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  • Ref NY Times: Physical Therapy Useless?

    This piece by Gina Kolata in the NY Times caught my eye. Treat me but no tricks please. Makes some good points.
    January 7, 2010
    PERSONAL BEST
    Treat Me, but No Tricks Please
    By GINA KOLATA
    I RECEIVED an e-mail message recently from an angry doctor. He’d torn his hamstring running on a beach and spent eight weeks — a total of 20 hours — in physical therapy. Then his insurer said the physical therapy was not covered.

    He couldn’t understand it. The therapy cost $150 a session, and he said it was “clearly beneficial and cost-effective.” (He added, though, that after eight weeks he was not yet running again.)

    Hmm. I also tore my hamstring running, but my doctor never mentioned physical therapy. Instead he referred me for platelet-rich plasma, an experimental treatment that involves having my own blood platelets injected into the torn tendon. The cost, including the radiologist’s fee, an ultrasound and the plasma injection, was $2,200.

    My insurer would not pay, which made sense to me because the plasma treatment is considered experimental. It might work; then again, it might not.

    But the letter the angry doctor had received from his insurer made me wonder whether physical therapy was different from the plasma treatment. Is there rigorous evidence showing it works?

    Unlike the doctor’s insurer, my health insurance companies have always covered physical therapy for sports injuries. Yet their willingness to do so is not necessarily an indication that the therapy is effective. The orthopedists in my town seem reflexively to write a prescription for physical therapy whenever I or any of my friends go to them with sports injuries. That, of course, is no indication, either.

    When I’ve gone to physical therapy, the treatments I’ve had — ice and heat, massage, ultrasound — always seemed like a waste of time. I usually went once or twice before stopping.

    My doctor at the Hospital for Special Surgery in New York, Joseph Feinberg, seems to share my opinion. “Very often, I think the hot packs, cold packs, ultrasound and electrostimulation are unnecessary,” he said, adding, “For sure, in many cases these modalities are a waste of time.”

    So has physical therapy been tested for garden-variety sports injuries like tendinosis? Or is it just accepted without much question by people who urgently want to get better?

    It depends, says James J. Irrgang, a researcher in the department of orthopedic surgery at the University of Pittsburgh and president of the orthopedic section of the American Physical Therapy Association.

    “There is a growing body of evidence that supports what physical therapists do, but there is a lot of voodoo out there, too,” Dr. Irrgang said. “You can waste a lot of time and money on things that aren’t very helpful.”

    Sometimes, manual stretching by a physical therapist can actually eliminate a sports injury, he said. His two examples are manual stretching of the shoulder for shoulder impingement syndromes, in which the shoulder blade rubs on a major tendon, the rotator cuff, and manual stretching of the ankle for ankle sprains.

    They are the exceptions. More common are the “voodoo” treatments, he said. And what might those be? None other than ice and heat and ultrasound, Dr. Irrgang said. Also, he said, there is no evidence showing laser and release — a massage technique — to be effective in helping injuries heal.

    Ice and heat, Dr. Irrgang said, “can control pain a little bit” but “are not going to take care of the problem.” The underlying injury remains.

    When I asked Dr. Irrgang for studies showing what worked, I was a bit surprised. To put it kindly, they left much to be desired.

    Researchers would mix treatments — stretching and massage and orthotic shoe inserts, for example. If patients said they felt better, it was impossible to know why. Some of the studies involved as few as four participants. And the researchers did not always assign subjects randomly to one treatment or another to see which one worked better.

    In addition, researchers routinely failed to follow a standard method of data analysis called intention to treat. It means that when you look at results, you include even people who dropped out of your study. After all, people are dropping out for a reason. Often it is because the treatment is not helping, or is making them feel worse. Those remaining might be having a placebo effect or might be getting better despite, rather than because of, the treatment. And even if those remaining are actually being helped, when the dropouts are not counted, the treatment will end up looking better than it really is.

    It is hard to defend such work, Dr. Irrgang said. “There are limitations,” he said. “There is room for improvement.”

