The other day I was reading an article in an online news story regarding the opioid crisis here in the US.Obviously this has been the buzz of healthcare news for some time now, but the article featured how physical therapists play an important role in treating those with persistent pain vs. the use of opioids.What struck me as interesting was the use of a specific phrase that described the treatment physical therapists provide for those suffering persistent pain:alternative medicine/treatment.
One must first go back to the definition of alternative medicine to truly respect why this phrase misses the boat on our profession and how we go about addressing pain.The NIH’s National Center for Complementary and Integrative Health states that when “non-mainstream practice is used in place of conventional medicine, it’s considered “alternative.”
To say that physical therapists provide non-mainstream treatments that are used in place of conventional treatments for pain made me ponder if this was truly accurate.I believe the viewpoint in the recent issue of JOSPT by Mintken and colleagues describes a number of ways PTs can help solve the opioid crisis – it is clear that we ARE the conventional treatment approach for the treatment of pain.
With this being stated, I had to wonder why folks tend to refer to PT as alternative care.Are we truly seen as non-mainstream?
In the Mintken viewpoint, they allude to some points on why this might be.The authors state that a Gallup poll performed found that most of those surveyed who suffered from spine pain would consider a physician, chiropractor or massage therapist before coming to see a PT.We have to be better than this.
It is clear that many in our society view physical therapists as part of the alternative medicine world.This needs to not be the case.
We are the conventional treatment approach for pain conditions and we need to become the mainstream option for addressing functional limitations and movement impairments associated with pain.
Thoughts?
@ShepDPT
––– Comments
David
Commented • August 13, 2018
We live in a time when the trust for institutions has become damaged, and there are many cases where this is with good reason. Unfortunately the replacing of hard science with antidotal evidence can also get results that are not in the best interest of health and well being. There is a balance that needs to be found, and it is not very likely that any one person or method has all of the necessary information to be correct every time. Thus, open discussion and the comparing of scientific results that will lead to better understanding is the answer... even if we don't like it.
Tim Mondaleu
Commented • May 15, 2018
Matthew, I'm with you on most of what you say above, pain is normal, necessary and indeed will never go away as a collective protective; fortunately. Pain's purpose of course is to protect, and in the absence of the real need for that protection the important question to us is what is the safest, cheapest, and most effective nervous system/brain input cocktail to change that unnecessary protective output? Surgery is certainly often an incredibly powerful input supported by a narrative of removing old terrible pathoanatomy, and replacing it with shiny new space aged stuff. Now that's powerful, but it isn't very safe, or inexpensive. And on down the line. My point is that our job is to create the most powerful input we can, safely and relatively inexpensively. "stuff" can be useful in that as long as we are intellectually honest, first with ourselves, then with our patients. I think there is ample evidence supporting manual therapies, combined with movement, combined with BPS education maximizing comfort and function, and we shouldn't lose that perspective. We need to remember the target is always the brain. I tell patients all the time when I'm having them do exercises or I'm doing manual therapies on them, the brain is the most important tissue I'm trying to affect. All we have to do is permanently convince the brain that there is no danger, and presto! Sounds easy enough... :) Sorry to have gotten so far off of the original topic. Tim
Matthew Rupiper
Commented • May 12, 2018
If we, as a professional, stood behind our ability to guide people undergoing an injury, surgery, illness or disease to PHYSICAL activities we'd be the only option. Unfortunately, we, as a profession, want to call ourselves the conventional approach to pain. If we continue promoting soft tissue "stuff," "manipulation," and "dry needling" get comfortable being called and associated as complementary or alternative. We don't talk enough about "disability." This is our value. Pain is normal, necessary and will never go away. Its time to stop "targeting" it with "tools from the toolbox." This "stuff" has questionable "evidence" (I'd call it tooth-fairy science) to support its implementation into pain management. We can play an important role for those with persistent pain. The role is guiding those toward their PHYSICAL limitations within a multidisciplinary BSP framework. Confrontation and coping skills are important. We can be part of it. It can be done. It's not sexy. It doesn't require tools or "stuff." It requires discipline on all parties, compassion, empathy, motivation, education, re-assurance and guidance. Something I stole from "gb" above.
