Advocacy

When will they quit viewing Physical Therapy as an Intervention?

This morning, I read an article review published on Medicinenet.com 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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18 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.

    Z

  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.

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