There’s nothing quite like having to limp around on crutches or dress yourself with just one arm to make you appreciate your "normal" life, is there? After injury or surgery (or both), it’s widely accepted that patients must commit to a rigorous physical therapy regimen to regain lost abilities... so can you imagine how frustrating it would be to learn that you’ve worked incredibly hard, doing difficult, boring, time-consuming exercises that didn’t actually help?
What’s the Problem?
It’s not that physical therapy (PT) is a waste of time -- but there are relatively few evidence-based standards in place regarding what works and what doesn’t work. What one patient does in PT compared with another who has the same problem is determined by the therapist, so there is some hit or miss in the regimen. While professional judgment always will be relevant, researchers are now working to develop "standards of care" -- exactly as has happened already in other branches of medicine.
In this case, it’s a challenge along the lines of developing guidelines for judging gymnastics or figure-skating competitions. How do you quantify what works, given the countless variables that can affect a particular patient’s outcome, ranging from motivation to fitness to cardiovascular health? I called James J. Irrgang, PT, PhD, a researcher in the department of orthopedic surgery at the University of Pittsburgh, president of the orthopedic section of the American Physical Therapy Association, and leader of this new effort, to learn more about how his team is approaching the task.
Dr. Irrgang told me that the researchers are sifting through existing studies and categorizing PT treatments into three groups: "A" for treatments with strong evidence supporting their use for a particular injury... "B" for treatments that have some but not much evidence backing their use... and "C" for treatments that are worth considering but have not had many studies evaluating their efficacy. The final recommendations are not yet complete, but Dr. Irrgang was happy to share some of the group’s preliminary findings.
Sneak Peek at the Research
First of all, you may be surprised to learn that there isn’t much evidence supporting some of our most common treatments for muscle strains and sprains. I’m talking about ice, heat and massage, all of which are certainly helpful for pain -- but as far as facilitating healing, not so much. According to Dr. Irrgang, "While ice may be beneficial for reducing pain and swelling after a new injury, complete recovery will require exercises to restore motion, improve function and prevent recurrence."
Here’s how treatments for two common injuries are playing out...
Sprained ankle. What works? Into the "A" bucket goes a treatment plan consisting of manual stretching done by the physical therapist, combined with exercises for strengthening and range of motion. Taping the ankle to provide support while healing, as is often done by athletes, is in the "C" category -- optional. If it seems to help, fine -- if not, don’t bother.
Achilles tendonitis. If you suffer this painful overuse injury, the only research-affirmed treatment is "eccentric strengthening exercises for the calf muscles," said Dr. Irrgang. An example is this heel-lowering exercise: While standing on the first step at the bottom of a staircase, use both legs to raise your body weight up -- then, using only the injured leg, lower your body weight in a controlled manner so that your heel is below the stair. Meanwhile, high-tech treatments such as low-level laser (using light energy to reduce pain and promote healing) and iontophoresis (delivering anti-inflammatory medications to the painful area via an electrical current) go into the "B" category... while basic stretching exercises and orthotics for your shoes may or may not help, making these "C" treatments.
Leave Room for Individual Needs
Don’t view this as a report card, urges Dr. Irrgang. While there may be scant evidence supporting particular treatments -- for example, ultrasound -- many people will still find them beneficial. There are many variations from one person to the next, including severity of the injury, pain tolerance or even your level of expectation as to the benefits of a particular treatment (the placebo effect). In his view, as long as a therapy makes you feel better, does no harm and is not costly (and ultrasound treatments fit the bill on all three counts), he sees no problem with using it for a short course of time to see if it helps.
Since research is ongoing, be sure to ask your physical therapist what current evidence supports recommended treatments -- it’s always wisest to first try the therapies with the strongest evidence to back them. Dr. Irrgang noted that it’s likely that these new guidelines, when finalized, will affect insurance coverage -- for instance, it’s possible that insurers will reimburse only for "A" and "B" treatments, perhaps disallowing those in the "C" category. That’s not yet the case though, so for now, just check to make sure that your insurance coverage includes PT, how many appointments are covered and what your co-pays will be.
James J. Irrgang, PT, PhD, ATC, researcher, department of orthopedic surgery, University of Pittsburgh. Dr. Irrgang is president of the orthopedic section of the American Physical Therapy Association.