When will they quit viewing Physical Therapy as an Intervention?

This morning, I read an article review published on called “Physical Therapy May Not Improve Hip Arthritis, Study Finds“. After reading this article, I had several thoughts. Here they are:

  • I suspect we can easily replace the words Physical Therapy with other interventions, such as NSAIDs, glucosamine, etc. and nod in agreement. But what would happen if this author would have replaced Physical Therapy with the term “Medicine”? I doubt it would have been published in JAMA…
  • I am tired of Physical Therapy being viewed as an intervention, that is performed consistently based upon a diagnosis, when in reality, there is little consistency in the intervening patterns of licensed Physical Therapists. This is due to many reasons, including the individualized nature of each individuals presentation. So do we (Physical Therapists) treat Osteoarthritis (OA)? Or do we treat Individuals who present with hip pain or an inability to perform _______ with a radiographic finding of OA?
  • An individual within the article was quoted as saying, “Azar noted that physical therapy doesn’t usually help arthritis of the hip. Injections of steroids and painkillers are more effective, she said. Physical therapy tends to be more useful with people who aren’t physically active or who have balance or other walking problems, she added.” FACEPALM. If anyone needs an explanation why, Ill be more than happy to elaborate in the comments…
  • Is this study consistent with treatment plans of care typically prescribed by Physical Therapists? This study had each participant complete 10 sessions over a 12 week period. I am not convinced that we can conclude that much when we attempt to tightly control for internal validity. The author of this review (not the original article) actually extrapoloated the results to state that an entire profession (Physical Therapy) may be unable to treat individuals with hip osteoarthritis effectively…maybe this was to increase social media exposure?
  • I hope the APTA will respond to this piece and define that we are a Profession of Physical Therapists who provide interventions, often to individuals in Pain (who may have hip OA). The days of viewing us an interventionists are over.    Unfortunately, there is one thing hold this back:  our over-reliance upon physician’s script-pads…


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19 replies »

  1. Love the perspective in the first two points Joe. I do wonder though if we are “hoisted upon our own petard” given that PT seems to place such emphasis on technique that the term PT has become synonymous with technique.

  2. Btw, why is a rheumatologist, Dr. Natalie Azar, speaking on behalf of Physical Therapists? I have zero tolerance for this.

    Here is the entire quote from the article on how she views “Physical Therapy”:

    “Dr. Natalie Azar, a clinical assistant professor in the departments of medicine and rheumatology at NYU Langone Medical Center in New York City, said, “I have found that the benefit of physical therapy varies so much with each patient, as well as the state of the disease.”

    Azar noted that physical therapy doesn’t usually help arthritis of the hip. Injections of steroids and painkillers are more effective, she said.

    Physical therapy tends to be more useful with people who aren’t physically active or who have balance or other walking problems, she added.

    For some people, physical therapy may not be recommended at all. Specifically, physical therapy could make someone with torn cartilage in the hip worse (called a hip labral tear), Azar said.”

    • Dr. Azar treats these conditions with injections and painkillers; of course she is going to say injections and painkillers are more effective.

      The article itself, while loosely based on a study, is mostly a bunch of professionals giving their “expert opinion”.

  3. Facepalm indeed. This hurts to read. Unfortunately I don’t think our over reliance on the physician’s script pad is the only thing holding us back, although it’s a major one. There are still way to many PT’s out there relying on radiographic evidence to explain painful conditions; this is holding us back as well. Plenty of PT’s out there need to get on board with the abundance of education showing radiographic evidence doesn’t correlate to pain.

    The other day I heard a PT state “that’s bulging disc pain right there. The bulging disc is pinching a nerve causing pain down your leg when you move.” I know he’s not the only one doing this, it’s probably the majority, until this changes we’re not moving anywhere. (I hate to sound cynical, just get frustrated watching ourselves hold ourselves back).

    • The patient I mentioned has called and cancelled all his appointments, will probably stay at home and not move, and end up having fusion surgery with a 1/20 chance of returning to his normal activity. We can do better, we have to do better.

  4. We are having high clinical diagnostic accuracy. Its prooved. Physical therapy is as good as surgery, this also proved. Have to show these things to them……..

  5. Joe, I just read the article and listened to the lead author’s (Bennell) commentary for JAMA. I was mystified by her conclusion regarding the relationship between outcomes and the non-specific effects of treatment based on the results of this trial. “Physical Therapy” included “mandatory” manual therapy techniques (long axis inferior thrust, proximal inferior or lateral distraction oscillation, prone pelvic oscillation to increase IR, and “soft tissue or deep tissue massage of quads, adductors, hamstrings, psoas, lateral hip muscles, and/or posterior hip muscles and associated fascia.”)

