Author Response

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

We thank Bjordal and colleagues¹ for their interest in our ProfessionWatch article, “The American Physical Therapy Association's Top Five Choosing Wisely Recommendations” (CWR).² We welcome the dialogue generated by the publication of these recommendations and are pleased to have the opportunity to clarify several aspects of the article.

In an earlier letter, Belanger and colleagues³ also questioned the use of the words “passive” and “active” in APTA's first CWR: “Don't use passive physical agents except when necessary to facilitate participation in an active treatment program.”² We refer readers to our response to those comments.⁴ We reiterate here that the specific recommendation in question was developed not because of the passive nature of the intervention, but because of lack of evidence of the intervention's value as a stand-alone treatment for many conditions. We appreciate that the phrase “active treatment program” may be misinterpreted because of the multiple meanings assigned to its use. However, a focus on whether the “active” aspect of treatment refers to the patient/client, the physical therapist, or the goal of the treatment distracts readers from the point of the recommendation, which is that physical agents should not be used except when necessary to facilitate the achievement of functional goals directed toward optimizing movement.

Although the wording of the first recommendation is not inaccurate, we recognize that the use of the words “passive” and “active” in the recommendation has resulted in some misunderstanding, and we will consider modifying this wording at the next opportunity for revision.

The American Board of Internal Medicine (ABIM) Foundation guidelines for list development state that “There should be generally accepted evidence to support each recommendation.”⁵ The phrase “there is strong evidence that demonstrates that the service offers no benefit to most patients” was paraphrased in our article and did not accurately reflect the intent of the ABIM Foundation guidelines. We regret any confusion this may have caused. The 5 ABIM Foundation guidelines for list development include the following: (1) organizations can determine the methodology for creating their lists; (2) each item should be within the purview and control of the organization's members; (3) practices should be used frequently and carry a significant cost; (4) there should be generally accepted evidence to support each recommendation; and (5) the process should be thoroughly documented and publicly available upon request.⁵ The Work Group followed the ABIM Foundation guidelines⁵ and operating principles for clinician organizations' participation in the Choosing Wisely campaign⁶ in developing the recommendations, and they, along with APTA members who participated in the process and APTA's Board of Directors, agreed that all 5 of APTA's Choosing Wisely recommendations met the ABIM Foundation guidelines.

Bjordal and colleagues comment that the first recommendation has not been adequately substantiated by evidence. Table 5 in our article includes 11 key citations to support the recommendation.² The article was written as a ProfessionWatch report and not as a systematic review (SR); therefore, we did not include a citation for each of the more than 500 articles that were reviewed during the CWR development process. The complete citation list reviewed by the Work Group will be posted on APTA's website at http://integrity.apta.org. More than 150 of these citations are on physical agents and include many RCTs, SRs, and clinical practice guidelines.

The CWR in question refers to the use of physical agents as defined by the Guide to Physical Therapist Practice, second edition,⁷ and includes (1) cryotherapy, (2) hydrotherapy, (3) sound agents, and (4) thermotherapy.^4,7 Because many of the articles and reviews retrieved during the literature search also included investigation of the effectiveness of electrophysical agents, this might have led to an assumption that the recommendation refers to the use of electrophysical agents. This was not the intent of the recommendation, and it was an oversight that we did not clarify the definition of “physical agents” for this recommendation.

Bjordal and colleagues question the statement in the justification section related to potential for harm to patients from use of physical agents. As stated in our earlier response,⁴ substituting ineffective or inappropriate treatment for effective treatments can, in fact, harm patients by (1) misleading patients about the value of the treatment and (2) delaying recovery, which may lead to poor outcomes or unnecessary use of more invasive or more expensive treatments.^8,9 Bjordal and colleagues refer to physical agents as “harmless substitutes for expensive and potentially harmful analgesic medication.” We have not seen convincing evidence pointing toward heat and cold being an equally effective substitute for analgesics. Additionally, physical agents are not inexpensive when taking into consideration the Current Procedural Terminology (CPT) coding system and the physical therapist's time.

We agree with Bjordal and colleagues that evidence supports addressing fear-avoidance behavior with cognitive and movement therapies. APTA's first CWR supports the judicious use of physical agents as an adjunct to cognitive and movement therapies or to other treatments based on each patient's individual situation and the physical therapist's clinical judgment. It is injudicious and indiscriminate use that is wasteful and inevitably leads to poorer outcomes.

We disagree with the statement by Bjordal and colleagues that the literature search was biased and aimed at supporting the statement and disregarding opposing references. For the literature review, the Work Group members and APTA research librarians discussed and agreed on the literature search parameters during the planning stages of the process. The terms and parameters were further refined at the beginning of round 3 of the list development process when the Work Group had more information about the recommendations that were under consideration. This process is described in the article.²

The first steps in the development of APTA's Choosing Wisely list included establishing the methodology and appointing the Work Group. The Work Group was appointed prior to the item submission process. These appointments were not informed by topics that would later be brought forth from the membership for consideration. Work Group members were selected to be as representative as possible of the many physical therapist clinical specialties and practice settings and to possess both clinical expertise and familiarity with research and practice in their identified content areas. We are confident that the Work Group had the background necessary to consider all recommendations that were submitted by members, to review and interpret the literature, and to refine the recommendations to reflect best evidence.

In preparation for the biannual review and revision of APTA's Choosing Wisely list in 2016, we have implemented a process to collect and summarize new evidence related to all of the recommendations. Although the first recommendation does not refer to the use of electrophysical agents, APTA may consider these types of interventions in the next iteration of the Choosing Wisely list. We look forward to a robust discussion during the process of review and revision of APTA's list and welcome input from all stakeholders.

The importance of Choosing Wisely comes from its potential to reduce the use of identified low-value health care services. This change will require revision of practice patterns and patient expectations that have been shaped and reinforced by habitual overuse. We agree with Bjordal and colleagues that “our professional practice and ethos are centered on the active and movement-centered approach.” It is this focus on optimization of movement and conscientious use of evidence that is key to the recognition of physical therapists as providers of high-value care.¹⁰ Like Bjordal and colleagues, we embrace the tenets of evidence-based practice and believe that the Choosing Wisely initiative is one of many tools that will support physical therapists in providing the most effective care for our patients.

• © 2015 American Physical Therapy Association