Author Response

[Editor's note: Both the letter to the editor by Belanger and colleagues and the response by White and colleages are commenting on the author manuscript version of the article that was published ahead of print September 15, 2014.]

We thank Belanger and colleagues¹ for their interest in our article and for their comments regarding APTA's first Choosing Wisely recommendation: “Don't employ passive physical agents except when necessary to facilitate participation in an active treatment program.”^2,3 Because one of the main goals of the Choosing Wisely initiative is to promote conversation,⁴ we appreciate the opportunity for dialogue on these recommendations as well as on the process for the development of APTA's Choosing Wisely list. We hope that by addressing some of the questions raised by Belanger and colleagues, we can help clarify the intent of APTA's first recommendation and continue to spark discussion about the best care for our patients.

First, Belanger et al question the use of the word “passive” and ask why APTA recommends questioning only passive physical agents and not all passive interventions. Whether an intervention was active or passive was not a primary factor in the development of the recommendation. APTA's Choosing Wisely Work Group developed its recommendations from the 178 submissions received from members, of which approximately 35 specified the improper use or overuse of physical agents. Decisions on how to phrase recommendations and which ones to put forward to membership for a vote were based on a review of the evidence, the frequency of use of the intervention in practice, and whether the intervention is either unnecessary, excessively costly, or potentially harmful. The final decision on the recommendations was made by APTA members and approved by APTA's Board of Directors as described in the article.³ Although we believe the use of the word “passive” in the recommendation may be unnecessary, we do not believe that it is inaccurate.

Belanger et al also ask if APTA believes that the use of passive interventions in medicine should be questioned. Tests and treatments that have been shown to be ineffective, excessively costly, or harmful should be questioned regardless of who provides the intervention or whether these interventions are active or passive. Through participation in Choosing Wisely, APTA has joined more than 60 medical societies and professional organizations in a broad commitment to reduce the use of unnecessary tests and interventions throughout health care.

Second, the Choosing Wisely recommendation in question refers to the use of physical agents. The Work Group did not include electrophysical agents in the development of this recommendation. The Guide to Physical Therapist Practice, 2nd edition, includes the following in its list of physical agents: (1) cryotherapy, (2) hydrotherapy, (3) sound agents, and (4) thermotherapy.⁵ It was an oversight in the article that we failed to make clear the definition of “physical agents” for this recommendation. A number of the articles and reviews retrieved during the literature search also included investigations of the effectiveness of electrophysical agents. This may have led to an assumption by Belanger and colleagues that both the literature search and the recommendation include the use of electrophysical agents. Additionally, the justification statement for the recommendation indicates that the recommendation is referring to treatment for musculoskeletal conditions. Treatment of wounds was considered in the fifth recommendation, “Don't use whirlpools for wound management,” but was not included in the recommendation related to use of physical agents.

Third, the article was written as a ProfessionWatch report and was not a systematic review of the literature for each of the recommendations that were considered. In an effort to be transparent about the list development process, we provided extensive online tables with detailed information about the submitted recommendations and the process used by the Work Group to develop and refine the list of recommendations. We did not, however, include a citation for each of the more than 500 articles that were reviewed during the list development process. The full list of citations reviewed by the Work Group will be posted for review on APTA's website at http://integrity.apta.org.

Finally, Belanger and colleagues question the statement in the justification section related to the potential for harm to patients from improper use or overuse of physical agents. In general, substituting ineffective treatments for effective treatments can cause harm by (1) misleading patients on the fidelity of treatment received and (2) delaying recovery. In certain patient populations, use of physical agents during physical therapy episodes of care was associated with poorer clinical outcomes and, therefore, decreased effectiveness.^6,7 We believe that it can be argued that unwarranted or continued use of physical agents may be harmful to patients seeking physical therapist treatment.

Because the primary goal of Choosing Wisely is to reduce the use of unnecessary tests and procedures in health care, all Choosing Wisely recommendations are written in the negative. APTA appreciates the suggestion about the development of “to do” lists based on evidence. Through programs such as PTNow and clinical practice guideline development, APTA is well positioned to collaborate with its sections in the development of these types of positive, evidence-based recommendations to guide clinical decision making. Again, we thank Belanger and colleagues for this suggestion and for the opportunity to discuss APTA's Choosing Wisely recommendations.

• © 2015 American Physical Therapy Association