Brian D'Orazio DPT, MS, OCS
Commented • May 9, 2018
This is a tough one for me. So, just my opinion, we are considered mainstream if you need rehab for a hip fracture, stroke, etc. We aren't considered mainstream for pain; in fact we aren't usually considered at all. Even among orthopedic surgeons we aren't understood ( a generalization with many exceptions ). They don't know what we do, why we do it, and aren't consistently impressed that it matters. They understand surgery, medicine, medical imaging, injections and everything else is often discarded as non-essential. They view us as holding the patient's hand, and mostly wasting money. Primary care MD's view mainstream as their colleagues. CMS and insurance view us as wasteful (see recent OIG report) and our importance is reflected in both the horrible reimbursement we receive and the regulatory demands. Patients follow what their MD's think. I'm not at all sure what we need to do to overcome these and many other issues. My mother-in-law recently fell, fracturing her wrist and hip. She received inpatient rehab and the PT portion of this involved nothing other than walking her. Not even exercise. Reimbursement is so poor apparently this is the role of PT...which isn't very impressive for anyone viewing this who either does or doesn't have a medical background. For pain management, patients and MD's alike don't view us as diagnosticians (we don't order medical imaging and that is mainstream to both of these groups...DC's do order imaging). We can't order labs, prescribe meds, perform injections. In fact, there is very little of what we do that has great research support. Exercise has fairly good research backing...and MD's often view that patients can exercise at the YMCA on their own. The APTA thought that restricting practice to use of a PTA only would make us mainstream because it looks like the way MD's practice.....so even they don't understand what we do. Now we celebrate the lack of a cap on services, but CMS no longer needs a cap since they've reduced out practice to a leveraged statistical package that limits our interactions with patients to 45 minutes...and how can we make a significant contribution to reducing a patient's pain given this constraint? I think our current model is no longer viable. We aren't going to reach our goals under the current constraints. If we wish to play a larger role in reaching patients, a role considered more mainstream, then perhaps we need to change our education system in a way similar to what DO's did many years ago. We need the tools to help our patients and these include a full range of mainstream medicine in addition to the things we do. We need to be reimbursed so we can make a reasonable living for our level of education. We need to order imaging and labs, we need to perform injections beyond dry needling, and we need to prescribe at least some meds. Lots more to it, but I think we may need to move toward a different educational model that ultimately leads us to be considered mainstream medicine because we aren't going to get there just wishing and hoping. Brian
Tim Mondale
Commented • May 7, 2018
Couldn't agree more Michael, full unrestricted direct access, starting with Medicare should be the most important and all encompassing legislative issue on our agenda...still. Feels to me we've let this ball roll away to the side of the court for some reason. I hope I'm wrong, but we don't hear much about it anymore from our national governing body.
gb
Commented • May 5, 2018
Being about as direct and blunt as I'm afraid I have to be but...it's somewhat ironic that a blog post upset with branding Physical Therapy as "alternative" takes place on a site called "evidence in motion"....a group which advocates and teaches dry needling. Anyone else find that at least somewhat ironic on various levels?
Michael Hudack
Commented • May 5, 2018
Interesting post. Thanks for stimulating thought and discussion on this important topic. It might first be helpful to address ,in a bit more detail, definitions of these commonly used (and misused) terms. As you mentioned, alternative treatments are used in place of conventional treatments. Complementary treatments are used in addition to conventional treatments. When viewed in this light, I actually do not have a problem with physical therapy being viewed as an alternative treatment approach (or even under certain circumstances complementary) to the (previously) conventionally accepted opioid treatment approach to pain (particularly non-cancerous chronic pain). If we do a good job with this momentous task (which involves PT's utilizing largely conventional ,i.e. scientific, approaches to the treatment of pain rather than a disjointed approach utilizing many unscientific, alternative treatment approaches) we may eventually be viewed as the conventional preferred treatment of pain conditions. On the other hand, I believe that physical therapy should not be viewed as alternative or complementary therapy in the treatment of neuromusculoskeletal conditions. Unfortunately, how we view ourselves is not always the same as how the general public views us. Why are we so infrequently mentioned (or mentioned almost as an afterthought) in so many health and fitness publications? One striking observation about those that are frequently mentioned (including in this post referencing the Gallup poll results: physicians, chiropractors, or massage therapists) is that consumers can access all of these directly. Yes, I know we have direct access, but does it really function as we wished that it did? There are too many restrictions to physical therapy direct access and patients view these other practioners as truly directly accessable. Too often, patients still think that we must be told (via MD prescription)what is wrong with them and told what to do about it. We need to (in every state) get rid of all restrictions to direct access to physical therapy, and educate everyone on the training, skills, and value that we have to offer.
Mark Shepherd
Commented • May 4, 2018
I do believe we are getting better, but still have a long way to go. I think one thought I have had is whether we want to be associated with typical "alternative medicines/complimentary medicines" given the lack of evidence for which many are founded upon. I think we as a profession have done a nice job of centering ourselves as a legitimate healthcare provider (although there are some crazy things out there in PT). I think the pendulum could swing the complete other way and now we rush to find some intervention, any intervention, that is different than opioids and this can lead to other issues. So I am OK with some distance, but we need to do a better job of telling society why we can help solve this opioid crisis.
Sheik Abdul khadir AMK
Commented • May 4, 2018
What a pragmatic viewpoint. Completely agree. In the attempts of being special we should have alleviate ourselves from mainstream. We are unique but in mainstream.
Allison Suran
Commented • May 4, 2018
Interesting! Although I agree that we do not fit in the complimentary medicine definition I have had another observation. When article after article cites alternative such as chiropractic, massage, acupuncture and others and never mentions PT I am equally frustrated. I just want PHYSICAL THERAPY to be in every article anyone ever mentions about solutions for our opioid crisis. AND, yes, we need to do better! Having been in this profession for 31 years now (yikes), PT's have relied more on MD referrals than community marketing. We're getting better and will hopefully continue to improve!