This essay is a result of a recent prescription I received from a Podiatrist which read: Physical Therapy for Achilles Tendonitis. Eval and Treat with Ultrasound and Electrical Stimulation. I am frustrated that despite our gained autonomy and direct access rights, we are still recognized as interventionalists who simply perform modalities. This essay is to identify how we became a profession, what we know as a profession and how we can move forward. This essay is important.
Part 1: Historical Review of Physical and Manual Therapy PracticeEarly roots of Physical Therapy and Rehabilitation date back as far as 460 B.C. Physicians, such as Hippocrates and Galenus, documented the medical use of manual therapy, massage and hydrotherapy in treating various ailments. In the 17th and 18th centuries, the practice of “bone setting” was all the rage, and practitioners believed that bones would dislocate and you would need to set them back in (this fad died out—kind of…). American Indian tribes were also documented around this time in using primitive forms of joint manipulation by walking on each others backs. In 1895, a magnetic healer named Daniel David Palmer, founded the manual profession known as chiropractic and believed illnesses could be treated through the repositioning of dislocated vertebrae.1
Early reminants of modern Physical Therapy entered existance in the United States in the late 19th century. In 1881, the Sargant School, in Boston, MA, opened up their doors to welcome the first Physical Training class.2 Dr. Dudley Sargant, who founded the school, built a reputation as an innovator in promoting health through physical conditioning and wellbeing and recognized that physical rehabilitation was a necessary part of the healing process of musculoskeletal disorders.3
Over the next several decades, other programs began to be offer similar training. In 1918, women were recruited to assist orthopedic surgeons in restoring function to those injured in World War 1. This lead to the development of the Reconstruction Aide. These individuals served in military hospitals in the US and overseas as assistants in the rehabilitation of injured soldiers. Around this time. the first, official, Physical Therapy school was developed at Walter Reed Army Hospital in Washington DC. Other schools also began offering Physical Therapy training.4 In 1921, the first recognized Physical Therapy Association came into existence in the United States, and was called the American Women’s Physical Therapeutic Association which eventually became the American Physiotherapy Association by the end of the 1930s.
From its start, Physical Therapy was developed as an occupation which acted in a supportive role to physicians. Practitioners were considered “educated trained assistants to the members of the established medical profession”.4 Manual therapy was an integral part of early physical therapy, and in a paper written in 1923 titled, “Physiotherapy in Stiff & Painful Shoulders”, the author stated that “on forceful manipulation it is found that the scapula moves coincidentally with the arm”. Other treatments recommended for a stiff shoulder included: heat, chlorine ionization, massage, stretching, monipolar high frequency vacuum tube and exercise.5
The profession came into much greater demand in the 1940s and 1950s following the second World War as well as during the height of the polio epidemic. At this time, over 8,000 individuals became members of the professional organization, which changed its name to the American Physical Therapy Assocation.2 Physical Therapists played a crucial role in field testing the polio vaccine, prior to its mass distribution, and continued to treat those inflicted with the disease.
Currently, there are close to 200,000 licensed physical therapists employed in the United States.6 In forty-seven states and the District of Columbia, Physical Therapists can practice as Direct Access providers (without a physicians referral). This has been a huge step forward, in the recognition of Physical Therapists as highly trained, autonomous practitioners.
But despite this move forward, we must understand that we are still evolving. The general public is still largely unaware that they can seek our care without a medical referral, and many would seek another professional before us in the care of musculoskeletal issues. As so-called “musculoskeletal and movement” experts, we still hold onto some “questionable” beliefs and interventions, and I suspect a stronger sense of coherence and agreement is needed, before we will be recognized at this caliber.
Part 2: Evidence-Based Interventions: What do we know?
