep a simple written log with them, one line a week, so a reassessment has something to work with.
If you want to know what a thorough first appointment should have covered in the first place, our guide to what happens at a first physical therapy visit after 50 walks through it.
Is it normal to be sore after physical therapy? Some soreness in the day or two after a session is common, particularly when new exercises or heavier loads have been introduced. What is not expected is pain that is sharp, that is worse than your usual symptoms, that lasts several days, or that gets worse session after session. Tell your therapist either way, because soreness is information they need to set the load correctly.
How long before I should expect to feel anything? It depends heavily on the problem. Low back pain cohorts show marked improvement over the first six weeks and slower change afterward. Shoulder problems that respond to non-surgical care generally do so within 6 to 12 weeks. Acute nerve pain from the neck into the arm most often settles over 8 to 12 weeks. The GLA:D program for knee and hip arthritis runs 12 supervised exercise sessions, twice weekly, over six weeks. Two weeks is almost never long enough to judge.
Can I ask for a different approach? Yes, and it is a normal request. You can ask why a particular exercise was chosen, whether there is an alternative that fits your life better, and what the plan is if the current approach has not moved anything by a set date. A good therapist will welcome the question, because a program you will actually do beats a better program you will not.
Is it rude to get a second opinion? No. It is a routine part of health care and clinicians deal with it constantly. The order matters more than the etiquette: raise it with your current therapist first, ask for a reassessment second, and seek a second opinion if those do not produce a change. Bring your records with you so the next clinician is not starting blind.
What if my pain is worse after a session? Mention it at the next visit, or call sooner if it is significant. A short-lived increase after new or harder work is common and is usually a dose issue that gets adjusted. A pain increase that is severe, that persists for days, or that comes with new numbness, weakness, or any of the red flags above should be raised immediately rather than pushed through.
I have been going for three months with no change at all. Should I just stop? Stopping is one option, but it is rarely the best next step on its own. Ask for a formal reassessment first, and ask directly whether the diagnosis should be reconsidered. Three months of no measurable change on any outcome is a legitimate reason to change something substantial: the diagnosis, the plan, the dose, or the clinician. Simply stopping changes nothing about the underlying problem.
At HWY Physical Therapy we work only with adults over 50, and a reasonable share of the people we meet are already partway through a course of care somewhere else and are not sure where they stand.
If that is you, a Wellness Screening Call is a straightforward place to start. It is a virtual conversation with Dr. Raj Pusuluri, PT, DPT, about where you are, what has been tried, what has been measured, and what a sensible next step looks like. Sometimes that next step is going back to your current therapist with better questions. We will tell you if that is what we think.
We are direct-pay, so no insurance is required and no referral is needed to be seen. If getting to a clinic is the obstacle, our Start From Home option runs the same conversation over video.
For some nerve and chronic pain presentations we use the Neubie, an FDA-cleared device that delivers direct current and is not a TENS unit. It is available in-clinic only and no other physical therapy clinic in Salem currently offers it. It is one tool among many and it is not the point of this article.
Book a Wellness Screening Call: https://meetings.hubspot.com/raj-pusuluri/hwy-pt-schedule Or call us: (971) 202-1979
HWY Physical Therapy North Salem: 2615 Portland Rd NE, Salem, OR 97301 (at Center 50+) South Salem: HWY Physical Therapy Clinic South Salem, 180 Ramsgate Square S, Salem, OR 97302 Phone: (971) 202-1979 Hours: Monday to Friday, 8:00 AM to 5:00 PM. Walk-ins welcome. Book online: https://meetings.hubspot.com/raj-pusuluri/hwy-pt-schedule
This article is general information for adults over 50 and is not a diagnosis or a substitute for individual medical advice. It is not a recommendation to stop or change any treatment you are currently receiving. If you have concerns about your care, speak with your treating clinician.