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  • Choosing Wisely: APTA Releases List of Procedures That PTs and Patients Should Question

    Passive physical agents that aren’t part of an active treatment plan, under-dosed strength training for older adults, and the use of whirlpools for wound management are among the "5 Things That Physical Therapists and Patients Should Question," according to a list recently announced by APTA. The list, developed through member suggestions and refined by an expert panel, is now part of a national campaign that encourages patients and health care providers to talk about whether a given procedure is really necessary based on the patient's individual circumstances.

    The list announced today is part of APTA's partnership with the Choosing Wisely® campaign from the American Board of Internal Medicine (ABIM) Foundation. The initiative aims to help consumers make informed health care choices by providing lists of procedures that tend to be done frequently, yet whose usefulness is called into question by evidence. APTA is the first nonphysician group to release a list, joining more than 50 medical specialty societies.

    "A well-informed patient is a well-treated patient," said APTA President Paul A. Rockar Jr, PT, DPT, MS, in a news release. "The Choosing Wisely campaign addresses the patient's role in good health care, and we are happy to join this effort."

    The 5 recommendations, which are expanded upon with citations at the Choosing Wisely website and in the downloadable list of "5 Things Physical Therapists and Patients Should Question," are:

    • Don’t employ passive physical agents except when necessary to facilitate participation in an active treatment program.
    • Don’t prescribe under-dosed strength training programs for older adults. Instead, match the frequency, intensity and duration of exercise to the individual’s abilities and goals.
    • Don’t recommend bed rest following diagnosis of acute deep vein thrombosis (DVT) after the initiation of anti-coagulation therapy unless significant medical concerns are present.
    • Don’t use continuous passive motion machines for the postoperative management of patients following uncomplicated total knee replacement.
    • Don’t use whirlpool for wound management.

    The process for developing the list began with an open call for APTA members to submit their lists of questionable procedures. After receiving more than 170 submissions, APTA convened an expert group of physical therapists from a wide range of practice settings and areas of clinical expertise. The group reviewed all nominations and conducted extensive literature reviews to narrow down the list to 9 procedures. The list of 9 was presented to the 88,000 members of APTA, who voted on the final 5.

    To help patients and clients understand what APTA’s Choosing Wisely recommendations mean for them, APTA has partnered with Consumer Reports to create a free consumer-friendly summary, which will also be made available in Spanish. Consumer Reports already has reached more than 100 million consumers with Choosing Wisely information through its network of consumer communications partners.

    APTA's Choosing Wisely list is also the subject of a ProfessionWatch paper e-published ahead of print in Physical Therapy. The paper details the process of the list's development and provides professional context for APTA's decision to partner with the ABIM Foundation in Choosing Wisely.

    The partnership is a component of the larger APTA Integrity in Practice campaign, an effort to support the profession of physical therapy as a leader in the elimination of fraud, abuse, and waste in health care. An APTA Center for Integrity in Practice has been created and will be developing resources throughout the course of the campaign, but already offers a primer on preventing fraud, abuse, and waste, and an online course on compliance and professional integrity.

    "Care that is best for the patient has always been a priority for APTA," Rockar said. "Choosing Wisely is an outstanding effort, and its mission to foster better, more efficient care through informative dialogue between patients and health care providers dovetails perfectly with the goal of our Integrity in Practice campaign."


    • About time!

      Posted by Kathleen Clarke on 9/15/2014 7:12 PM

    • I am conflicted. While I am glad we participated in this campaign, I think we could have made a bolder statement.

      Posted by Joel Dykstra on 9/15/2014 11:21 PM

    • Thanks, that was a real page turner! Show me the evidence! If I am to do battle against questionable practices, I'll need something a little more substatnial. As you know, expert opinion in one of the lowest forms of evidence. The article mentioned a panel of experts performing an extensive literature review regarding their recommendations. Is there any way that I can access this literature review- especially regarding the use of whirlpools? I was hoping for a nice and tidy Cochran review expounding the detriments of the use of whirlpool treatment. I have not found one, probably because it does not exist. However, every little bit helps. Thank you! David

      Posted by david krantz on 9/16/2014 10:21 AM

    • I am disappointed that the APTA expects PTs to have a "one size fits all" approach to patient care. Aren't we supposed to evaluate each patient and initiate a plan of care based on individual needs?

      Posted by Paul Jones on 9/16/2014 4:10 PM

    • I think it's a good initiative to help patient to participate actively in the treatment decisions. But, like you claim, it's important to match with the evidences, so join the references please. Moreover, it should be more finely-shaded, because it can be wrongly interpreted by the patient, for example that applying ice is never a good thing.

      Posted by Marjorie F on 9/17/2014 10:15 AM

    • David, Thank you for your comment. The original literature reviews for each of the finalist recommendations were quite substantial (for example the whirlpool list of titles and abstracts only was 39 pages). The expert panel reviewed the literature in order to inform the recommendation(support/refute) and then representative references were chosen to best summarize the data . I invite you to review some representative references for each recommendation in the paper that is available on-line ahead of publication at: http://ptjournal.apta.org/content/early/2014/09/15/ptj.20140287.full.pdf+html Specifically refs 31-35 relate directly to the whirlpool recommendation. Also each recommendation with the corresponding representative refs are available in .pdf form elsewhere on this site at: http://integrity.apta.org/ChoosingWisely/ Click on the •5 Things PTs and Patients Should Question (.pdf) Page 1 has recommendations and page 2 the corresponding refs... I hope that helps you link directly to the sources you need. Tara Jo Manal

      Posted by Tara Manal -> =GYaBF on 9/17/2014 10:26 AM

    • Show me the studies done with significant findings. Don't just give a blanket statement like this that can be taken in so many different ways. Insurance carriers will suddenly quit paying for exercises that they can claim is an under dosed strength training program. What if I am trying to improve endurance and not just strength. A concerned member of the APTA.

