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Editor's Notes |
jules-rothstein@attbi.com
Whether through neglect, incompetence, or perhaps even a conspiracy worthy of an Oliver Stone movie, our profession has been done irreparable harm by those who don't understand who physical therapists are and what physical therapists do. The problem arises out of our failure to differentiate our profession from our interventions, a problem that is compounded by those who, by accident or by intent, prefer to advance themselves or their own groups rather than the profession as a whole. We are physical therapists, but there are those among us who would prefer to be called, for example, manual therapists, certified NDT therapists, certified McKenzie therapists, chest therapists...
A recent example will help me illustrate the problem. The May 21, 2002, issue of the Annals of Internal Medicine1 contained an article entitled "Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain: A Randomized, Controlled Trial." When last I checked, manual therapy was an intervention offered by physical therapists, and that is exactly what occurred in this study. How the authors—who included physical therapists and other people who are knowledgeable about physical therapy—missed this point is beyond me. They do, however, have a lot of company when it comes to using sloppy titles and, to some extent, sloppy research designs.
In this study—which showed some efficacy for what the authors called "manual therapy" and, to some extent, for other treatments—two forms of physical therapy interventions were compared. From the title, however, the reader might get the impression that manual therapy and physical therapy are mutually exclusive. Because of their misleading title and discussion, the authors (and the journal) served neither science nor the health care system. Just imagine if a physician had submitted an article entitled "Appendectomy, Surgery, or Continued Care by a General Practitioner for Patients With Appendicitis: A Randomized, Controlled Trial"!
A particularly quirky part of the research reported in the Annals article dealt with something that the authors called "physical therapy," but which was really just an amalgam of interventions consisting of exercise, stretching (traction), and massage—all offered, with no discernible logic or rules guiding treatment, by therapists who were not approved by the Netherlands Manual Therapy Association. The manual therapy patient group, meanwhile, received care from people who had been previously "blessed" by that association. We never found out what would have happened had the noncertified therapists been allowed to deliver manual therapy. We also never found out whether the noncertified therapists had levels of experience similar to those of the certified manual therapists.
In describing their interventions, the authors were as clear and informative as a Mafia don testifying before the US Congress. They said that they used an eclectic approach based on the work of Cyriax, Kaltenborn, Maitland, and Mennel. As a physical therapist, I have no idea what was done in this study. Some of these folks strongly disagreed with one another—and that is putting it mildly.
This article (and many others like it) shows that some editors and authors do not appreciate the difference between the name of a profession and the treatments rendered by members of that profession. There were two sets of treatments that could have been characterized as falling under the purview of any well-trained physical therapist. We may discuss surgical and nonsurgical approaches when it comes to patient management, but the discussion would be silly if the participants didn't understand the nature of the surgery and the specifics of the alternate forms of care.
The proper use of terms—such as "physical therapy techniques" rather than "manual therapy" or even "physical therapy"—would have been in line with the new Medical Subject Headings (MeSH) developed for MEDLINE (www.nlm.nih.gov/mesh/replaced2002.html).
As an editor, I believe that sloppiness in the literature is growing. Only the most perceptive and diligent of readers, health care policymakers, and payers will note what might as well be considered the fine print of many articles—that is, the information that deals with the nature of a treatment, as opposed to the name of a profession.
Until the Annals article, my best example of misrepresentation came from an article in Lancet entitled "Effectiveness of Active Physical Training as Treatment for Long-Standing Adductor-Related Groin Pain in Athletes: Randomised Trial."2 The authors described what they called a "physiotherapy group," which received—as best as I can determine—laser, friction massage, stretching, and transcutaneous electrical nerve stimulation (TENS). These interventions seem to have been applied in an unsystematic fashion, and their use did not seem to be based on examination data. Apparently, random assignments to groups wasn't the only aspect of this study that was random.
In the discussion, the authors state: "We found that treatment of long-standing adductor-related groin pain with an active programme of specific exercises aimed at improving strength and coordination of the muscle acting on the pelvis was significantly better than a conventional physiotherapy programme." These authors, who were Danish, characterized these almost randomly applied interventions—masquerading as physical therapy—as "conventional." This characterization left open the possibility that there are other interventions that also could be provided by physical therapists. But the authors omitted the fact that the alternative to what they called "physiotherapy" is, in most parts of the world, probably the most likely intervention that a physical therapist would offer. Here again, two treatments were offered—both of which are within the practice and expertise of physical therapists.
I could cite many more articles to illustrate my point. For some of the articles in which physical therapy is considered nothing more than a collection of thermal, electromagnetic, and electrical modalities and techniques that are no more sophisticated than massage, the problem lies with national differences. However, these differences alone cannot explain the misrepresentations. That's because, in much of the world, physical therapists select from a wide variety of interventions based on the use of scientifically investigated measurements and on the evaluation.
APTA's Guide to Physical Therapist Practice,3 which was developed by US physical therapists and has worldwide reach and influence, clearly describes who physical therapists are and what they do:
Every national body has a right to its own view of what physical therapy is, but I doubt that any practice document differs from the APTA document so radically as to state: "Physical therapy and physiotherapy are a bunch of modalities offered in a semi-random fashion, and the name of the profession is synonymous with the treatments rendered."
With the compliance of physical therapists, two otherwise excellent medical journals have published confusing papers that misrepresent the questions being studied. More importantly, what these studies refer to as "physical therapy" amounts to worst-case practice—if it is physical therapist practice at all. The time has come for members of the physical therapy profession throughout the world to stop using the name of our profession as though it were synonymous with our treatments. In addition, we need to examine interventions with the specificity that makes our research worthwhile and applicable. Surgeons perform surgery, whereas physical therapists provide physical therapy; but in any meaningful discussion, we need to consider the specifics of the treatment, including how we select interventions and how we examine our outcomes. This is especially true when we conduct clinical trials.
Authors and editors can help by avoiding titles that only confuse and cause chaos. You may have been trained as a manual therapist—or as an NDT therapist or a McKenzie practitioner—but first and foremost, like other health care practitioners, you are a member of a profession. Just as there are surgeons who specialize in certain techniques, there are physical therapists who specialize in certain techniques; in either case, we are talking about the repertoire that people can offer their patients—not the creation of an entirely different professional.
References
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