    So, aside for the complete lack of acknowledgement that living patients have skin, how often would you say that you would automatically apply a thrust technique to a patient with hip OA, not to mention the lack of clinical decision-making that takes place when one decides on which joint mobilization technique to utilize?

    Dr. Bennell’s conclusion that this study provides evidence that non-specific effects are likely as important as specific effects for patients with hip arthritis BASED ON THIS STUDY is woefully inaccurate. If she weren’t so uninformed, and tell her that she should be ashamed of herself.

  6. Personally I think this article demonstrates how inept physicians are at directing physical therapy treatment. The protocol that directs manual therapy for two visits or treats everyone once a week for ten weeks fails to take into account individual differences of patients and their present state of condition. I would be interested in a study that evaluated the physicians treatment with pain killers and injections. They could use radiographs (their favorite and sometimes only evaluation) to evaluate anatomical change in condition with the addition of functional status/condition evaluation of the patient. Probable outcome “Patient has significantly less pain, even though the patient can no longer walk to bathroom causing incontinence, and condition has progressed on radiographs.”

    Studies like this irritate me to no end, particularly when compared to other studies with significantly less bias and appropriate intervention supporting the other side of the issue.


  7. Richard,
    I don’t see that physicians were involved in directing the active intervention in this study. The researchers seemed to base the active treatment on what they determined from the literature has shown some benefit for patients with painful hip OA. They attempted to individualize treatment by allowing the PTs to use optional manual and exercise interventions in addition to the mandatory ones. But how often do most PTs use thrust manipulation for patients with hip OA? In my experience, some patients with hip OA have a very irritable condition that suggests a florid inflammatory response. Would it be judicious to thrust a patient’s hip in this case? That doesn’t make any sense to me at all. However, long-axis distraction thrust was mandatory and so were aggressive soft tissue mobilization techniques. The treatment protocol seemed to undermine the PTs’ responsibility to dose manual therapy based on clinical reasoning.

    In a short audiotaped interview with the lead author at JAMA online, she specifically addresses the issue of heterogeneity of hip OA clinical presentations and the possibility that the active treatment may have not adequately accounted for this; however, there’s no mention of this in the actual article. She even talks about the possibility that subgroups exists that might benefit more from “a more physical program” versus “a more psychological program”. The Discussion section didn’t address this external validity threat at all. And I suspect since it was medical people providing peer review, they have no idea if this active intervention is consistent with Physical Therapist clinical practice.

    I don’t know who disappointments me more: the research team who developed the active intervention protocol or the PTs who agreed to implement it on real patients. I would never agree to providing the mandatory interventions that were included in this trial on every patient with painful hip OA.

  8. Thanks for identifying this study of 102 people. From this, of course we can generalise it to the….how many people across the world with OA hip? Anyhow, they are not OA hip people, they are individuals who happen to experience pain and other manifestations of the way in which the body protects itself (e.g./ altered motor control, guarding, altered cognition, emotional responses etc). Did the author determine whether central sensitisation was a feature? Any neuropathic pain mechanism hiding in there? Manual therapy is not likely to do much with these features stand-alone, especially if the patient’s model of understanding pain is based on a structure or pathology.
    For me, this article and the review purport, yet again, an ancient way of thinking about pain that potentially sways readers opinions and drives them deeper into the world of dualist thinking. Pain can and does change, but people are rarely given the chance to experience this when the thinking follows the route of this piece. Sad.

  9. I think we are missing the psychological impact that this study has embedded in it. It says “Receiving physical therapy did not add any greater benefit over simply seeing a CARING physical therapy and having POSITIVE expectations about treatment.

    Im my humble opinion we should be asking what physical function assessments are they evaluating in this study because it is well researched that individuals become sarcopenic with age so if they are only looking at transfers, ambulation on level or stairs then maybe they should look at physical function in more detail because this would help define successful aging and this is where our value is in addition to our vast understanding of how pain can be absent with/without arthritis.

  10. To answer your question, physical therapy will be viewed as an intervention until we as therapists change the manner in which we are viewed by healthcare as a whole. This is going to take a large paradigm shift which needs to start with therapists presenting a unified front which will require us to actually be unified. The majority of therapists are not members of the APTA. Increased membership will lead to increased revenue and therefore increased exposure and research that is able to be conducted to refute the study you have referenced above. As a profession, we need to stop viewing ourselves as simply salaried employees who practice based on protocols provided by other healthcare disciplines that have no basis in any evidence rather than independent licensed professionals who can think and practice on their own. We also need therapists who are not intimidated by other healthcare professional and are able to confidently communicate and collaborate in a judgment-free healthcare environment. In my opinion these are key steps in the process of of answering your question.