      Posted by Perpetuo A Gutierrez on 9/17/2014 11:29 AM

    • Paul, As a practicing clinician and member of the working group on the Choosing Wisely recommendations I do not support dictating care decisions. The recommendations are evidence based assessments of the literature and are intended to assist and inform physical therapists and their patients about care that is/is not likely to achieve the best outcomes. Decisions about care should be made based upon the best available evidence, the clinical judgment of the physical therapist, and the preferences and goals of the patient. As a therapist, the current Choosing Wisely Recommendations that say "imaging for low back pain" (which can be linked to in the list of tests hotlink in the paragraph above) put out by the Academy of Family physicians- is very useful in educating my referral sources and my patients about when/why they do/do not need imaging prior to my treatments. The goal of the initiative is to provide summarized literature in 5 areas, to educate, support and inform PT's and their patients, allowing the therapist to do what they do best- evaluate and treat.

      Posted by Tara Manal -> =GYaBF on 9/17/2014 1:22 PM

    • Most PTs I know, myself included, will be happy when patients and other clinical practitioners here in the Philippines finally understand these simple points mentioned i this article! Finally!!! 👍

      Posted by Chermarie Geronimo on 9/17/2014 11:46 PM

    • I don't quite understand this negative approach towards validating the practices of our profession. The title of this article itself leads anyone reading it (whether a therapist or patient/ consumer) to perhaps make generalized presumptions that there are perhaps lots of other things they/we should be questioning about our profession. Not saying that we shouldn't be doing it, but I think the approach is wrong, because the title of this article in itself would lend itself to more doubt and credibility issues for the general layman reading this article, at a time where the average person already has very little knowledge and understanding of our profession already ("Oh, you do massages, right?"), so why bring even more attention to it and promote the wrong message? Instead, re-word it and re-focus our research on what we should be doing to be more effective and get better outcomes, and general common sense would lead the clinician to utilize these treatment interventions over others. Glass half full instead of half empty I suppose, but can make a powerful difference in how the public perceives our profession. Not sure if I worded these comments properly to get my point across, but I'm already frustrated with insurance companies mis-using whatever they can to deny our services, so why give them any more ammunition to use against us? Our battles are tough enough already, so why make it harder on ourselves? Is that not common sense enough to the people publishing this article?!

      Posted by Andre Huu on 9/18/2014 12:19 PM

    • While I respect Andre's concerns, we need to look at the bigger picture. I encourage everyone to click the second link in the story. It takes you to the Choosing Wisely website, where there are dozens of lists with headings that read "Five Things Physicians and Patients Should Question." I've been a PT a long time ... long enough to hear over and over from other PTs that we want to be treated like doctors. As a profession, we need to be mature enough and confident enough to realize that's exactly what's happening now. Our profession is being asked to examine itself with the same scrutiny that should be extended to every health care provider. That's our duty. Our loyalty is to the patient. I believe that clear, no-nonsense communication is the key to patients realizing that physical therapy is more than massage and often cheaper and more effective than surgery. But it's also the key to earning the trust of the public. Yes, our battles are tough right now. The concerns about insurance coverage are real. But for years we've demanded to be allowed into this larger forum. We're there now. We're not at the kids table anymore. And if we need to be coddled, shame on us.

      Posted by Joe Washington on 9/18/2014 3:32 PM

    • to all those yelling for evidence...I ask you to go back and review what you are doing in the clinic everyday. Where's the evidence for the everyday procedures. That is all this panel did...and yet you are scoffing at it. How about trying to do some research yourself? And as far as research goes I would argue that treatment should be the "three legged stool" with therapist experience & patient values guiding the process. Oh and one last question... where is the evidence that evidence based practice works? How about Evidence informed practice where you use evidence to help improve your knowledge and then use clinical experience & consultation with patient to guide your decisions regarding treatment. Have a good day.

      Posted by James Lewis on 9/19/2014 8:17 AM

    • What a waste of time and energy. Gosh there is a whole realm of mechanisms and treatment approaches that continues to be undiscovered or are in its testing phases and all you folks want to do is place people in Boxes. Physicians have done the same thing and look at the results they are getting based on EVIDENCE. Near 4 Decades I've been a PT and this is where we are at. WOW!

      Posted by Joey on 9/19/2014 5:09 PM

    • Well said Joe Washington! Let's move on into a new era of true professionalism and accountability.

      Posted by Matt on 9/19/2014 10:48 PM

    • Bravo APTA! And thanks to all who worked on this campaign.

      Posted by Dechie Bello-Rapoport on 9/21/2014 8:22 PM

    • The Consumer Reports Health 2014 guide "Physical therapy, Five treatments you probably don’t need" states "The main treatment for DVT is medicine that dissolves blood clots." The main treatment for DVT is anti-coagulation, which does not dissolve clots. Thrombolysis may be indicated, but is not the "main treatment."

      Posted by Thomas Herring -> ?FVc? on 9/29/2014 1:21 PM

    • Isn't the idea of the physiotherapist going to university learning all about diagnoses and treatments and what they do -then choosing wisely enough? If this isn't happening, why? Perhaps we really need to be examining the course contents of CPD and basic university degree instead of asking 5 questionable questions... I am already experiencing unqualified "case managers" from WorkCover and insurance companies telling me what to do without even seeing the client after only having a 5 minute conversation with said client.

      Posted by Rosemary Gaddes on 11/23/2015 10:22 PM

    • Don't is a very bold statement. I didn't think it was that black and white. Where is the evidence?

      Posted by Brendan on 3/8/2016 11:29 AM

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