The active future for the passive therapist (draft)
I've been asked by a few people this week if I can share a copy of the comment piece I've just written for JOSPT on the recent Editorial Musculoskeletal Physical Therapy After COVID-19: Time for a New “Normal”. Obviously the print version is covered by copyright, but here is a pre-print working version of the brief paper.
Traditionally ‘passive’ physiotherapy modalities like spinal traction, electrotherapy, hydrotherapy, massage, tissue mobilisation and manipulation, have all been subject to critique for some years now.
Most recently, these approaches have been labeled low-value care, because, it is claimed, they provide little or no benefit to the patient, and their risks outweigh their benefits (see appendix for recent research in this area).
So called ‘active’ approaches to therapy are promoted as holding higher value because they offer the ‘best care for the patient, with the optimal result for the circumstances, delivered at the right price’5, 2.
This argument is made in a recent article on the respective value of active and passive therapies to physiotherapy6. The authors suggest that we are at an inflexion point in the life of the physiotherapy profession. Active therapies and greater patient self-reliance, they argue, will move physiotherapy from an over-reliance on the hands-on, passive therapies of the past. I would argue, though, that debates over the distinction between active and passive therapies are only a symptom of a more profound and more significant set of issues that the profession should be discussing.
Describing this as physiotherapy’s ‘Sister Kenny moment’, Lewis et al offer a powerful metaphor for the kinds of disruptive change they and others have recently called for in practice. But the Sister Kenny metaphor may actually tell us something else about how physiotherapy might now think about the value of passive therapies.
'(S)elf-trained Australian "bush nurse" Elizabeth Kenny', is used by Lewis et al as a case study because she fought against the prevailing wisdom of the medical establishment and shifted the management of acute polio from passive to active care (ibid). But, in reality, Kenny was not ‘against’ passive therapies at all. Her first line of treatment was the repeated application of hot damp towels to reduce the patient's pain. These therapies were just as passive as the conventional bracing and splinting performed by doctors and physiotherapists at the time, only much more short-lived.
And while she critiqued the prolonged immobilisation of limbs13, her version of passive treatment was her main practice innovation. The active exercises Kenny recommended for the post-polio period were mostly generic.
Lewis et al also suggest that the polio vaccine contributed to physiotherapists 'embrac(ing) emerging passive therapies such as ultrasound, which was widely promoted in the 1950s, and various forms of therapeutic touch framed as treatment to "fix" biomechanical abnormalities'6. This is true on one level, but also slightly misleading.
Physiotherapists have always used 'passive' therapies. Galvanism and faradism, actinotherapy, massage, and various forms of tissue manipulation, have been cornerstones of physical therapy throughout the profession's history, despite 'questionable evidence' (ibid). Evidence of efficacy alone probably cannot explain why passive therapies have been popular in one era, and not in another.
What does seem to explain the fluctuations in all forms of hands-on or hands-off physical therapy are the cultural shifts that shape social attitudes towards health and wellbeing. We can see this throughout the history of the profession.
The popularity of remedial gymnastics in the 19th century, for instance, was a direct response to the soft indulgence of massage therapy14 and shaped European and North American physical therapy in the late 19th and early 20th centuries. Early physiotherapists' therapeutic exercise directly addressed anxieties about the fitness of the population and fed into eugenically-inspired concerns for racial decline12, 10.
The same can be seen in World War I. Early therapy for injured servicemen had been very much hands-on, mainly because this was the kind of work that the masseuses had been trained for. However, hands-on therapy also allowed young female therapists to prove that they could do the gruelling and painful rehabilitation work without scandal11.
Nevertheless, hands-on care proved time-consuming, labour intensive, and challenging to scale up to the enormous burden of disability experienced by servicemen during and after the war8. Even though the cost of rehabilitation was reduced by the employment of a primarily female - and therefore poorly paid - labour force, the size of the challenge was such that cheaper and more scaleable forms of group exercise-based therapy were promoted.