    To help physical therapists identify the best treatments for specific conditions and to minimize variations in practice, the orthopedic section of the American Physical Therapy Association is trying to put together clinical guidelines that assess and grade the evidence for treatments. So far, one review of evidence for treating a common sports injury — heel pain, or plantar fasciitis — has been published. Others are in the works on knee ligament instability, knee meniscus and cartilage problems, Achilles tendinopathies and low back pain.

    Dr. Irrgang was part of the group that assessed the treatments for heel pain. The doctors concluded that for plantar fasciitis, physical therapy treatments like massage, stretching and taping have little evidence to support them. There is some evidence, not particularly convincing, that stretching can provide short-term pain relief.

    But the best treatment for plantar fasciitis, orthotic inserts for your shoes, is the only one with a body of consistent (though not definitive) research behind it, and it may not even require a physical therapist. It does not even require a doctor. And, the studies indicate, off-the-shelf orthotics are just as effective as custom-made ones.

    Even orthotics, though, provide only temporary relief. There is no evidence to support the use of prefabricated or custom foot orthotics for long-term (a year) pain management or functional improvement, the review concluded.

    Dr. Irrgang, who has also been involved with the reviews that are in progress, gave a preview of some of the strongest findings.

    Stretching, he said, appears to help sprained ankles heal faster, especially if is combined with exercises — strengthening and range of motion. And studies have found that a common treatment, taping an ankle to immobilize it, may slow healing.

    There are good studies showing that Achilles tendinosis heals faster if patients do eccentric muscle contractions, like calf raises. Hamstring strains and pulls may heal better if patients do strengthening exercises.

    Why go to a physical therapist for as many as 20 sessions, though, in order to do strengthening exercises? Why not just go to a gym?

    Good question, Dr. Irrgang said. You can do exercises on your own at a gym, he said, but if you go to a physical therapist first, the therapist can do an evaluation and tell you what muscles are weak or tight, can design a personal exercise program and can teach you the exercises.

    “If you have access to a gym, you might go to physical therapy for one or two sessions, learn what to do and then return to physical therapy in a few weeks to check on your progress,” Dr. Irrgang said. “Often, you don’t need to go to physical therapy three times a week or five times a week.”

    With all that voodoo physical therapy out there, though, how can you tell if what you are getting is helping or useless?

    It’s not easy, Dr. Irrgang said.

    “You just have to be very inquisitive,” he said. “The physical therapist should be able to explain the various treatment options. You should ask about the benefits and risks, and ask what is the evidence that it will work.”

    And if the therapist can’t give you good answers, he added, you might want to rethink your choice of therapist.
    Eric Matheson, PT

  • #2
    There's a thread about this at EIM.

    My comment there in response to a PT who's apparently got her head in the sand (or some other place that doesn't get much light):

    Amy G. says: "This article left me with the feeling that so far physical therapists have made a lame attempt at advancing themselves as musculoskeletal professionals."

    The truth hurts.

    Some examples of the improving outcomes research in PT would have provided some grist to whatever argument it is you're making.

    The bottom line is that PT practice is by-and-large driven by procedural reimbursement, not results. And evidence-based practice is mostly a slogan, not a reality, in our profession. And even when it is a reality, the consistency and quality of application of evidence is spotty and effect sizes are rather small.

    We have to come to grips with the fact that the scientific maturation of our profession has been stunted by a health care delivery system- in complicity with an educational system- that doesn't value results. There is virtually no external incentive to be a quality PT.

    Irrgang is just another messenger who's under friendly fire.
    John Ware, PT
    Fellow of the American Academy of Orthopedic Manual Physical Therapists
    "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
    “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
    be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

    Comment


    • #3
      I don't disagree that we need more evidence for our interventions but there are clearly inaccuracies here. There is good evidence for PT for heel pain/plantar fasciitis and certainly of higher quality than that supporting orthotics. I'd like to see the author take on spine surgery too. Those modalities don't have much to back them up (and I don't use them) but we aren't fusing spines either.
      Jason Silvernail DPT, DSc, FAAOMPT
      Board-Certified in Orthopedic Physical Therapy
      Fellowship-Trained in Orthopedic Manual Therapy

      Certified Strength and Conditioning Specialist


      The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

      Comment


      • #4
        Interesting, however seems the writer interested in orthotics and supports it .
        It is just rest which works .
        cheers
        Emad
        :rose:

        Comment


        • #5
          I'd like to see the author take on spine surgery too. Those modalities don't have much to back them up (and I don't use them) but we aren't fusing spines either.
          I made a similar comment to James Dunleavy, our New York Chapter President, in regards to his intended reply letter. I had asked about research outcomes for chiropractic or massage therapy, specifically.