So when I say “questionable”, what do I mean. Well, one thing that we do very well as Physical Therapists is perform research about our diagnostic skills, interventions and outcomes. One thing, I do not believe we do well is incorporate some of that research into practice. Now don’t get me wrong, experience is important. Very important. Especially for deductive reasoning. But to truly be an evidence-based practitioner, you must also be performing scientifically sound interventions. Here are some things to consider:
- Modalities:Ultrasound: We all learned about the magical qualities of ultrasound in Physical Therapy school. We learned about it bringing nutrients and cells via bloodflow to damaged and inflamed tissues. We learned about those cool little cavitation bubbles. Well here’s how those theories stood up in the literature…A systematic review performed in 1999 by van der Windt found that there is little evidence to support the use of therapeutic ultrasound in the treatment of musculoskeletal conditions. 76 studies were found by the researchers, 38 of which were included in this review (after inclusion/exclusion were met). The majority did not find a statistically significant difference between therapeutic ultrasound as compared to a sham interventions.8 Another review performed in 2001 by Robertson et al had the same, exact conclusions.9 A systematic review which assessed the use of ultrasound for the treatment of knee/hip OA found no beneficial effect as compared to placebo.10
TENs: A systematic review performed in 1996 determined that TENs had no statically significant difference as compared to placebo in controlling pain or disability.11
Thermotherapy/Cryotherapy: A 2009 systematic review and meta-analysis on cryotherapy, after total knee arthroplasties, determined that despite theoretical applications in the reduction of pain and swelling following surgery, the evidence does not support the routine use of cryotherapy (there were only very small benefits when used immediately after surgery).12
- Exercise:Unlike modalities, exercise has been demonstrated to be highly effective in the treatment of many disorders in the literature. Unfortunately, the type of approach to exercise does not appear to matter, as much as simply movement. A recent study prospectively assessed the outcomes of 172 individuals with chronic, nonspecific LBP who were randomized to receive either motor control exercises or graded activities. The results indicated that both approaches were effective in decreasing pain and disability in individuals with chronic LBP but one approach wasn’t superior to the other.13 Another study, compared traditional core stabilization exercises with trunk balance activities in the treatment of LBP, and found that the trunk balance group had more significant improvements in disability and quality of life.14 A preventative study performed by George et al. found that education, not core stabilization, was more important in preventing care seeking for incidences of low back pain.15 Maybe all that stuff about the tA and multifidis really isn’t that important. Or at least as important as we thought…please don’t hate the messenger.
- Manual Therapy:Manual therapy, like exercise, has been demonstrated by countless articles to be an effective treatment, often when combined with other therapeutic interventions. A systematic review on the treatment of mechanical neck pain found that multimodal manual therapy care including exercise was superior to controls in improving pain and patient perceived outcomes.16 Similar studies and outcomes have been demonstrated in the treatment of low back pain.17 The evidence is inconclusive whether manual therapy is effective in treating hip and knee OA.18
Part 3: What barriers have we created for ourselves?
Barrier #3: Too much emphasis on board examinations for new graduates. I doubt many will have an argument with this. Much of what is taught in Physical Therapy schools in the United States is driven by the state licenser examinations and accrediting bodies. Emphasis of education should be built on teaching the most current, scientific methods of treatment. Instead we are spending time teaching students about theories which have been ultimately outdated (convex/concave rules, veretebral and sacral rotations—palpating the ILA, etc.) so that they can pass an outdated examination.
Barrier # 1: Continued Use of Non-Evidence/Scientifically Supported Interventions. As you can see from part 2, we have built a profession that utilizes some great, evidence-supported interventions but also one that routinely performs and bills for unnecessary modalities. There continues to be a large reliance on holding onto what we believe(d) to be true, and a resilience in letting go of our comfort tools (definition of tool: a handheld device that aids in accomplishing a task. What task are we accomplishing if we are using modalities?).
Barrier #2: Too Much Emphasis on “Suspected” Tissues. We have also become too focused on “tissue-specific theoretical interventions” and less on scientific plausibility. As Physical Therapists, one of the most common symptoms our patients tell us about is Pain. And despite this, we have over-simplified pain by thinking of it as a bottom-up response, in which the tissues are injured and and therefore hurt. The true scientific explanation of the pain involves the neuromatrix, which is a brain-involved, top-down response, in which the brain and nervous system defend an injured tissue through sending a perceived signal, pain. Ignoring that the brain is the ultimate player in ALL pain is a costly mistake. The brain’s defense of a tissue may not only be related to the damage of the tissue, but also to the environment in which the tissue was injured, the psychological well-being of the individual, the history or memories of past injuries, etc. Below is a diagram of the neuromatrix which demonstrates all of the associated inputs into the brain which may cause it to respond by sending a pain output.
Barrier #4: Unscientific Continuing Education Courses. I get daily brochures promoting continuing education courses which will teach me the skills to eliminate anyones pain or dysfunction! Unfortunately, many of these courses are teaching outdated treatment models or pure garbage (don’t get me wrong—there are some fantastic courses out there). Sciencebasedmedicine.org wrote a blog a few months back about visceral manipulation being embraced by the APTA. For those of you who aren’t familiar with this magical hands-on approach, it is built around a theory that through hands-on evaluation, you can determine structural imbalances throughout the body (involving different organs and tissues), and you improve balance through manipulation of organs. Ummmm yea….
Part 4: How do we overcome our barriers?
Barrier # 1: Continued Use of Non-Evidence/Scientifically Supported Interventions. We must agree as a profession to gently let go of interventions which have been demonstrated to be of little therapeutic value. Plain and simple. It will be hard at first, I’m sure. But in the end it is the right thing to do.
