Do physios manage pain properly?

When people visit a GP clinic or hospital in Australia or the United States, they receive the recommended care around 55-57% of the time.

Recommended care means they get the tests or treatments that evidence-based guidelines say a patient should receive for their condition. This is usually because they're the most effective or cost-effective option. The recommended care for people with knee osteoarthritis, for example, is exercise and weight loss.

Clinicians may not provide recommended care for several reasons. These include wishes of the patient, lack of trust in the evidence or guidelines, or experience providing certain types of care.

Doctors often refer patients with musculoskeletal problems such as back pain and osteoarthritis for physical therapy. But until now, it has been unclear how often physiotherapists provide the recommended care for these patients.

Our review of the international evidence, published today in BMJ Open, found 63% of physiotherapists provided recommended treatments. But 27% provided treatments that weren't based on evidence and that the guidelines recommended against.

Fortunately, failing to provide recommended care is unlikely to harm patients. Nevertheless, ditching non-recommended treatments could result in more efficient care and fewer resources being wasted.

Our study

We reviewed 94 studies from 19 countries, including Australia, to investigate the treatments physiotherapists provided for a range of musculoskeletal conditions. These included back pain, knee osteoarthritis, neck pain, whiplash, foot or ankle pain and shoulder pain.

We used physiotherapists' clinical notes to determine which treatments they provided. We then compared their treatment choices with recommendations from evidence-based guidelines, or guidelines that were considered most credible for each condition.

Overall, we found 63% of physiotherapists provided recommended treatments, which appears higher than in hospitals and GP clinics overall. A 2012 Australian audit, for example, found 57% of patients surveyed received recommended care.

But in our study, almost half of physiotherapists (45%) provided treatments that guidelines didn't mention because there wasn't enough evidence to say if they worked or not.

And one in four (27%) provided treatments the guidelines recommend against. This was usually because the evidence showed they're ineffective.

Physiotherapists can provide a range of treatments, some recommended and others not, so these percentages don't add up to 100. Of the 63% who provide recommended care, for instance, some might also be providing treatments that are not recommended or that are not mentioned in guidelines.

Why does it matter?

Back pain, neck pain, osteoarthritis and other musculoskeletal conditions can have a substantial impact on people’s lives, and often cause disability.

Traditionally, these conditions were managed with medication and surgery. However, medications such as opioids cause harm and there is growing evidence that some common surgical procedures are ineffective. This has prompted a shift in what is recommended for musculoskeletal conditions.

Today, clinical practice guidelines recommend treatments provided by physiotherapists over medication and surgery.

There is, however, a range of treatments physiotherapists can provide.

Some treatments are effective, such as exercise for knee osteoarthritis. Other treatments are not, such as acupuncture for low back pain.

To ensure patients receive the right care, physiotherapists are expected to follow recommendations from clinical practice guidelines. These guidelines are often multidisciplinary and intended to be used by GPs, physiotherapists, and surgeons.

Physios manage some pain better than others

When it comes to following clinical guidelines, we found physiotherapists manage some conditions better than others.

For shoulder pain, up to 76% of physiotherapists provided recommended treatments (such as strengthening exercises and massage). Only 8% provided treatments that were not recommended (such as magnetic field therapy, which uses an electrical current to alleviate pain).

There is room for physiotherapists to improve their use of recommended treatments for knee osteoarthritis and low back pain.

For knee osteoarthritis, 65% of physiotherapists provided recommended treatments (to advise patients to stay active, undertake aerobic and strength exercises and lose weight). One in five (21%) provided treatments that were not recommended (such as acupuncture and advice to reduce activity levels).

For low back pain, half provided recommended treatments (advice to stay active and reassure patients that most people recover from back pain without formal treatment); while 18% provided treatments that were not recommended (acupuncture, lumbar braces, or advice to rest in bed until the pain goes).

Concluding remarks

Physiotherapists have a lot to offer patients with musculoskeletal conditions. But it's important they don’t dilute appropriate care with inappropriate care.

Better adhering to clinical practice guidelines could increase the efficiency of physiotherapy services and ensure patients only receive care that is truly necessary.

This article was first published on The Conversation and is written by Dr Joshua Zadro from the University of Sydney at the Institute for Musculoskeletal Health.  

Declaration:  Joshua Zadro does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.