          If the author wants to make a beef about the paucity of research in physical therapy, then she'd better be prepared to look into what other professions in health care have as evidence. She'd be surprised to see that we're not bad compared to some.
          Nate Mosher, PT, DPT, SCS, CSCS
          Board-Certified Clinical Specialist in Sports Physical Therapy

          Comment


          • #6
            I wrote a little blog post about this, and about some other stuff, here: Taking Stock.
            Diane
            www.dermoneuromodulation.com
            SensibleSolutionsPhysiotherapy
            HumanAntiGravitySuit blog
            Neurotonics PT Teamblog
            Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
            Canadian Physiotherapy Association Pain Science Division Facebook page
            @PainPhysiosCan
            WCPT PhysiotherapyPainNetwork on Facebook
            @WCPTPTPN
            Neuroscience and Pain Science for Manual PTs Facebook page

            @dfjpt
            SomaSimple on Facebook
            @somasimple

            "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

            “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

            “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

            "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

            "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

            Comment


            • #7
              I'd think that most of you on this board would be happy to see an article like this, because it is critical of traditional PT in the U.S. Then again, we have no idea what Dr. Irrgang, a researcher in orthopedics, would think is "voodo".

              But in our society, it does seem like PT, in many departments, has been given a free pass. As the author mentioned, orthos "seem reflexively to write a prescription for physical therapy" for sports injuries. I don't think PT is questioned much by the public.

              I've come across many people who have politely told me they don't believe in chiropractic, I've never heard anyone say the same of PT. I realize that old-school chiropractic philosophy and dogma are a big reason for skepticism.
              Brian Allen, DC, ART, CSCS

              Comment


              • #8
                You can find another article by Gina Kolata in this thread.
                "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

                Comment


                • #9
                  Old discussion

                  Hello Forum,

                  This is actually an old discussion. In the Netherlands it started in the 90ies, with a couple of medical doctors writing an article with the title "1,3 Million dutch a year think physiotherapy works". It was actually an article about ebm in physiotherapy. Since then a lot has changed in public. Courses are now called evidence based, our colleques did courses in EBM, first contact management etc. But still there is a lot of voodoo around, probably because (just like patients) some therapist aren´t able to work in a scientific, logical paradigma and need a magical, illogical one.
                  To the article: I personally think that the active role of the physiotherapist in the healing of a muscle tear, sprain or strain is very limited. In animals these injuries heal very well without the need of a therapist. Humans though, are often hindered in their healing by false behaviour, caused by the surroundings (workplace, sportcolleaques etc.) or false cognitive processes and choose wrong paths in healing. Therefore, I think, our actual role in sportsinjuries is a coaching one. Our specific knowledge can lead the patient on the right healing paths and accompany him until full recovery.

                  Geert

                  Comment


                  • #10
                    Sports injuries aside, there is ample evidence that physical therapy provides low cost and low risk interventions that compare favorably or are superior to more risky and invasive options offered by others in the health care system.
                    I hate therapeutic ultrasound too, but let's not even pretend PT expenditures are even a drop in the bucket compared to all the waste out there.
                    The article is true about unproven modalities, but almost irrelevant and misleading in the context of the greater health care system issues.
                    John Ware did a great job on the ToTheCenter site responding, and the physician author, to his credit, appeared to back down somewhat from his position when he got the reaction he did and appeared honestly interested in learning more. Hopefully he comes here and learns some more...
                    Jason Silvernail DPT, DSc, FAAOMPT
                    Board-Certified in Orthopedic Physical Therapy
                    Fellowship-Trained in Orthopedic Manual Therapy

