Paradoxically, it is easier to perform a sham trial in
surgery, the most invasive physical act, than in physiotherapy because the
patient is asleep when it is delivered. Physical therapy involves physical acts
that are hard to imitate as placebo treatment, but the influence of the patient-therapist
interaction makes it important to tease out any placebo effect. Researchers
have, however, performed sham trials in physiotherapy.
A study from JAMA in 2014 (here)
tested a 12 week multimodal physical therapy program (combined with home
exercises) for patients with hip osteoarthritis, against sham physiotherapy
involving an inactive ultrasound machine and some inert gel (combined with home
application of the gel). Even though patients tended to guess what group they
were in (those getting real physiotherapy thought they were getting the real
treatment), the results still showed no difference in pain and function scores
at 24 weeks, with the pain scores slightly favouring the sham group. There were
also less adverse events in the sham group. It seems that physiotherapy hurts,
and provides no benefit beyond placebo.
The same group did a similar study of knee osteoarthritis
published in 2005 (here),
also showing that the active multimodal treatment was not significantly better
than sham treatment.
These are important studies because they tease out the effect
of the interaction with the therapist, an important factor in getting patients to
feel better. A review (here) of
the effect of this ‘treatment alliance’ between the patient and the therapist has
shown that it positively affects patient outcomes.
The placebo effect in studies of osteoarthritis has been previous
summarised (here), concluding
that placebo treatment is better than no treatment, particularly in patients
with more severe symptoms and if the intervention is ‘active’, with treatments
involving needles doing best.
The bottom line
Sham studies of physical therapy for hip and knee osteoarthritis show no benefit over placebo. Given that open (not blinded or sham) studies of physical
therapies often show only marginal benefits (often less than what is considered
clinical meaningful), perhaps we should be looking at doing more sham studies
of physical therapies. And maybe doing a little less physical therapy in the meantime.
Another RCT showed benefit from exercise therapy for hip osteoarthritis.
ReplyDeletehttp://www.ncbi.nlm.nih.gov/pubmed/25249361
The main difference between the exercise protocols used in the two studies was that the successful trial included exercises to strengthen the hip extensors, while the unsuccessful trial focused on the quadriceps and hip abductors.
Thanks for the link. It should be noted that that study showed no difference in quality of life, and that the differences in pain and function scores were well below the minimum differences considered to be "clinically important". Still not a good advertisement for physical therapy.
DeleteDr. Skeptic,
DeleteAs a physical therapist….thank you for writing this. In the end healthcare has become a turf war seeking the dollars of those with pain. Physical therapists continue to advertise "we are as effective as…" How about everyone say, we aren't effective?
Physical therapists should stick to what science and common sense shows us: progressive physical activity can improve strength, endurance and function. This holds true for any population with and/or without disease or pain. Trying to "treat" pain is like "treating" love or someone's mood. All systematic reviews will continue to show little to no effect when treating an emergent phenomenon that is pain.
Patients have two options:
1. Do less. See who that works
2. Stay fit or do more.
Good to see Physiotherapy receiving some scrutiny from outside the profession. Perhaps it might stimulate a more robust and refreshing debate within. Too little criticism has allowed many practices which are well past their sell by date to prosper potentially to the detriment of those seeking care.
ReplyDeleteGood to see Physiotherapy receiving some scrutiny from outside the profession. Perhaps it might stimulate a more robust and refreshing debate within. Too little criticism has allowed many practices which are well past their sell by date to prosper potentially to the detriment of those seeking care.
ReplyDelete