Likewise, the popularity of passive treatments like ultrasound and spinal manipulations in the second half of the 20th century may have had more to do with a Western culture that was enamoured with consumer technology, and the emergence of the musculoskeletal therapist as a 'heroic' (male) challenge to orthopaedic medicine and surgery, than any profound shift in our understanding of back pain.
I would argue that the times when physiotherapists have turned more to active therapies have had little to do with patient preference, evidence, or therapist skill, and much more to do with politics, cultural shifts, and economic expediency.
It is perhaps not surprising, then, that physiotherapists are now moving towards active therapies because Western countries have been promoting personal responsibility and healthcare choice for more than 40 years. Indeed, as far back as 1977, Ivan Illich wrote that 'the age of disabling professions… When people had "problems", experts had "solutions", and scientists measured imponderables such as "abilities" and "needs"… is now at an end'7.
What is perhaps surprising is that it has taken the physiotherapy profession this long to respond. So while moves to marginalise hands-on therapy and promote self-responsibility and 'active' therapy are as old as the profession itself, what is perhaps new is a growing realisation that physical therapies are very much tied to shifting cultural attitudes towards health and wellbeing.
There are some crucial implications of this shift that physiotherapists need to consider if they are to move once more towards active therapies. Perhaps the greatest of these is whether the profession is happy to have its practice principles tied to the rhetoric of neoliberalism.
Today, personal wellbeing and self-care are in vogue. We are all asked to take more responsibility for our health, as governments throughout the Western world try to manage unrelenting public demand for healthcare, increasing consumer choice, declining trust in orthodox medicine, and ageing populations, whilst also under pressure to reduce direct taxation and public spending. Health promotion, self-management, hospital-at-home plans, care pathways, continuous quality improvement, healthy conversations, public-private partnerships, and active therapies are all part of that phenomenon, as Bill Hughes argued in 2000;
'there is no doubt that this apparent democratisation of the relationship between professional and patient suited Western governments intent on reducing public expenditure and squeezing the welfare state. The idea of self-care and health maintenance is the layperson's responsibility rather than the professional became, in the 1980s, important ideological tools in the privatisation of health care activity'6.
Calls for patients to become less reliant on the therapist, and more focused on self-management, and lifestyle change are also ways of describing the 'ideal citizen under neoliberalism', who is 'autonomous, entrepreneurial, and endlessly resilient, a self-sufficient figure whose active promotion helped to justify the dismantling of the welfare state and the unravelling of democratic institutions and civic engagement'1.
People have been writing for decades about the drive to create 'consumers and enterprising individuals'4, and the way this is now shaping healthcare practice. Writing on nursing recently, Thomas Foth argued that;
'By emphasising patient’s active participation in the planning of their care, the nursing process became a means to realise the neoliberal idea of self-responsibility and entrepreneurial decision-making of both nurses and patients. It was the foundation that enabled the implementation of evidence-based nursing, best practice, quality management, and other technologies – the building blocks of the neoliberal transformation of nursing and healthcare'3.
I would argue then, that we should look at the current debate around active and passive therapies as a much broader and more profound question about the place of physiotherapy in society, and what kind of messages we want to send to people we care about.
The idea that passive therapies represent low value care, ignores the fact that low value care is a fraught concept15. There is little agreement about what ‘low value’ means, and much of the research suggests that the idea of ‘value’ is being driven by economic, rather than social factors (note, for instance, that high value care is defined as best care ‘at the right price’)2, 5. Although it claims to be patient centred, most of the research to date has ignored the consumer’s voice. What is more, it is almost impossible to disentangle physiotherapy approaches from the myriad other orthodox and informal caring mechanisms in place for people with long-term health conditions, and research driven by reductive variables does little to capture the complexity of the care pathways for most service users. Labels of low-value care are also deeply political, and have been used by some to make judgements about the work of other professional competing disciplines. And there are significant gaps and regional variations between the evidence and everyday practice that low value care cannot explain.
