Are physical agents the same as rehabilitation? (Letters to the Editor).

To the Editor:

As dedicated advocates of evidence-based practice, we were both alarmed and disappointed following our reading of the Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions in the October 2001 issue of Physical Therapy. (1) We are concerned that based, on this special issue of the Journal, the vast majority of clinicians, payers, and regulatory agencies will view physical therapist practice as only a collection of physical agents with a little therapeutic exercise thrown in for good measure.

It would appear that a purpose of the selection criteria for studies evaluated by the Philadelphia Panel members was to a priori exclude the very interventions that have some demonstrated efficacy in the treatment of musculoskeletal disorders, in particular manual therapy (manipulation/mobilization). The relative uselessness of most physical agents as stand-alone interventions is well established, and it would seem to be a tremendous waste of resources to further study these interventions and ignore interventions that are used by physical therapists and that have some documented efficacy, such as manipulation. The Guide to Physical Therapist Practice (2(pp118-119)) clearly outlines manual therapy techniques (including mobilization/manipulation) as procedural interventions used by physical therapists. Unfortunately, these interventions were excluded from consideration. If we included these interventions as part of our practice, why were they excluded from this systematic review? Were these interventions excluded because there is a "sufficient body of knowledge supporting their use or less frequent use"? (1(p1631))

The Philadelphia Panel members never explicitly stated the reason for this omission in the methods section. As faculty members in programs grounded in an evidence-based practice framework, we routinely teach and test students on mobilization and manipulation skills used in physical therapist management of musculoskeletal problems, particularly those with demonstrated efficacy in the management of spinal and extremity disorders. (3-7) We can only assume the reason that these forms of rehabilitation were noticeably absent from this series was because a sufficient body of knowledge exists. However, many Journal readers may not be familiar with this evidence. Consequently, we are concerned that this issue of the Journal will provide more than ample opportunity to further reduce our profession from one that provides a wide range of rehabilitation strategies based on a thorough examination of our patients to a profession that applies a few physical agents.

The Guest Editor of this special issue previously stated:

   Over the past 10 years, for example, we have seen some very compelling
   evidence supporting manipulation for patients with acute LBP [low back
   pain], yet manipulation is used by physical therapists in typical
   outpatient settings at a lower-than-expected rate.... What seems to be
   incontrovertible is the fact that evidence exists to support the use of
   certain treatment procedures for patients with LBP and, like other health
   care professionals, physical therapists' behavior, in many instances, does
   not comply with such guidelines. (8(p706))

Evidently, we should add that panel members' and editors' behavior, in many instances, does not comply with such guidelines. Is it little wonder that physical therapists use these interventions at lower-than-expected rates when our own reviews fail to include these interventions?

In closing, as advocates of evidence-based practice, we must stress that we strongly support critical appraisal of the literature, the use of a hierarchy of evidence for making treatment decisions, and the need to summarize evidence into practice guidelines. (9) It is for these reasons that we are disappointed that the Philadelphia Panel reviews deliberately ignored treatments such as mobilization and manipulation that have been shown to be efficacious in certain disorders and instead focused on other treatments whose relative uselessness is fairly well established. It is difficult to promote the increased use of treatments such as manual therapy that are supported by evidence within the profession when our professional journal publishes practice guidelines that appear to indicate that such treatments are not a part of our practice. Montori and Guyatt (10) have provided an excellent framework for identifying bias in systematic reviews, including the criteria for inclusion and exclusion of primary studies, and we would encourage the Journal readership to seek out this source for more information. The Philadelphia Panel guidelines provide an excellent example of professional bias in the literature against certain treatment approaches. Therefore, we will accept Dr Rothstein's and Dr Delitto's challenge to discuss this in the classroom and the clinic.

References

(1) Philadelphia Panel Evidence-Based Clinical Practice Guidelines on Selected Rehabilitation Interventions. Phys Ther. 2001;81:1620-1730.

(2) Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:9-744.

(3) Bang M, Deyle G. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;30:126-137.

(4) Bigos SJ, Bowyer O, Braen G. Acute Low Back Problem in Adults. Clinical Practice Guideline No. 14. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service, US Dept of Health and Human Services; 1994. AHCPR Publication No. 95-0642.

(5) Bronfort G, Evans R, Nelson B, et al. A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine. 2001;26:788-797.

(6) Deyle GD, Henderson NE, Matekel RL, et al. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med. 2000; 132:173-181.

(7) Hurwitz EL, Aker PD, Adams AH, et al. Manipulation and mobilization of the cervical spine: a systematic review of the literature. Spine. 1996;21:1746-1759.

(8) Delitto A. Clinicians and researchers who treat and study patients with low back pain: are you listening? Phys Ther. 1998; 78:705-707.

(9) Guyatt G, Haynes B, Jaeschke R, et al. Introduction: the philosophy of evidence-based medicine. In: Guyatt G, Rennie D, eds. Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. Chicago, Ill: AMA Press; 2002:3-12.

(10) Montori V, Guyatt G. Summarizing the evidence: publication bias. In: Guyatt G, Rennie D, eds. Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. Chicago, Ill: AMA Press; 2002:529-538.

Timothy W Flynn, PT, PhD, OCS,
FAAOMPT
Associate Professor and Director
US Army-Baylor University Graduate
Program in Physical Therapy
3151 Scott Rd
San Antonio, TX 78234

Julie Fritz, PT, PhD, ATC
Department of Physical Therapy
University of Pittsburgh
Room 6035, Forbes Tower
Pittsburgh, PA 15260

Robert S Wainner; PT, PhD, ECS, OCS
Assistant Professor
US Army-Baylor University Graduate
Program in Physical Therapy

Julie Whitman, PT, OCS, FAAOMPT
Associate Graduate Faculty
US Army-Baylor University Post-Professional
Doctoral Program in Orthopaedic and
Manual Physical Therapy
Brooke Army Medical Center
San Antonio, TX 78234