New guidelines for physical therapists and their patients were published recently under the "Choosing Wisely" campaign in partnership with the American Physical Therapy Association (APTA).

The campaign, run by the American Board of International Medicine (ABIM) foundation, aims to spark conversations between therapists and their patients by providing public guidelines for treatment protocols. ABIM hopes this will encourage patients to take a more active role in their own care and recovery.

The five-point list for physical therapists appears to have a running theme, along the lines of increasing exercise rehabilitation for patients (especially the older population) and reducing the use of "passive physical agents."

The point that seems to have had the biggest response from therapists, and some patients, is the first on the list: "Don't employ passive physical agents except when necessary to facilitate participation in an active treatment program." The term "passive physical agents" covers anything that is applied to the patient without effort from either the therapist or patient and produces some form of physical response.

Such treatments may include heat pads, whirlpools and electrotherapy such as ultrasound, TENS, interferential and laser. Instead, the recommendation is to implement an "active treatment plan," which according to APTA has a greater impact on pain, mobility, function and quality of life.

While there may be a modicum of controversy over the suggestion that passive physical agents should be thrown out, I don't think this is really what is being said. There has been a large question mark over the efficacy of such treatments for a good while now. Research generally doesn't support the use of electrotherapy such as ultrasound and interferential.

However, the guidelines don't say, "Do not use ever!" They simply advise that their use should be "supported by evidence and used to facilitate an active treatment program." Read into this what you may, but to me that statement says that if such a treatment may help the patient to start performing rehabilitation exercises sooner rather than later, then go for it.

I agree that exercise rehabilitation is the way forward in the vast majority of cases. But, if a patient is in too much pain to undertake even the most gentle of exercises, then there has to be some form of treatment first to reduce pain, and this is where these therapies come in. Provided that as soon as exercises can be comfortably introduced, this becomes the main focus of treatment, this approach falls within the framework of these guidelines.

Many therapists were taught to use passive physical agents as part of our undergraduate studies and have done so ever since, often with some degree of success. For myself, ultrasound is the one therapy I still use, albeit not often. Despite the fact that many research papers have demonstrated no positive effects of ultrasound (over either no treatment or a "sham" ultrasound) I still tend to use it in cases of severe tendinopathy.

Research may say one thing, but clinical results are another thing entirely. I think most therapists would agree that if you have seen results when using a treatment you will continue to use it, provided it is considered safe, regardless of research deeming it ineffective.

As long as the decision to use such a treatment is safe, you can justify its use based on previous success (does this count as evidence?), then why not. What do we have to lose? Treatment can then progress to a more exercise-based approach once pain and other symptoms subside.

In summary, the "Choosing Wisely" list is a good thing. Anything that encourages more communication between patients and therapists to ensure the patients are "in the loop" when it comes to their treatment can't be a bad thing.

However, there may be some confusion when it comes to interpreting the first point on the list. I think the aim of the board when compiling this list was to make both patients and therapists question their treatment choices. I don't think they are putting a blanket ban on any form of "passive physical agent," but instead trying to encourage treatment sessions that are more proactive and enable the patient to play a bigger role in their own care.

A move toward stronger exercise rehabilitation values, which has proven to be the most effective form of therapy for treating and preventing most forms of injury, is a step forward.