We should also re-educate ourselves in the scientific method and become aquatinted to new understandings of pain, fatigue, etc. Things evolve. So should we. I recommend we move forward through open discussion in the work place, online (websites such as somasimple), etc. Everyone, in some point of their career (for me, daily) has had the thought in the back of their mind, “I wonder if this is really doing, what I think it’s doing”. Discuss these thoughts. Try to make sense of them. If you haven’t ever been able to palpate the ILA, determine which leg is longer, vertebral rotation, etc, join the club.
Barrier #2: Too Much Emphasis on “Suspected” Tissues. As I stated above, we must question what we think we are doing and what we think we are affecting. When we place are hands on a patient, how do you know you are touching anything but the skin? Our reliability in palpatory skills is inherently low. And this is because of human anatomy variability. But who cares. By adopting a neuromatrix explanatory model of pain, we understand that the human pain experience is much more than a tissue and determining the tissue at fault is not necessary (after ruling out systemic involvement through symptomatic screening). By moving past the “this-tissue-is-the-cause-of-your-pain-model”, will result in lower nocebo responses and ultimately better long-term outcomes. For more about this topic, read here.
Barrier #3: Too much emphasis on board examinations for new graduates. This is one barrier I do not see changing. I’m just being honest. But, if I had any influence on accrediting bodies, my idea would be:
- Drop the current board examination and require a 6-month to 1 year residency for specialization in a desired field of therapy
- Residency would involve clinical mentorship by fellowship-trained mentor
- Have a comprehensive board examination, written and practical, following completion of residency
Barrier #4: Unscientific Continuing Education Courses. I recommend “taking out the garbage” here. I believe a peer-review process should take place for all CEU course applications. All information included in the course should be well-cited and have scientific basis and plausibility.
Part 5: Let’s move forward
Alright, so this essay has been quite exhaustive but in my opinion, quite necessary. We need to be forward thinking if we want to move past prescriptions which state Physical Therapy for Achilles Tendonitis. Eval and Treat with Ultrasound and Electrical Stimulation. We must all work together in making this change.
Please comment and let’s start a discussion, not an argument, on how you will make a change to move our profession forward. Are you willing to hang up the ultrasound head?
1. Paris S. A history of manipulative therapy through the ages and up to the current controversy in the United States. JMMT 2000. 8: 66-77.
5. Granger. Physiotherapy in stiff & painful shoulders. Physical Therapy Review. 1921.
8. van der Windt D, Geert JMG. Ultrasound therapy for musculoskeletal disorders: a systematic review. Pain 1999: 81: 257-271.
9. Robertson VJ, Baker KG. A review of therapeutic ultrasound: Effectiveness Studies. Physical Therapy 2001. 81: 1229-1250.
10.Welch V, Brosseau L, Peterson J, Shea B, Tugwell P, Wells GA. Therapeutic ultrasound for osteoarthritis of the knee. Cochrane Database of Systematic Reviews 2001, Issue 3. Art. No.: CD003132. DOI: 10.1002/14651858.CD003132.
11. Carroll D, Tramer M, et al. Randomization is important in studies with pain outcomes: systematic review of transcutaneous electrical nerve stimulation in acute postoperative pain. British Journal of Anaesthesia 1996. 77: 798-803.
12. Adie S, Naylor JM, et al. Cryotherapy after total knee arthroplasy: a systematic review and meta-anlysis of randomized controlled trials. The Journal of Arthroplasty 2010. 25: 709-715.
13. Macedo LG, Latimer J, et al. Effect of motor control exercises versus graded activity in patients with chronic nonspecific low back pain: a randomized controlled trial. Physical Therapy 2012: 92; 363-377.
14. Gatti R, Faccendini S, Tettamanti A, Barbero M, Balestri A, Calori G. Efficacy of Trunk Balance Exercises for Individuals with Chronic Low Back Pain: A Randomized Clinical Trial. J Orthop Sports Phys Ther 2011: 41(8); 542-552.
15. George SZ, Childs JD, et al. Brief psychosocial education, not core stabilization, reduced incidence of low back pain: results from the Prevention of Low Back Pain in the Military cluster randomized trial. BMC Medicine 2011: 9; 128.
16. Gross AR, Kay T, et al. Manual therapy for mechanical neck disorders: a systematic review. Manual Therapy 2oo2: 7; 131-149.
17. Slater SL, Ford JJ, et al. The effectiveness of sub-group specific manual therapy for low back pain: a systematic review. Manual Therapy 2012: 17; 201-212.
18. French HP, Brennan A, et al. Manual therapy for osteoarthritis of the hip or knee- a systematic review. Manual Therapy 2011: 16; 109-117.