Jump to comment:

• Evidence based physiotherapy needs evidence based statements from researchers
  Alan J Taylor, Roger Kerry and Fiona Moffatt
  Published on: 23 November 2018
• Response to the Need for Evidence-Based Marketing
  Daniel I Rhon, Chad E Cook
  Published on: 11 November 2018

• Published on: 23 November 2018

  Evidence based physiotherapy needs evidence based statements from researchers

  • Alan J Taylor, Physiotherapist/Assistant Lecturer University of Nottingham
  • Other Contributors:
    • Roger Kerry, Physiotherapist/Assistant Lecturer
    • Fiona Moffatt, Physiotherapist/Assistant Lecturer

  The editorial article by Zadro, O’Keefe and Maher1 entitled ‘Evidence based physiotherapy needs evidence based marketing’, highlighted both the importance of conveying clear, consistent messages and having robust data to support any statements that appear in the public domain. To use the words of the authors, statements or claims by physiotherapists or physiotherapy organisations should be grounded in ‘rock solid research data’. Their article however, appears to fall foul of the very thing they are railing against. The mid-section of the paper, which discusses the marketing of the timing and type of PT treatment, contains a misleading statement which lacks the solid evidence that the authors call for.

  The authors state “Early access to harmful or ineffective physical therapy treatments (e.g. kinesiotape and electrotherapy), irrespective of timing, is unlikely to improve patient outcomes” The claim that some physiotherapy treatments e.g. Kinesiotape and electrotherapy are ‘harmful’ to patients is unsupported by the robust data that the authors mandate. ‘Electrotherapy’ for instance is a broad umbrella definition for a range of treatments ranging from neuromuscular electrical stimulation and extracorporeal shock wave therapy, (both of which, have recent systematic reviews to support their efficacy 2, 3 ), through to therapeutic ultrasound which has little or no evidence to support its efficacy. Crucially though, none of these examples have any robust RCT data to sugg...

  Show More

  The editorial article by Zadro, O’Keefe and Maher1 entitled ‘Evidence based physiotherapy needs evidence based marketing’, highlighted both the importance of conveying clear, consistent messages and having robust data to support any statements that appear in the public domain. To use the words of the authors, statements or claims by physiotherapists or physiotherapy organisations should be grounded in ‘rock solid research data’. Their article however, appears to fall foul of the very thing they are railing against. The mid-section of the paper, which discusses the marketing of the timing and type of PT treatment, contains a misleading statement which lacks the solid evidence that the authors call for.

  The authors state “Early access to harmful or ineffective physical therapy treatments (e.g. kinesiotape and electrotherapy), irrespective of timing, is unlikely to improve patient outcomes” The claim that some physiotherapy treatments e.g. Kinesiotape and electrotherapy are ‘harmful’ to patients is unsupported by the robust data that the authors mandate. ‘Electrotherapy’ for instance is a broad umbrella definition for a range of treatments ranging from neuromuscular electrical stimulation and extracorporeal shock wave therapy, (both of which, have recent systematic reviews to support their efficacy 2, 3 ), through to therapeutic ultrasound which has little or no evidence to support its efficacy. Crucially though, none of these examples have any robust RCT data to suggest that they are harmful to patients. Whilst most agree there is a lack of compelling evidence to support the use of Kinesiotape, there is no research data (rock solid or otherwise) to demonstrate that this practice is measurably harmful.

  The public assertion that a treatment is ‘harmful’ is a serious one indeed, and if patients are truly being harmed by any element of care, then an inquiry at the highest level (Physiotherapy governing bodies) would be required to identify and prevent future adverse events. Other professions are very successful at both defining and quantifying harmful events 4 5. They do this with a specific professional interest in future prevention, and providing patients with a measure of the risk of interventions6 or screening7. There is no reason why physiotherapy cannot aspire to this level of scientific scrutiny.

  The concept that the use of non-efficacious physiotherapeutic management options may lead to delays to ‘best care’ is well understood, and is frustrating to observe. However, to suggest that this somehow translates into material harm is at best distortion of reality and at worst a wilful manipulation of the available data. This unfortunately manifests into opinion based medicine, or fake news, which is misleading to therapists, patients and the general public alike. The validity of recording patient safety and capturing harm data is affected by many factors, including the variable definitions of patient harm, together with the lack of valid and reliable data on the types of harm and prevalence rates in practice across all areas of healthcare. These acknowledged limitations affect our ability to quantify harm, BUT should not deter us from attempting to do so.

  This response to the editor, categorically does not support the use of non-efficacious treatments. However, in the interest of communicating health risk in science publications 8 it does support the concept of conveying clear, consistent messages. This requires accurate definitions and robust data to support statements that appear in the public domain and may impact on patient decision making, safety and care.

