Awful Physical Therapy Article in the New York Times

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The past several days have been interesting!  If you haven’t heard yet, the New York Times published an article on physical therapy that was not very positive, questioning the efficacy of our profession.  The article goes into detail asking why not just go to a gym rather than physical therapy?!  The author did a terrible job with the article and took a very small sample and total blew it our of proportion.

This has created a large stir, obviously and rightly so, within our profession.  Many of you have emailed me and I have already been in many email chains with people around the country discussing.  If you haven’t read it, here is the link to view the article:

http://www.nytimes.com/2010/01/07/health/nutrition/07best.html

The disappointing aspect of the article is that Dr. Jay Irrgang in Pittsburg was quoted throughout the article and his comments did not help defend our profession, maybe even hurt it a little bit!  Also, don’t forget that Dr. Irrgang is the current president of the Orthopedic Section of the APTA.

To defend Dr. Irrgand, who is a great contributor to our profession, participated in an email chain with myself and many other notable therapists in the country.  His response clearly expressed disappointment in the author of the article and her attempts at manipulating his comments etc.  He was initially asked a simple question:

Are there randomized controlled trials for physical therapy for sports-related injuries such as tendinosis?

His response was clear and accurate:

There are randomized trials to support interventions that are commonly used by physical therapists for the treatment of tendinosis including the use of eccentric exercises.

Apparently, he was not completely aware of the intent of the article and was just answering interview questions that seemed simple at the time.  However, all of his responses were not included and his comments were cherry-picked to create the illusion of what the author was trying to relay.  Dr. Irrgang even sent me the list of references that he provided to the author showing the efficacy of physical therapy for various treatments like impingement, patellofemoral pain, ACL reconstruction, etc.  It appears, as usual, that the author manipulated Jay to convey the story the way she wanted it to appear!

There was a large amount of reader comments (182) that were mostly positive regarding the profession, some even saying that “physical therapy saved my life.”  There are also many PT’s that were able to comment and defend.  But interesting enough the New York Times stopped allowing comments to the article.  This is disappointing as articles like this do not do our profession justice.  We should at least have the right to discuss.  Isn’t that what the internet is supposed to be about in 2010, online discussion and collaboration?

Don’t get me wrong, there are likely lousy therapists in this world, just like there are lousy people in every profession, but we can not simply define our profession by one bad experience. 

 

What is the Take Home?

Articles like this really motivate me to continue promoting evidence-based medicine.  Don’t get me wrong, I too get sick of the extreme evidence-based clinicians that will only perform treatments that have published scientific efficacy.  This is an extreme and our profession is a balance of art and science.  Let’s be honest about that.  But negative perceptions within the media about physical therapy being a waste are likely true if you are just treating your patients with heat, ultrasound, ESTIM, and ice.  This is NOT physical therapy!  I would be naive to say that this does not happen, but this is the exception not the norm!

So let this be your motivation, if you find yourself falling into the grind and relying on modalities (for example) for your treatments, stop and think about what else you could be doing.  If you are one of these clinicians, question the efficacy of what you are doing.  Ask “why?”  Read more, pick up a new book or journal, go to a CEU course or anything else to stimulate your brain.  We are all better than that and as I always say in my presentations, we are not just clinicians, we are scientists.  Act like one.

Unfortunately, “clinicians” like this probably aren’t reading this website…

28 replies
  1. charles
    charles says:

    Really–you all are standing up for what you do?

    Most of you treat multiple patients at a time. Oh yes EBR–as you put them on the nustep for 15 minutes to “warm up” –every patient

    Most of you continue to treat the “chronic pain patient” which is usually the chronic obesity or anxiety ridden patient that you cannot solve–and neither can I.

    Most of you have no sense of ethics–you conform to the manager and the productivity expectations.

    For most of you, you are glorified athletic trainers–except the trainer actually sees people one on one.

    Our profession has become a joke–and a bad one at that. Don’t like my comment? Then ask yourself if you are one of the above scenarios. Because in my 18 years exp 80% of you are.

    Cheers and enjoy that debt, Doctors

  2. Brad Hogenmiller
    Brad Hogenmiller says:

    I'm curious if the original author was shooting for controversy to generate readers or really lost faith in physical therapy through her own experiences.

    This just shows how much bloggers and other online media professionals can 'stir the pot' by bending the rules of journalistic integrity. It also shows how much of an effect one bad experience can cause in the wrong hands.

