Indirect Effects of Physical Therapy

I’ve already established my strong distaste of the term “non-specific effects.” Don’t even think of using those combined words with me!

After reading a recent JAMA abstract on the effects of physical therapy for hip osteoarthritis AND listening to the podcast interview with the lead investigator, I’m in favor of the term indirect effects.

When I see a title like, “Physical Therapy for Hip Osteoarthritis may not Lead to Significant Benefits” and we see a crappy photo of a group parachute activity, my immediate mode is attack mode. I mean, seriously, who the heck does that parachute thing for hip osteoarthritis?

Before getting defensive and raising the hackles over the abstract (I haven’t seen the full text) or even the stupid 2 Minute Medicine article, it’s interesting to instead take a step back and reflect.

No study is perfect. I truly believe the intent of the study was to determine the value of conservative treatment with physical therapy as a focus. I also believe thought was put into creating a standardized process to capture the effect. Is it difficult to hear that whether the subject spent time with a clinician providing reasonable care that seems on par with evidence OR whether the subject spent time with a clinician providing care that should not provide positive benefit both resulted in improvement in pain in function? You bet it is!

I don’t want to nitpick the study… instead, think of what this means… think of how this can alter your practice. I am not saying we should all begin doing sham ultrasounds or rubbing inert gel on hips (for those of you who know me, you know that would never be my advice).

We need to definitely accept indirect effects. We need to accept that what we code and bill and actually physically do with patients may not be the most relevant aspect of our role. We need to begin to standardize processes to capitalize on indirect effects.

If we don’t acknowledge and implement the science involved with indirect effects, we are no better than anyone who uses homeopathy. We need to banish the image of tossing our hands in the air and stating “non-specific effects.” We need to begin focusing on what triggers the indirect effect and understand specifically what happens, when it happens, how it happens & why it happens… we need to figure out how to measure it is actually happening… we need to figure out the maximal intensity or strength of positively skewed indirect effects… we also need to figure out what substantially reduces positively skewed indirect effects. The answers may not even lie in quantitative studies… the answers will probably be found in qualitative studies. Google Glass and video analysis… recording, measuring and analyzing behaviors (body language and verbal language) to then managing our own behaviors to improve the indirect effects. The answers may even already be out there in the realm of sociology and psychology…

Are we ready as professionals to accept a big piece of our value may not necessarily be tied to the evidence we use for the basis of our interventions?

Until next time,


17 responses to “Indirect Effects of Physical Therapy

  1. John Childs says:

    Great post Selena and couldn’t agree more. We unwittingly use words like “non specific” and “placebo” as a disguise for the fact that the effects may not be directly attributable to something we can readily understand…yet. We’re slow to admit the potential for something benefiting a patient unless we have some tried and true model that tells us why in a way that our finite and minuscule minds can readily understand. If only we could be more secure in our uncertainty….

  2. Dave Twetke says:

    Interesting study. Just a note. as a fellow PT, I think the language you use here should be more professional. i.e. using the word “stupid” as an adjective is not exactly professional and serves only to incite hostility, as opposed to academic discourse.

    Nonetheless, I agree with the general subject of the post – but I think everyone should read the actual study as well.


    1. Selena Horner says:

      My apology, Dave. I try to have fun when I write and convey my thoughts. I tend to think that by being me, you’ll have no surprises if we were to ever meet! Technically, the parachute photo was the stupid part of the 2 Minute article. :) Thanks for the feedback. By the way, a colleague sent the study to me. I have seen the full text. It was well done.

  3. Now you are talking Selena! Again, I say look at the dopaminergic effects on both pain relief and function. Never mind serotonin, endorphins and anti inflammatory cytokines(Some myokines) No other practitioner can even come close to us in the effects we can create on these substances. We influence these substances for better or worse from the relationship that we and our staffs create with the patient, the type and intensity of the exercise we provide,and even stuff we may not believe in like modalities and massage. Even manipulation so highly regarded by most of us has much more than a mechanical effect.

    All of the above might explain why relatively unsophisticated PTs have a clinic full of patients while some highly skilled practitioners scramble for a minimum share of the market and why so many clinical studies contradict each other.

    Jim Glinn,SR PT (aka PT Geezer Guy)

    1. Selena Horner says:

      I have a feeling it will be quite interesting in the future… when we really bring to focus what’s going on with indirect effects. I wasn’t even thinking of the chemical reactions that occur! I was thinking more of the psychological aspect… you are absolutely correct though! I bet there are human chemical reactor changes. We are just one big ol’ ongoing chemical reaction.

  4. Well,yes Selena, but the psychological effects are also .chemical-neurochemical. We are, as you say, one(actually a lot) of big ol’ chemical reactions……… but in my mind , and I am not a neuroscientist,just an old beat up PT, even the psychological is based on chemical reactions, so to divide the physical and the psychological up, as we have done in our education, makes no sense to me.