  We challenge the authors of this editorial to provide the harm data on the specific physiotherapy interventions named, OR withdraw their claim on the basis that it is not supported by their Utopian ideal of ‘rock solid research data’.

  References

  1. Zadro JR, O'Keeffe M, Maher CG. Evidence-based physiotherapy needs evidence-based marketing. Br J Sports Med 2018 doi: 10.1136/bjsports-2018-099749 [published Online First: 2018/10/29]
  2. Xiang J, Wang W, Jiang W, et al. Effects of extracorporeal shock wave therapy on spasticity in post-stroke patients: A systematic review and meta-analysis of randomized controlled trials. J Rehabil Med 2018;50(10):852-59. doi: 10.2340/16501977-2385 [published Online First: 2018/09/29]
  3. Hauger AV, Reiman MP, Bjordal JM, et al. Neuromuscular electrical stimulation is effective in strengthening the quadriceps muscle after anterior cruciate ligament surgery. Knee Surg Sports Traumatol Arthrosc 2018;26(2):399-410. doi: 10.1007/s00167-017-4669-5 [published Online First: 2017/08/19]
  4. Rozental A, Kottorp A, Boettcher J, et al. Negative Effects of Psychological Treatments: An Exploratory Factor Analysis of the Negative Effects Questionnaire for Monitoring and Reporting Adverse and Unwanted Events. PLoS One 2016;11(6):e0157503. doi: 10.1371/journal.pone.0157503 [published Online First: 2016/06/23]
  5. Duggan C, Parry G, McMurran M, et al. The recording of adverse events from psychological treatments in clinical trials: evidence from a review of NIHR-funded trials. Trials 2014;15:335. doi: 10.1186/1745-6215-15-335 [published Online First: 2014/08/28]
  6. The Health Foundation. Levels of harm: ; 2011 [Available from: https://www.health.org.uk/publications/levels-of-harm accessed 21/11/2018 2011.
  7. Cotter AR, Vuong K, Mustelin L, et al. Do psychological harms result from being labelled with an unexpected diagnosis of abdominal aortic aneurysm or prostate cancer through screening? A systematic review. BMJ Open 2017;7(12):e017565. doi: 10.1136/bmjopen-2017-017565 [published Online First: 2017/12/15]
  8. Freeman ALJ, Spiegelhalter DJ. Communicating health risks in science publications: time for everyone to take responsibility. BMC Med 2018;16(1):207. doi: 10.1186/s12916-018-1194-4 [published Online First: 2018/11/14]

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top
• Published on: 11 November 2018

  Response to the Need for Evidence-Based Marketing

  • Daniel I Rhon, Physiotherapist Baylor University
  • Other Contributors:
    • Chad E Cook, Physiotherapist

  The editorial by Zadro and Colleagues' calls for caution in marketing physical therapy services, and focuses on a lack of high-quality evidence to support all current claims made for PT First. Of this, we 100% agree. The purpose of our response is to highlight considerations we feel may be beyond the research-based concentration outlined in the authors’ editorial.

  First and foremost, effective marketing strategies are influenced by many factors and vary depending on targeted end users, policy makers, and payers. These factors account for variations in the delivery of medical care, payment models, and the role of enforcing organizations. In Australia, it has been reported that a majority of patients receive appropriate evidence-based care for challenging and costly conditions such as low back pain.[1] In countries such as the United States, which boasts high rates of unnecessary imaging,[2] and high percentages of opioid prescriptions as initial treatment choices for nonspecific low back pain (>50% of patients), care is less guideline based[3], and heavily influenced by direct-to-consumer marketing strategies. The United States is immersed in a situation in which many high-risk, low-value treatments are easier to obtain, with insurance policies that comprehensively cover low-value care earlier (opioid prescriptions and steroid injections[4]); whereas low-risk, high-value interventions, such as those available from physical therapy, often require more out-of-p...

  Show More

  The editorial by Zadro and Colleagues' calls for caution in marketing physical therapy services, and focuses on a lack of high-quality evidence to support all current claims made for PT First. Of this, we 100% agree. The purpose of our response is to highlight considerations we feel may be beyond the research-based concentration outlined in the authors’ editorial.