    Scary stuff!
    -Brad (@SPOTonChicago)

  3. Mike Reinold
    Mike Reinold says:

    Thanks for joining in David, appreciate your perspective. I'm not saying to use this as an excuse to not challenge yourself, but realistically I do many effective things each day that are not backed by evidence. Are you suggesting that we avoid anything that doesnt have evidence?

    Problems I have with basing too much of our profession on evidence:

    1. It is impossible to control studies to determine much of our evidence. We cant put humans in cages and have them just do knee extension for 6 weeks and see if this increases quad strength. Why do you think there is no good study on rotator cuff rehab after surgery, control is inadequate. This will always be a problem.

    2. The way that an exercise or technique being performing in a study may differ from how I perform it. Let's be honest, just because it is published doesnt mean it is perfect. Maybe the person doing the joint mobilization in the study was doing it wrong?

    3. Along the lines of the last comment, many published studies have methodological flaws that make their results difficult to assess. Do you really think that a patient not going to PT after ACL reconstruction will do as well as someone who does? I can find an article to state this, if you want. But we all know it isnt true, the methods/control was poor and their definitions of outcome was subjective.

    4. Much of the research in our field is being done by people that do not treat patients. Is this as valid as it could be?

    I agree we need to continue to make strides and we must all challenge ourselves to ask "why" and to base as much of our practice on evidence as possible. But if I continue to get good results with techniques in my hand (and thats the key point) then I will continue to perform them. Until I publish (and you and everyone else) a study documenting the efficacy of MY techniques in MY hands on every technique that I do, then anything else isn't the same. Ask Brian Mulligan about this – not much efficacy but outstanding results. What does the patient want more results or research? That is the blend of art and science. There is room for it both in our profession and those that offer this blend will set themselves apart.

    Thanks again for adding to the discussion, I see your points and agree with you, just caution to not take efficacy too far. It is important and needed, but until everything is proven/disproven we have to make judgement decisions.

  4. David Logerstedt, PT
    David Logerstedt, PT says:

    Although the article doesn't paint a great picture of physical therapy, Christine made some valid points.

    And I have to disagree with you, Mike. Our profession shouldn't be a balance between art and science. Continuing to think of physical therapy of art and science can only delay our profession in developing a science based approach. Many therapists continue to use this logic to justify the use of therapies that have no scientific basis for their use. However, because our profession does not have a large amount of evidence to justify many of our treatments,including exercise (see Cochrane reviews and clinical practice guidelines in JOSPT), therapists do need to rely on clinical judgment when treating patients.

    I can't agree more that our profession as a whole needs a swift kick to expand the literature regarding the justification of PT and changing conceptions about what PTs do. Walter points out that many physicians have a misconception of PT. We should be pointing the finger at ourselves for where we are.

  5. Craig Liebenson, D.C.
    Craig Liebenson, D.C. says:

    The real challenge would be for PTs & DCs to show their worth. Many personal trainers are ill-informed,zealously believe in a "boot camp" approach & think they can treat patients. Obviously, clinicians are trained to rule out Red Flags & make appropriate referrals. Yet, we are in a topsy turvy world when PTs & DCs in the trenches are overutilizing passive modalities and fitness specialists who sometimes actually do know their limits are getting patients out of pain faster than the clinicians.

    The challenge is for the clinical world to put active self-management above dependency producing passive approaches. And, to prove that supervised training is superior to self-management. Anne Mannion showed it is not. Others have shown a rule for supervised care. The NY TImes article is simply highlighting the controversy & putting a challenge before any health care clinic that offers care programs that don't live up to the W.H.O.'s mandate that we promote INDEPENDENT FUNCTION.

    Thanks,
    Craig

  6. Kory Zimney, PT
    Kory Zimney, PT says:

    Great comments everyone. I just wanted to bring up another angle to consider. Is that when you talk to the media often times your comments and intent may not come out in the print version as you would hope. Talking the media is a great way to get info out to consumers about what we do, but we need to work to make sure it is the message we want to get out.

    I great tip I learned from a communication specialist at a hospital I worked at was make sure you have one or two points you want to deliver when talking to the media. And do everything to frame that message with almost every answer you give. Just a tip that has helped me when I do interviews with the media for different items about PT. When I work hard to frame my one or two point message, there is less chance of comments being taken out of context. The media person is looking for a story, it is our jobs while getting interviewed to frame that story the way we want it, not the way they might want it.

    Also it is helpful to get to know the people that might interview you. I think we can learn from those in the sports profession. If you want the media to put you in good light it is better to be on their good side. I think we have seen athletes that aren't friendly to media, often get a pretty ugly slant put on them by the media.