    Thanks again for the website, we need more “forward thinking PT” in healthcare now more than ever.

  11. I know it’s a year later but I accidentally ran into this article now. Here’s my take on this:

    There is so much I can say. I don’t like this any more than all of you do. Where I practice, the physio role in the healthcare system is even more archaic than the rest of Canada and the other English speaking countries. So, when I present this article to my colleagues they all look at me in the same way housewives looked at suffragettes when they were talking about women’s right to vote at the turn of the century. They didn’t understand where the problem lied because they were more distracted by screaming hungry babies and boiling pots in the kitchen. Me and my fellow PTs we are now fighting for pay equity and other financial problems in our local healthcare system. We can’t even start to think about more professional freedom, because we’ll all have a nervous breakdown. You guys in US have a lot more turf compared to PTs in other parts of the world. So, enjoy it. The world will never be perfect.

    Working with MDs for a long time I realized that most of the time the MDs are not even aware that they are insulting our profession when they say these things. If they would know, many of them would modify their wording if you give them suggestions on how to. Sometimes, because they work with different PTs they’re not even sure what we CAN do across the board. Once a colleague of mine did an in service to some neurologists and neurosurgeons, and they were pleasantly surprised to find out that PTs are actually very well trained to rule out serious malignant disease, and pathologies that are not suited for PT care. They didn’t know we COULD do that, bu also mostly because there are many PTs who just don’t apply themselves, because they don’t have to. MDs take all the responsibility. But if we show we CAN, many of them are more than happy to pass some things over to us.

    On one hand, I know PTs who are happy to be considered an intervention, and they encourage this in the MD community. They feel protected by the MDs orders so they don’t have to take too much responsibility on their shoulders. Being an intervention, there is less pressure to apply specific treatment, or follow pre-established guidelines of care, because physio is physio. MDs use care maps and have very little freedom with their choice of treatment; that is why it is easy for them to specifically test one treatment plan vs another.

    MDs all come into agreement with what their job is. PTs don’t. Studies show that PTs view their roles very differently from one another depending of where they work. Some PTs are happy with just walking with patients and feel fulfilled and feel they’re real PTs, others prefer giving orthopedic diagnoses and hate being the guy who gets patients up in the hospital.

    Also, MDs have been around for longer than we have been. They have more research to back them up. The value of research cannot be underestimated. It is the body of evidence they accumulated over centuries that gave MDs so much power in the healthcare world. In addition, pharmaceutical companies have great interest in investing with MDs research. Actually they fund a lot of drugs research and they support anything that is biased towards the use of medication. It’s their interest after all. If PTs start prescribing meds, we will then feel the pharmaceutical companies pounding on our doors with incentive to prescribe meds more often. Pharmaceutical business is a gigantic market and MDs control this market.

    On the other hand, PTs only started researching very recently, and that research supported our autonomy of practice right. However, there are not sufficient studies in PT world to say that one approach was better than another on different groups of people, because we individualize treatments too much. That is why it remains physiotherapy as a generalization of what we do. MDs are aware that we are individualizing treatments. But please give them a suggestion on how to word that article to better suit our ego.

    Future studies should be more geared at seeing what PT CAN do for OA, or what OA really means as a diagnosis, or how many patients with OA findings on XRays have symptoms. There were similar studies done regarding back pain and disc herniations. MDs did get that one and started to use PTs’ advice more often then before regarding surgical options. After all they are healthcare professionals and they also took the Hippocrates’s oath to do no harm. Unnecessary surgery that could be avoided is considered harm to the patient. So is over prescribing antiinflammatories. I doubt any physician would take a bad decision because he/she wants more money. They are looking for best treatment options for their patients and get influenced from different sources. We must try to influence them our way, if we think we hold the secret to curing OA pain.

    If we sit here and complain about how doctors say this and that but we are unaware of all the players in the healthcare business who can outsmart us, we have a lot to lose. MDs are the least of our problems. Pharmaceutical companies are the monster.

    MDs don’t hate us and they don’t want to insult us. They do respect what we do, they were just not given a better option to name what we do. We must give them better options and also convince them that meds are not always the solution with good quality research.

    Happy treating in the physio room!

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