                    Certified Strength and Conditioning Specialist


                    The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

                    Comment


                    • #11
                      ...the physician author, to his credit, appeared to back down somewhat from his position when he got the reaction he did and appeared honestly interested in learning more. Hopefully he comes here and learns some more...
                      He just accused me last night of "ad hominem attacks on my intelligence" because I told him that he's clueless about the profession of physical therapy. My assessment of his knowledge of PT was based on his own description of a typical PT visit for ankle sprain:

                      The visits will include ice massage, heat, instruction in stretching and exercising and expert evaluation of the injury.
                      In addition to being rather dated and simplistic, he's committed a gross error of omission here by leaving out what are likely the most common treatments for such a condition, including manual therapy, gait/assistive device instruction, bracing/taping.

                      It's actually rather silly that he even used ankle sprain as an example, since it is a such a minority of the conditions that most PTs treat on a daily basis in outpatient clinics, where apparently all of this massive fraud and over-utilization is occuring.
                      John Ware, PT
                      Fellow of the American Academy of Orthopedic Manual Physical Therapists
                      "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
                      “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
                      be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

                      Comment


                      • #12
                        Was that ToTheCenter thing a live phone-in or something, or is it a web event with a link? If there is a link, could someone bring it? I'd love to read the interchange.

                        I went through the comments - overwhelmingly favorable to PT - reassuring. Nice opportunity for the PT profession to see some unsolicited, spontaneous feedback.
                        Diane
                        www.dermoneuromodulation.com
                        SensibleSolutionsPhysiotherapy
                        HumanAntiGravitySuit blog
                        Neurotonics PT Teamblog
                        Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
                        Canadian Physiotherapy Association Pain Science Division Facebook page
                        @PainPhysiosCan
                        WCPT PhysiotherapyPainNetwork on Facebook
                        @WCPTPTPN
                        Neuroscience and Pain Science for Manual PTs Facebook page

                        @dfjpt
                        SomaSimple on Facebook
                        @somasimple

                        "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

                        “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

                        “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

                        "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

                        "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

                        Comment


                        • #13
                          This just in: Newer Treatment for Achilles Tendon Disorder Does Not Appear to Be Effective

                          ScienceDaily (Jan. 13, 2010) — An apparently increasingly used treatment method for a type of Achilles tendon disorder that includes injection of platelet-rich plasma into the tendon does not appear to result in greater improvement in pain or activity compared to placebo, according to results of a preliminary study published in the January 13 issue of JAMA.
                          Diane
                          www.dermoneuromodulation.com
                          SensibleSolutionsPhysiotherapy
                          HumanAntiGravitySuit blog
                          Neurotonics PT Teamblog
                          Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
                          Canadian Physiotherapy Association Pain Science Division Facebook page
                          @PainPhysiosCan
                          WCPT PhysiotherapyPainNetwork on Facebook
                          @WCPTPTPN
                          Neuroscience and Pain Science for Manual PTs Facebook page

                          @dfjpt
                          SomaSimple on Facebook
                          @somasimple

                          "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

                          “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

                          “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

                          "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

                          "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

                          Comment


                          • #14
                            Here's the link to the "ToTheCenter" discussion on PT and health care costs.
                            John Ware, PT
                            Fellow of the American Academy of Orthopedic Manual Physical Therapists
                            "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
                            “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
                            be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

                            Comment


                            • #15
                              Who-ee John, glad you're on our side.
                              :thumbs_up
                              Diane
                              www.dermoneuromodulation.com
                              SensibleSolutionsPhysiotherapy
                              HumanAntiGravitySuit blog
                              Neurotonics PT Teamblog
                              Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
                              Canadian Physiotherapy Association Pain Science Division Facebook page
                              @PainPhysiosCan
                              WCPT PhysiotherapyPainNetwork on Facebook
                              @WCPTPTPN
                              Neuroscience and Pain Science for Manual PTs Facebook page

                              @dfjpt
                              SomaSimple on Facebook
                              @somasimple

                              "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

                              “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

                              “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

                              "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

                              "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

                              Comment

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