  7. Trevor Winnegge
    Trevor Winnegge says:

    Christie-
    love the going over the word limit. shows how passionate you are on this topic!!!!! I think healthcare pricing in general-not just PT-is a mess. Look at equipment we use-20 bucks for foam, 16 for a stretch out strap that looks like a dog leash that costs a dollar, 120 for bosu, 30 for ball, etc. now, i happen to love these products but they are overpriced. and dont even get me started on braces/orthotics. i agree-we could spend another week discussing all of these pricing issues in healthcare and PT!!!

  8. amy castillo
    amy castillo says:

    The APTA has embarked on a journey to address this disconnect between research and practice that is highlighted in the article.

    The December conference : Vitalizing Practice Through Research and Research Through Practice, was a formal step in the right direction. The webpage is open to all APTA members to view its content.(see below)

    A strategic plan will be emerging in the near future through the Journal and national conferences. I think it is important that all PTs work with our professional organization to move us all forward.

    http://www.apta.org/AM/Template.cfm?Section=Letters1&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=67119

  9. Mike Reinold
    Mike Reinold says:

    Great comments everyone, thank you all for discussing and please continue to do so.

    I think we all agree that the article painted a poor, but sometimes true, perspective of all of the medical community – PTs, DCs, MDs, etc.

    The analogy I think of is simple – I think the new Jersey Shore televison show on MTV is awful, and when i mean awful, i feel like our nation is taking a giant step back. But I dont say that TV stinks, I say that this one specific show stinks.

    As a consumer – If you have a bad experience with a PT (or DC, MD, etc), go to a different one and this time do your homework on the level of care you may receive. Don't swear off the entire profession. I've changed dentists 3 times in the last decade for the same reason, but I still see the benefit of dentistry!

  10. Christie Downing, PT, DPT, Dip. MDT
    Christie Downing, PT, DPT, Dip. MDT says:

    ….Trevor…that was the first time I've ever been subjected to a word limit on here…I'm sure it exists for a reason, but I certainly violated it.

    …for the record, there's nothing at my facility where I can charge someone for $150 for 15 minutes of care…I was comparing the cost of a 30-60 minute treatment ($150 upwards) versus a 15 minute treatment. Oh, wait…I think we charge nearly $150 for e-stim (yes, I work for a hospital based facility)…not that we would ever get reimbursed that. But pricing in PT is a story for another day. Ms. Kolata might have something to say about that too….

  11. Brian O'Neil, PT
    Brian O'Neil, PT says:

    Mike, thanks for posting Dr. Irrgang's original responses. When I first read the article I had a feeling some of his comments were taken out of context.

  12. Walt Lingerfelt, DPT
    Walt Lingerfelt, DPT says:

    (continued from above)

    ,there needs to be more confidence in the rehabilitation professional which obviously, at times, can be mistaken for a personal trainer.

  13. Trevor Winnegge DPT,MS,OCS,CSCS
    Trevor Winnegge DPT,MS,OCS,CSCS says:

    wow-what a debate.Christie is obviously passionate in her argument-could be the first time I have seen a post to be continued!!!! haha. Christie-I ask if you think it is right to have someone pay 150 dollars for 15 minutes of care????? that said, i agree with a lot of your points. PT does need to be more evidence based across the board. While more clinical research would certainly help, what I mean by this is therapists need to be more aware of evidence out there. This goes along with what Mike says. we have all worked with PT's who do PT to collect a paycheck, earn their living, then go home and play with their kids, friends, or family. That is ok, but they need to keep up to date on literature and grow professionally. I recently gave a lecture on current post-operative shoulder treatment protocols to a bunch of complacent, middle aged therapists, at the request of a surgeon I work with. He felt if he was going to be sending some of his post operative patients out to this clinic, he wanted everyone in the clinic on board with his approach. When the lecture was over,one woman raised her hand and said "i will never use these protocols-they are too aggressive." For the record-the protocols were the wilk/reinold shoulder protocols that I use daily. Two other therapists then said they agreed and dont feel comfotable performing rhythmic stabilization that early, or doing any of the advanced exercises. translation-MHP, massage, rom, the same 4 theraband exercises, estim/ice. It was sad, and disheartening. When I informed the surgeon of the way it was received he stopped reffering patients to that clinic. The bottom line is doctors are constantly tweaking how they operate on patients. Newer surgeons continue to push the envelope with new surgeries and aggressive protocols. We all have to keep up with it. This website helps with that but reading journals, attending CEU's and conferences, and having clinical dialogue with colleagues helps to stimulate this process. Our profession needs more PASSIONATE scientists, not scientists looking to just collect a paycheck. Unfortunately this woman saw a PT who didn't have that fire inside for their profession, and it has been exposed. it is a good ick in the pants for some complacent PT's toget out of their rut and start being creative!

