Good Practice: Active vs. Passive Treatments

In 2014, the American Physical Therapy Association (APTA) became the first non-physician organization to join the Choosing Wisely campaign, a program that aims to educate patients and health-care providers in order to improve the quality of care delivered and eliminate wasteful practices. If that didn’t get your attention, it should have!

In order to be included on the APTA’s list of practices to question, a practice or treatment had to meet the criteria of being “offered to patients in the absence of evidence demonstrating benefit or, in some cases demonstrating disutility or harm.” The intent of the program was to “identify specific evidence-based recommendations that encourage both patients and physical therapists to make wise decisions about the most appropriate care.” You can read the full list here.

In my time as a practicing physiotherapist, and my time working here at the College of Physiotherapists of Alberta, I have had several patients tell me straight out that “physiotherapy doesn’t work.” As a proud physiotherapist, I have engaged in discussions with these people about the mountain of evidence that disagrees with their assessment. But when I listened to their stories, they have told me about physiotherapy practice that, frankly, meets the definition of bad practice.

Some examples include:

• Reports of patients receiving passive modality after passive modality.
• Patients who at no time during the course of their treatment received exercises or education regarding the long-term management of their condition.
• Physiotherapists who are going through the motions rather than using their skill to engage with their patients and improve health outcomes.
• Patients who seek and receive the passive interventions of needling, massage, or joint manipulation at great expense, and to the exclusion of other interventions.

When people ask me where to go for treatment my standard response is: “If you don’t spend more time working than you spend having a machine, hot pack or needle applied to you, you are in the wrong place—go somewhere else.”

The fact that I need to provide friends and family with that advice speaks volumes. Being a regulated physiotherapist matters. The profession is only as good as the people who deliver physiotherapy services. We all need to take the time to reflect on what we want our profession to look like to the public and our peers. Although I would never suggest that bad practice as I’ve defined it is commonplace, I will say that we all need to be on the lookout for these tendencies within ourselves and our colleagues and work to ensure that we aren’t the clinicians that are being complained about and that we are living up to our Standards of Practice and Code of Ethical Conduct.

As the APTA campaign identifies, we increasingly realize that a predominantly passive approach to treatment is not only ineffective,^3,4,5,6 but can harm patients, delay their recovery, and lead to poor long-term outcomes³ by reinforcing a passive role, promoting inactivity and disability behavior, and ‘medicalizing’ the patient.^6,7 This is as a result of “communicating to patients that passive, instead of active, management strategies are advisable, thus exacerbating fears and anxiety that many patients have about being physically active when in pain, which can prolong recovery, increase costs and increase the risk of exposure to invasive and costly interventions.”³ Based on the campaign’s comments, I’ve included needling, massage and joint manipulation as being equally questionable practices, when used in isolation. I’ve never been able to understand why we as a profession question the appropriateness of a hot pack or ultrasound, but don’t worry about the impact that these practices have in conveying exactly the same messages to patients.

“If you only have a hammer, you tend to see every problem as a nail.” - Abraham Maslow

Before those with the authorization to use needles in practice or perform spinal manipulation flood my mailbox with angry emails, let me be clear: I am not suggesting that the use of these techniques is inappropriate. I have confidence that the vast majority of practitioners who employ these techniques do so based on their assessment findings, in accordance with the theoretical constructs that underlie the technique, and with a specific treatment goal in mind. However, when the Registrar gets a call from an insurer asking if 99 needling visits without a change in function or mobility is reasonable (true story), it does make us wonder what the rationale might be for such a passive approach.

Active treatment programs should be our primary focus, with these passive interventions as an adjunct, not the other way around. If we plan to meet the expectations in the Code of Ethical Conduct, including the expectation that we “commit to maintaining and enhancing the reputation and standing of the physiotherapy profession” we need to make this our focus, every intervention, every patient, every time.

To me, that is the definition of good practice.

Page updated: 02/12/2022