  First and foremost, effective marketing strategies are influenced by many factors and vary depending on targeted end users, policy makers, and payers. These factors account for variations in the delivery of medical care, payment models, and the role of enforcing organizations. In Australia, it has been reported that a majority of patients receive appropriate evidence-based care for challenging and costly conditions such as low back pain.[1] In countries such as the United States, which boasts high rates of unnecessary imaging,[2] and high percentages of opioid prescriptions as initial treatment choices for nonspecific low back pain (>50% of patients), care is less guideline based[3], and heavily influenced by direct-to-consumer marketing strategies. The United States is immersed in a situation in which many high-risk, low-value treatments are easier to obtain, with insurance policies that comprehensively cover low-value care earlier (opioid prescriptions and steroid injections[4]); whereas low-risk, high-value interventions, such as those available from physical therapy, often require more out-of-pocket costs and a referral from another care provider. Referrals to physical therapy remain overall very low (7-16.3%). We would argue that the PT First strategy as a direct to consumer marketing approach is necessary and that this viewpoint likely varies based on the unique and complex interactions of healthcare delivery that are different between each society.

  Our second point involves the use of physical therapy services as a substitute for traditional methods that have not shown benefit. Recently, the Centers for Disease Control and Prevention (CDC) released guidelines that recommended nondrug approaches such as physical therapy over long-term or high-dosage use of addictive prescription painkillers.[5] They made this recommendation despite the current lack of high-quality research to support physical therapy; they did so because the current approach was not working. Although Zadro and Colleagues' state that early access to harmful or ineffective physical therapy treatments is unlikely to improve patient outcomes or the opioid crisis, harms associated with PT are lower than those associated with other common first-line choices. In addition to harm, it’s important to also consider other outcomes that are valuable to patients. Porter et al.[6] argue for the capture of outcomes such as prevention of inappropriate downstream care, burden of receiving care, and delay in receiving care, which are not routinely collected in clinical trials. Promising findings from the PT-First studies suggests that downstream use of opioids, injections, and surgeries decreases when PT is accessed early.

  Our third point is bound around the concept of high-value care. As Traeger and colleagues have stated, “Most commentators accept that the solution is not simply to stop providing low-value care, but rather that high-value healthcare requires the replacement of inappropriate care with appropriate care”.[7] We argue that replacement of inappropriate care is the backbone of the PT First initiative. Whereas further work is needed to optimize “appropriate care”, inappropriate care options are now well established. Reducing first line high stakes, high-risk options should at a minimum be a priority. Strategies designed to change system level issues are a priority. Insurance companies are paying attention and considering alternate payment and compensation models. Mass media campaigns have been called for to address the overemphasis of imaging, medication, and surgery,[8] and we feel that the PT First approach is a step in the right direction.

  In summary, we agree with the editorial that more research is needed to identify appropriate triaging for MSK pain. We argue that it is also needed to support a primary care first strategy, a surgeon first strategy, a chiropractor first strategy and essentially every other provider. We felt that the editorial points fell short in its assessment of the potential immediate benefits of a PT First approach. Yes, we must continue to improve and promote utilization of evidence-based treatments within physiotherapy but let’s optimize on the opportunities that are currently available and that are already known (e.g., reducing opioids, inappropriate imaging, and low-value surgical options). We do not feel that “PT First” marketing is anti-collaborative, “failing to be part of team-based care and wanting to create a hierarchy among providers” as the majority of PT-First studies took place in multi-disciplinary and collaborative care settings. The focus of “PT First” in marketing was intended to promote an alternative to opioids, injections, or advanced imaging as first-care choices. In other words, “choose PT first, before choosing other higher risk treatment strategies.”

  References
  1 Runciman WB, Hunt TD, Hannaford NA, et al. CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust 2012;197:100–5.
  2 Gidwani R, Sinnott P, Avoundjian T, et al. Inappropriate ordering of lumbar spine magnetic resonance imaging: are providers Choosing Wisely? Am J Manag Care 2016;22:e68–76.
  3 Friedman BW, Chilstrom M, Bijur PE, et al. Diagnostic testing and treatment of low back pain in United States emergency departments: a national perspective. Spine 2010;35:E1406–11.
  4 Lin DH, Jones CM, Compton WM, et al. Prescription Drug Coverage for Treatment of Low Back Pain Among US Medicaid, Medicare Advantage, and Commercial Insurers. JAMA Netw Open 2018;1:e180235–e180235.
  5 CDC Guideline for Prescribing Opioids for Chronic Pain. 2018.https://www.cdc.gov/drugoverdose/prescribing/guideline.html (accessed 11 Nov 2018).
  6 Porter ME, Larsson S, Lee TH. Standardizing Patient Outcomes Measurement. N Engl J Med 2016;374:504–6.
  7 Traeger AC, Moynihan RN, Maher CG. Wise choices: making physiotherapy care more valuable. J Physiother 2017;63:63–5.
  8 O’Keeffe M, Maher CG, Stanton TR, et al. Mass media campaigns are needed to counter misconceptions about back pain and promote higher value care. Br J Sports Med 2018;:bjsports – 2018–099691.

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top