  14. Harrison Vaughan, PT, DPT, Cert. SMT
    Harrison Vaughan, PT, DPT, Cert. SMT says:

    Mike and all,
    I love the intensity! This is what we need as a profession…practitioners to stand up and defend what we do. I agree with you, Christie and others that we do not and should not depend on these ridiculous claims of relying on modalities as our treatments. I have heard of some clinics offering everyone US, heat/e-stim & massage no matter what. It is out there unfortunately and disgusts me.

    As far as evidence-based practice…honestly you'll and I know if we only practiced it, then we will be out of jobs. Its just not backing what we see on a daily basis and easier said than done.

    However, we are all clinicians here who practice "evidenced-informed". This is a term that I hope we all get and use, rather than "evidenced-based". Meaning, we know what the research says, how to relay it to daily practice and offer our best professional advice to patients. But, it may not state it in a respected journal. This should come as our profession grows (remember we're still young).

    The author picked on a select few of our peers. There are good and bad apples out there. She chose the ones that have fallen to the ground. Lets bounce back with a vengeance and prove our profession.

    Harrison
    http://intouchpt.wordpress.com

  15. Walt Lingerfelt, DPT
    Walt Lingerfelt, DPT says:

    I think Christie makes valid points above. However, I think that some of the points that were made were somewhat out of frustration w/ some clinicians in the field (rightfully so) instead of what the author was actually depicting. I assume that the author wrote the article out of her own frustrations w/ past PT Rx's that she has had. She specifically mentions ice and heat, massage, and US. Obviously, the evidence is very porous for each of the aforementioned modalities, frankly for ANY disorder/pathology. So what she does, as Mike mentioned, is take the treatment methods of one individual or a few and tries to define the profession as a whole. I'm not sure about the percentages, but I would venture to say that the vast majority do not practice in such a way. I rarely use US (only to heat tissue for elongation), never use massage, and heat and ice only as an adjuct (usually at the end of Rx-unbilled). In addition Ms. Kolata began trying to examine a few isolated research articles, then attempted to explain the intention to treat concept-something she likely does not fully understand (side note- Do you think Ms. Kolata really understands even basic reserach methodology). Let's face it, there are poor research articles, such as those described in her article, in medicine, psychology, biology, etc.. It takes those w/ a greater understanding of research to actually understand and know that they ARE poor articles!
    I am also disappointed in Dr. Irrgang's conceptions. Not particularly of his comments in the article, but just a pure lack of understanding of what WE (as a profession) actually know and understand about the neuromusculoskeletal sciences of the body that, in all honesty, most orthopedic/neuro surgeons share. How many times have you gotten an order for xxx diagnosis and under it instructions for stretching and stregthening? Really, does it take 3 years of full time post graduate work to learn how to stretch/strengthen whatever? Kind of sad that is the general concensus from the MD/DO realm, but in my observations, it is very true. This discussion could go on forever, but enough for now. Again, good points Christie…I very much understand where you are coming from, but Mike I have to agree w/ you-total misconception of our entire field! Especially w/ the field moving toward a doctoring profession.

  16. Craig Liebenson, D.C.
    Craig Liebenson, D.C. says:

    Mike,
    I don't have the same reaction as the other DCs or even PTs who are miffed at Dr Irrgang. I feel this will drive patients to "evidence-based" NMS health care providers. Peddlers of prolonged passive care programs are bilking the public. The article's main point is that active self-care is the GOLD STANDARD treatment. Dr Irrgang was the 1st one I know who showed how to utilized the serratus punch or push-up w/ plus type manouvre for shldr impgmt. He walks on water in my world.

    This article can only help anyone who would enjoy your inspiring message too.

    Craig

  17. Geoff
    Geoff says:

    Mike

    I agree with Greg. Us chiros get tarred with the same brush all the time and unfortunately in this article so are PTs. Of course there are crappy practitioners out there but that goes for all professions, DC, PT, MD, DO, ND….etc etc.

    In reality, I find that the majority of each of the above professions are very basic and rarely do anything to enhance their abilities, instead just bash each other to make themselves seem superior. It is a sad commentary that everyone cant work together for better patient outcomes.

    On a side note, thank you for the articles and blogs you post…I have found them to be both informative and applicable. Keep up the great work.

