As part of the American Board of Internal Medicine Foundation’s “Choosing Wisely” initiative—a nationwide effort aimed at helping patients make more informed healthcare decisions—the American Physical Therapy Association (APTA) has released a list of physical therapy treatments that can be ineffective, even dangerous, if prescribed improperly. Surprisingly, the roster includes quite a few familiar therapies.
“The Choosing Wisely initiative’s purpose is to encourage conversation between providers and patients, which is key to positive health care outcomes in physical therapy and other disciplines,” says Neil Moss, partner and clinical director of Professional Physical Therapy in Bayside, New York.
Seniors are often prescribed physical therapy (PT) to help improve functional mobility following accidents and medical setbacks, such as a fall, a stroke, a broken bone or a surgical procedure. Working with a physical therapist can also be beneficial for patients with chronic conditions like Parkinson’s disease, chronic obstructive pulmonary disease (COPD) and multiple sclerosis (MS). Understanding the various parts of a physical therapy regimen and being able to discuss goals and techniques with a physical therapist can significantly improve one’s results.
Physical Therapy Treatment Plans
Practitioners typically go through a comprehensive process to determine the ideal physical therapy regimen for an older adult, beginning with a thorough evaluation of their specific needs. But a successful treatment program should be built on more than just a diagnosis. A patient’s goals and progress must be ongoing considerations as well.
“You can have two patients with the same diagnosis but very different physical findings,” Moss explains. “Each treatment plan must be personalized to help with a patient’s specific challenges.”
Physical therapists can choose from a wide range of equipment and techniques to help a senior regain their functional mobility and independence. Some of the most common tools include:
- Modalities (e.g. ice, heat and electrical stimulation)
- Therapeutic exercises to restore functional strength, range of motion, flexibility and endurance
- Neuromuscular re-education to restore balance, coordination, kinesthetic sense, motor coordination, posture and proprioception
- Directed therapeutic activities to restore functional performance
- Manual therapy (e.g. soft tissue mobilization and stretching) to restore mobility
The goal of physical therapy, according to Trisha Brabender, a physical therapist who specializes in geriatrics, is to help older adults remain as active as possible. “Whatever the patient can do to maximize movement, we then use that ability to improve their overall function.”
Physical Therapy Treatments to Question
The APTA reviewed countless PT treatments and created a list of interventions they felt might not always be as beneficial as some therapists and patients think. If you or a loved one are currently participating in a PT program or may begin one in the future, be sure to discuss the benefits and drawbacks of the following treatments with the therapist if any of them are prescribed.
- Ice packs, heating pads and ultrasound.
Ice packs, heating pads and other “passive physical agents” may loosen tight muscles and dull post-workout aches, but experts at the APTA claim that their effects don’t last long. Brabender says that, while she may initially use these interventions along with manual therapy techniques to increase a patient’s mobility, “the goal is always to move the patient away from passive physical agents and get them moving and pain free as quickly as possible.”
While these treatments are not harmful to PT patients, they can exacerbate fear and anxiety of engaging in physical activity while in pain. Essentially, therapists should not rely on passive physical agents unless they are necessary to facilitate participation in the PT regimen. A senior with any degree of nerve damage (neuropathy) should use caution when using a heating pad. Decreased sensation in the skin may cause an unintentional burn during prolonged use of an electric heating pad. - Whirlpool baths for wound care.
Older adults, especially those who are diabetic or who have poor circulation, can develop wounds that are slow to heal. One of the traditional treatments for such wounds is immersing them in a whirlpool bath. However, the possibility of infection from a dirty tub, trauma from powerful jets and exposure to harsh chemicals may further disrupt the healing process rather than encourage it. “Never use whirlpool therapy to treat open wounds,” the APTA states. Safer, healthier alternatives include directed wound irrigation and pulsed lavage with suction to cleanse and debride the affected area. - Subpar strength training programs.
The right strength training program can work wonders for an older adult, increasing their balance, minimizing their fall risk and improving their overall independence. Yet many physical therapists play it too safe when it comes to developing exercise programs for aging individuals. “Older adults are often prescribed low-dose exercise and physical activity that are physiologically inadequate to increase gains in muscle strength,” says the APTA.
Such moderation is unnecessary, especially since, as Brabender points out, aging adults are usually eager to improve their physical abilities. “Seniors are often much more compliant than younger people,” she says. “They typically have more time to devote to exercise if they are retired and they often feel very motivated to improve their health in order to enjoy their grandkids and activities in retirement or just age gracefully.”
Baseline strength levels should be established for each patient to create a challenging yet realistic exercise program that can be incrementally progressed to maximize results. Maintaining open lines of communication with a PT about pain and difficulty levels is crucial for striking the right balance. - Continuous passive motion machines.
The idea behind the use of continuous passive motion (CPM) machines for post-surgical rehabilitation is to promote healing and restore mobility in joints that have recently been operated on. However, studies have shown that using CPM machines after knee replacement surgery may not be effective enough to justify the cost of the devices (patients often have to pay rental fees).
A CPM machine also requires the user to remain in bed while performing the movements, thus limiting the length of time they spend getting up and walking around. “I have often felt that physical therapy overutilizes machines and that we are sometimes complacent when designing exercise programs,” Brabender admits. Moss claims that early mobilization is more effective than bed rest with CPM and that alternatives should be explored during rehabilitation discussions between therapists and patients. - Bed rest to prevent blood clots.
Deep vein thrombosis (DVT)—a blood clot that forms in deep veins like those found in the legs—poses a serious risk to older adults and people who’ve recently undergone surgery. If these clots break loose, they can travel to the lungs and become stuck, causing a potentially fatal blockage called a pulmonary embolism. In order to reduce the risk of clot formation, patients are often prescribed blood thinners and advised to go on bed rest following surgical procedures. However, research indicates that, for patients on blood thinners, pulmonary embolisms are no more common in those who walk around than those who remain in bed. Bed rest also weakens the body overall and can cause clots to grow in size. As long as an individual’s anti-coagulation goals have been met and they haven’t had a stroke or severe breathing issues, getting out of bed is probably their best option for jumpstarting their recovery, says the APTA.
These guidelines are not only supposed to give patients and providers pause when it comes to certain treatments, they are also meant to provide talking points for starting an honest, open dialogue. “During a rehabilitation program, it is critical to be an active, not passive, participant, not only when discussing one’s care, but also when it comes to doing the work,” urges Moss. “Patients must actively engage in physical therapy exercises to achieve optimal results with their recovery.”
Additional patient resources and information on physical therapy and various other medical specialties can be found on the American Board of Internal Medicine Foundation’s Choosing Wisely Initiative website, http://www.choosingwisely.org/.