American Physical Therapy Association

Five Things Physical Therapists and Patients Should Question

Released September 15, 2014; recommendation #1 updated November 18, 2015

  1. 1

    Don’t use (superficial or deep) heat to obtain clinically important long term outcomes in musculoskeletal conditions.

    There is limited evidence for use of superficial or deep heat to obtain clinically important long term outcomes for musculoskeletal conditions. While there is some evidence of short-term pain relief for heat, the addition of heat should be supported by evidence and used to facilitate an active treatment program. A carefully designed active treatment plan has a greater impact on pain, mobility, function and quality of life. There is emerging evidence that passive treatment strategies can harm patients by exacerbating fears and anxiety about being physically active when in pain, which can prolong recovery, increase costs and increase the risk of exposure to invasive and costly interventions such as injections or surgery.

  2. 2

    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.

    Improved strength in older adults is associated with improved health, quality of life and functional capacity, and with a reduced risk of falls. Older adults are often prescribed low dose exercise and physical activity that are physiologically inadequate to increase gains in muscle strength. Failure to establish accurate baseline levels of strength limits the adequacy of the strength training dosage and progression, and thus limits the benefits of the training. A carefully developed and individualized strength training program may have significant health benefits for older adults.

  3. 3

    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.

    Given the clinical benefits and lack of evidence indicating harmful effects of ambulation and activity both are recommended following achievement of anticoagulation goals unless there are overriding medical indications. Patients can be harmed by prolonged bed rest that is not medically necessary.

  4. 4

    Don’t use continuous passive motion machines for the postoperative management of patients following uncomplicated total knee replacement.

    Continuous passive motion (CPM) treatment does not lead to clinically important effects on short- or long-term knee extension, long-term knee flexion, long-term function, pain and quality of life in patients undergoing total knee arthroplasty (TKA). With rehabilitation protocols now supporting early mobilization, the use of CPM following uncomplicated total knee arthroplasty should be questioned unless medical and/or surgical complication exist that limit or contraindicate rehabilitation protocols that foster early mobilization. The cost, inconvenience and risk of prolonged bed rest with CPM should be weighed carefully against its limited benefit. As members of interprofessional teams involved in post-operative rehabilitation of patient following total knee replacement, physical therapists have a responsibility to advocate for effective alternatives to CPM for most patients.

  5. 5

    Don’t use whirlpools for wound management.

    Whirlpools are a non-selective form of mechanical debridement. Utilizing whirlpools to treat wounds predisposes the patient to risks of bacterial cross-contamination, damage to fragile tissue from high turbine forces and complications in extremity edema when arms and legs are treated in a dependent position in warm water. Other more selective forms of hydrotherapy should be utilized, such as directed wound irrigation or a pulsed lavage with suction.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their health care provider.

The American Physical Therapy Association (APTA) represents more than 88,000 physical therapists, physical therapist assistants and students of physical therapy nationwide. Physical therapists apply research and proven treatment to help people reduce pain and restore movement after injury, illness or surgery; prevent injury; and achieve fitness, health and wellness. No matter what area of the body, physical therapists have an established history of helping individuals improve their quality of life.

APTA seeks to improve the health and quality of life of individuals in society by advancing physical therapist practice, education and research, and by increasing the awareness and understanding of physical therapy’s role in the nation’s health care system.

For more information about APTA, visit www.apta.org.

How This List Was Created

The American Physical Therapy Association (APTA) invited all 88,000 members to suggest items for the Choosing Wisely® list. Communication of this request was distributed to members via website posting, e-mail blast and social media. APTA convened an expert workgroup of physical therapists representing a broad range of clinical expertise, practice settings and patient populations. A modified Delphi technique was used to rank and prioritize the recommendations based upon the Choosing Wisely criteria. An extensive literature search was conducted on the highest rated strategies. The expert panel reviewed the literature and provided a ranking of recommendations based upon the established criteria. The final list of five strategies was selected through a survey open to all APTA members who were asked to select five items from a list of nine, all of which met the established criteria. The final list was presented to the APTA Board of Directors for final approval.

APTA’s disclosure and conflict of interest policy can be found at www.apta.org.

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