How can we justify low-value physiotherapy interventions?

Recently there has been more debate around the role of low-value therapies such as cupping, dry needling, ultrasound, taping, etc. It has been interesting to read the varying arguments and justification and it has got me thinking a little more on it. Here are just a few of my thoughts and considerations, and some ideas as to what I think we need more of/less of in healthcare.  

Just for reference, I am defining low-value interventions as strategies that provide minimal benefit, if not no benefit. Low-value health care may lead to overtreatment, overdiagnosis, sub-optimal care, and can potentially cause harm (REF). To do an intervention because you think that the patient/client expects it, wants it, or because you assume that they want analgesia, is, in my mind, short-sighted. Ultimately, we are providing healthcare.

With a lot of the debate, I have started to query how often some practitioners are questioning what healthcare truly means.

Analgesia is a small component of providing care to an individual and not always why a person seeks our help. Interestingly, in low back pain, a systematic review by Ferreira et al. in 2011 found that the intensity of low back pain was only slightly associated with care-seeking behaviour (REF). People are often shit-scared of their pain because of the common societal understanding that pain is bad and is equal to damage. Interestingly, pain related fear may be more disabling than pain itself (REF). A systematic review by Smith et al. in 2017 found that prescribing exercise that evokes pain is no worse in the long-term than pain free exercises and may even have a short-term benefit (REF). Some people may be more concerned about pain relief over anything else, but I think that is far less common than we let on. When that is the case, I still feel there are plenty of options that may provide relief that an individual can administer independently without a practitioner. My bias leads me to prioritising exploration of these active avenues prior to entertaining the idea of passive modalities. But, hey, that’s debateable!

Perhaps we need to get better at communicating and help people understand things like pain (and no, I’m not saying just explain pain at them). This can help decrease pain related fear and distress, and consequently provide an opportunity for them to regain some control. I am a strong proponent that we need to be prioritising strategies that work to create an attentional shift away from pain and more toward an individual’s meaningful goals. If a practitioner is worried that a patient won’t have buy-in if they don’t do (insert therapy), I’d argue that if you are helping them move to what they deem meaningful, it will enhance their life regardless – they will see value. We need to respect pain, but understanding pain is important.

There are three established key points that have emerged as mediators of an effective therapeutic alliance. One of those mediators includes ‘the patient and therapist agree on the intervention’ (REF). If you don’t believe an intervention is efficacious for an Individual or may even promote harm (negative beliefs or whatever else), is it ethical to still provide it? What if we were to work on how we guide people to more efficacious treatment strategies that align with their goals rather than just providing what they expect? Just because it may not be the original expectation it doesn’t mean they won’t be excited, hopeful and motivated by a different strategy; we can shape expectations. I think facilitating new cognitions and helpful beliefs that lead to promotion of higher evidenced care is absolutely our role as healthcare professionals.

To provide an intervention because that is a patient’s initial expectation or because it creates “a window of opportunity”, or “because it gets them coming back so you can educate them further”, are, in my mind, just justifications for practitioners to do whatever they like and not necessarily patient-centred care based in science. We can justify anything if we think in such ways.

I also think we need to be mindful of the idea that just because you provide a positive narrative with your treatment intervention it doesn’t mean that’s what the person will take away from the experience either. We cannot control the implicit beliefs taken from a therapeutic interaction and there are times where what you say and what you do may create conflict in an individual’s meaning of what has helped/happened.

An example:

Practitioner: “I’m not putting anything back into alignment, all I’m doing is changing an input to your nervous system that results in a change of output” (in an attempt to move away from structural beliefs when not indicated), at the same time as performing a manipulation or mobilisation.

The implicit meaning of the improvement in symptoms/function etc. may (potentially) be that – “the practitioner did something to my joint and now it feels better” – and the practitioner narrative may be totally lost on them. Providing a positive narrative isn’t the justification for us to do anything we want. Other literature has suggested by providing a specific treatment to an area may increase attention to that area, surmising that this attempt to provide short-term analgesia, paradoxically may increase long-term sensitivity (REF). Maybe something for us to at least consider in the clinical reasoning process.

I’m not picking on any specific modality here and I think it also includes some specific exercise approaches, but I think these common arguments are just ways to deflect the critical appraisal of our own practice and to justify what our anecdotal experience has confirmed for us. As humans, what we perceive may not be true of our world; we seek confirmation, we are prone to biases and logical fallacies, and we use heuristics to short cut the world and we can’t be aware of all the ways we infer the world. Taking the time to stand back and reflect on our own arguments, practice, and why it is we do the things that we do is something we all need to do more of – and yup, I am no exception.

The last few questions I’d like to leave you with are, how does your argument affect the person you are treating? How does it affect societal expectations and the current pain epidemics we are seeing emerge? Does your belief of what constitutes a patient’s perception of value in your session stunt or even regress societal health literacy? I’d argue that what a patient perceives as valuable in your session is more plastic than what we give credit to.

Some further readings if you are interested is this qualitative paper by Riikka Holopainen et al. from 2018 that explores perceptions on clinical interaction factors that patients deem positive and negative (REF).

How can we justify low-value physiotherapy interventions?
Brendan Mouatt