    I think maybe a better term than “indirect effects” might be “non-mechanical”.

    I think, in the very near future, all PTs will be taught to use the reward and opiate centers in patients to open paths for increased function.For example, take a triathlete with a chronic overuse injury who has not worked out for a few weeks, give him or her a good blast of dopamine through conversation,followed by a healthy dose of endorphins and antiinflammatory myokines by working the crap out of the patient in non-painful ways then add a little more endorphin and dopamine at the end by manipulating or mobilizing adjacent structures. None of this may return him to competition, but the athlete will still leave as one happy camper plus a stellar patient-therapist relationship has been developed,all of which is helpful to healing as well as a whole pile of new patients in the clinic via word of mouth marketing. What do you think of the term “non-mechanical”,or maybe “non biomechanical??

    Geezer PT Guy

    1. Selena Horner says:

      I’m not sure… it’s almost as if we need a map of the human chemical reactor. The cascade of chemical reactions that occur via various inputs: body language, verbal language, visual (including imagery), smell, manual intervention and physical intervention. At the same time, it’s almost as if we also need to know the patient’s current chemical state (that’s probably not the right term). Human chemical reactors aren’t even in a consistent state of balance, which creates a challenge. If you are as old as you say you are, you might not understand my next thought! We need a Magic School Bus episode to help simplify the human reactor! lol

  5. Reading moods requires empathetic listening, which in itself can create neurotransmitter changes in patients that are likely to alter their reaction to our interventions. Substance abuse counselors and even marketing reps have been taught these basics for years. The human systems are indeed complex. Magic School Bus?? Is it powered by horses or oxen?

  6. Matthew Rupiper says:

    Someone smarter than I (Bas Asselberg) suggests the term “contextual effects.” I think this is a much more useful term. We all understand context plays an important role, from the front office to therapist. Indirect and non-specific still make folks think placebo or inert. Contextual is easier to understand, grasp and accept in my opinion. Someone also smarter than I (Cory Blickenstaff) suggests we are mostly ‘contextual architects’ as physical therapists. I can’t disagree with either of them…

    1. Selena Horner says:

      Nice thought, Matthew. Context doesn’t help describe the chemical interactions that occur physiologically. Individuals may have differing responses to the same context. The key is being able to monitor and manage the response and change the context vs anticipating that a predetermined context will have a predictable response. It goes back to what The Geezer PT shared – that stuff is powerful stuff.

  7. Larry says:

    There are certain terms in medicine (and in particular research) that makes PT’s uncomfortable-placebo and non specific effects are 2 of them. Many PT’s for whatever reason believe that placebo effect is a “bad thing” even though technically placebo is both a positive and very real from a biological standpoint (Geezer PT gives some examples). Our interactions and interventions should come with instructions on how to accentuate placebo, negate nocebo, and best current evidence (Selena’s points well taken). I have gotten the impression that PT’s often dismiss the relevance of placebo or nocebo and Whether we call it “indirect”, “contextual”, “non specific”, or” unintentional” isn’t nearly as important as acknowledging their presence and importance.

    1. Selena Horner says:

      To find an appropriate term that fits multiple touch points in our interactions would be gold. The situation is far more than acknowledging to me – applying would be my preference.

  8. Larry says:

    By the way, a somewhat related TED talk on hope and optimism in medicine. Perhaps that is what we do better than others?

    1. Selena Horner says:

      That’s the kind of magic we all need to understand and harness. People’s beliefs are so powerful.

  9. Greg Ohanessian says:

    Osteoarthritis is usually a physics equation that has gone bad. Joints work around a physiological axis of motion and when that axis is thrown off from trauma, congenital effects or imbalances, etc. the rate of breakdown of cartilage will escalate. I think that by the time a person has advanced stage 4 OA there isn’t much PTs can do to heal cartilage and the patient will benefit from surgical intervention and post-op PT.
    I believe having easier direct access to Physical Therapist will allow people with early stages or patients at risk for hip OA to be diagnosed earlier and implement treatments earlier to slow the progression of OA. Research is lacking in this at the moment but there are current longitudinal studies in the works as we speak.
    If General practitioners or internal medicine doctors want to say PT is not good for OA they need to greatly improve their diagnostic skills to find the OA earlier and get them into the experts (PTs, ortho MDs) for better evaluation and more optimal interventions. Dispensing Opiates for pain management of a musucloskeletal issue it not the answer.

    1. Selena Horner says:

      Or… maybe we need to step up as professionals and reach out to the public on when they need to seek services? We shoulder just as much of the problem, don’t we? Could we create a short video of what early OA would feel like? How the person might begin moving? We haven’t taken responsibility to create public awareness.

      1. Greg Ohanessian says:

        Agree 100%!

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