    Cheers

  18. Christie Downing, PT, DPT, Dip. MDT
    Christie Downing, PT, DPT, Dip. MDT says:

    4. She reiterates to us something that is hard to hear, but that we all know…we need more research; and yes, she does highlight some of Dr. Irrgang's comments about areas where we do have solid evidence, so we cannot criticize her for totally disregarding where we do have appropriate care guidelines. We, as therapists, have to learn to take this criticism as critical, constructive feedback. In my opinion, PTs get way too defensive about feedback and have to learn how to take it and use it constructively. In the end, her skepticism is healthy for not just her, but also our profession.

    5. There are definetely cases where prolonged therapy is required and certainly, I don't think Ms. Kolata would dismiss that, nor would I. However, we've got to wake up to the fact that we do have an overutilziation problem in our field. Some of it is our fault, however, I think a lot of it is multifactoral and due to cultural issues of both patient perception and the ever present paternalistic culture that physicians still play in our field. I've highlighted these concerns in a comment to a retired surgeon here:

    http://tothecenter.com/index.php?readmore=12098&c_start=0

    I am csptqt.

    In the end, Mrs. Kolta gave many of our colleagues just what they need…a good swift kick in the pants. We learn nothing by being complacent, but will grown as we respond to feedback.

  19. Christie Downing, PT, DPT, Dip. MDT
    Christie Downing, PT, DPT, Dip. MDT says:

    I'm actually one person who thought that the article actually made some excellent points and I agreed with her on many. Surely, there are some obviously sematical flaws and some of the comments are obviously hand picked; however, here is what I found beneficial about the article:

    1. She was skeptical about some of the treatments she was receiving…namely US and e-stim. So she researched it by talking to both an orthopedist and Dr. Irrgang. Skepticism is healthy for out profession. I commend her for taking the time to question what she was being given…more patients need to do the same

    2. She exposed to the public the fallicies of some of the treatments that many of our patients still request, if not demand…and sometimes we give in rather than loose the client…no matter how much education we give them. The public has now had it put out in a medium that is available for them to read at their own level rather than hidden in a journal which requires priveldged access.

    3. Certainly going to the gym and physical therapy is not the same thing, but there are many, many cases where a PT clinic is being treated like a gym. Someimes due to stage of healing, precautions, or the level at which the patient is functioning, they are on a good program, but just simply need a place in which to execute it and give it TIME to heal. Sometimes the most cost effecient way to execute this is not in the PT clinic, it's in the home or a gym. For those who have such access and have such an ability to complete the program independently, why do so many PTs still coddell their patients by bringing them into the clinic (and then the patient still often does the same exercises at home)? How many of you have your patients on a walking program at home at part of their recovery, but still have them walk on the treadmill in the clinic…worse yet, you charge them for that…I see it all the time. I see no reason to make patients do the same exercises in the clinic that they are doing at home (and again, CHARGE them for that)…other than a few reps to review and correct technique. Rather, our sessions should focus on any hands on technqiues that may need to be done and progression of a program and reserve performance of gym based exercises for those who truly need the supervision for verbal cuing or have no such access. As another example, I'll use achilles tendonopathy since it was mentioned in the article. How many of you are still bringing these patients into the clinic 2-3 x a week when the literature demonstates that for mid-substance pathologies, 190 heel drops spread throughout the day are required…in this case, it wouldn't matter if that patient came in every day…if they are not following up at home, it's a moot point to have this patient come into the clinic at all. Its our job to convince that patient what needs to be done and the coddelling needs to stop. Each time I have a patient come into the clinic, I make sure there is a good reason for them to be there…and not just because we've had 2-3 x a week for 4-6/wks engraned in our brains. Ask yourself…"would I pay $150 to hear/experience what I just heard?" Many times, I cut my treatments to the nitty gritty…15 minutes, they are out the door…and guess what, they get better because they know what it takes to get better. They see a value in what I've told them and shown them…and they are willing to do it.

    (to be continued)

  20. Greg Arnold, DC, CSCS
    Greg Arnold, DC, CSCS says:

    Now you know what chiropractors go through nearly every month in the media, Mike. It's a constant fight for legitimacy.

  21. Mike Reinold
    Mike Reinold says:

    That is funny, "maybe she should write an article about how nobody is buying newspapers anymore." Good one Anony!

  22. Anonymous
    Anonymous says:

    She obviously has very little knowledge of the Physical Therapy field, and I love the fact that the overwhelming majority of comments were positive. Maybe she should have written an article about how nobody is buying newspapers anymore.

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