The use of language like low- and high-value care in physiotherapy suggests that the tension between active and passive therapies is a zero-sum game, in which a yard gained for one side is a yard lost for the other? But does it have to be an either/or calculation? Why not and/and? Physiotherapy needs passive therapies. People need passive therapies. History suggests they always have, and presumably, they always will.
We are moving inexorably from a time of passive therapies to an era of passive therapists, when healthcare professionals sit behind computer screens and treat at a distance. Hands-on therapies seem as remote in 2021 as they would have done in the polio era, with some even labelling them ‘low value care’15. However, time passes, and people recover. And many will return to wanting skilled, trusted, hands-on care, from well-trained practitioners they respect and can afford.
Human connection through touch is one of the most distinctive aspects of physiotherapy practice, particularly in orthodox healthcare where so much touch is procedural and incidental. Whether through massage and mobilisation, assisted movement or reassurance, the experience of how and when to touch therapeutically will be vital in shaping physiotherapy practice into the future.
We need advocates for touch-based therapies more than ever today, because when the page turns on this latest appalling chapter, and people think again about therapy for their illness and injury, they might just want to be passive for a while, and let someone else treat them in a way that has not been possible for weeks, months, maybe even years.
Sister Kenny believed passionately in hands-on, passive, and rest-giving therapies, just as much as active exercise and self-care. These approaches will be as valuable to people in the future as they have been throughout history. There are looming serious societal issues for us to tackle in the coming years that will need our full toolkit if we are to help.
References
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Committee on the Learning Health Care System in America; Institute of Medicine. Best care at lower cost: The path to continuously learning health care in America. 2013;8. Washington, DC: National Academies Press.
Foth T, Lange J, Smith K. Nursing history as philosophy-towards a critical history of nursing. Nursing Philosophy. 2018;19:e12210. https://doi.org/ 10.1111/nup.12210
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Gardner CG, Moseley L, Karran EL, Wiles LK, & Hibbert P. Implementing high value back pain care in private physiotherapy in Australia: A qualitative evaluation of physiotherapists who participated in an “implementation to innovation” system. Canadian Journal of Pain. 2020;4:1,86-102, https://doi.org/10.1080/24740527.2020.1732808
Hughes B. Medicalized bodies. In: Hancock P, Hughes B, Jagger E et al., eds. The body, culture and society. Buckingham, UK: Open University Press; 2000:12-28.
Illich I. Disabling professions. London: Marion Boyars; 1977
Lanckenau NI. Rehabilitation by modern methods of exercise. In: Doherty WB, Runes DD, editors. Rehabilitation of the war injured, a symposium. New York, NY:Philosophical Library; 1943:614-621.
Lewis J, McAuliffe S, O'Sullivan K, O'Sullivan P, Whiteley R. Musculoskeletal Physical Therapy After COVID-19: Time for a New “Normal”. [editorial]. Journal of Orthopaedic & Sports Physical Therapy 2021;51(1):5. https://doi.org/10.1111/nup.12210
McKenzie S. Getting physical: the rise of fitness culture in America. Lawrence, Kansas: University of Kansas; 2013
Nicholls DA. The end of physiotherapy. London UK: Routledge; 2017
Putney C. Muscular Christianity: Manhood and Sports in Protestant America, 1880-1920. Cambridge, Mass: Harvard University Press; 2009:310.
Rogers N. Polio Wars: Sister Kenny and the Golden Age of American Medicine. New York, NY: Oxford University Press; 2014
Todd J. Physical Culture and the Body Beautiful: Purposive Exercise in the Lives of American Women, 1800-1870. Macon, GA: Mercer University Press; 1998
Zadro J, Peek AL, Dodd RH, McCaffery K, & Maher C. Physiotherapists’ views on the Australian Physiotherapy Association’s Choosing Wisely recommendations: a content analysis. British Medical Journal Open. 2019;9:e031360. https://doi.org/10.1136/bmjopen-2019-031360