Therapeutic Modalities: Attitudes, Acceptance, Opinions, and Reality

While traditional classroom and lab-based education in the principles and administration of therapeutic modalities have remained in educational curricula within there habilitation sciences, clinical use has wavered. The last several years have seen a notable shift in the way therapeutic modalities are accepted and used. Whether based on evidence, clinical opinion, experience, perpetuated myth, attitude, anecdotal story, or other, therapeutic modalities have come under great scrutiny. Consequently, there has arisen an all-too-common bias against use of therapeutic modalities and unfortunately, this bias is threatening the continued use of these co-therapies aimed at complementing other skilled interventions.

Propagated in part from the movements toward evidence-driven practice, much of this bias or negative attitude is commonly perpetuated from a limited view of the available literature. Biases and negative attitudes often develop from a lack of having thoroughly analyzed and synthesized the collective literature in order to justify such opinions. Unfortunately, the obligation to this comprehensive process of analysis and synthesis is far too often left unfulfilled. What a thorough examination of the literature has shown is not so much a lack of evidence for therapeutic modalities, but rather three realities; 1) early scientific inquiry of therapeutic modalities was plagued by a history of poorly designed studies which unfortunately continue to be used as a basis for current attitudes, acceptances, and opinions despite more robust and significant improvements in research quality in the past decade, 2) past and current use of therapeutic modalities often fails to incorporate newer understandings of proper administration, particularly newer evidence on appropriate dosing, and 3) lack of evidence does not mean a therapeutic modality does not do what it is intended to do; rather, how the efficacy of therapeutic modalities is assessed is more often faulty.

In 2014, the American Physical Therapy Association’s (APTA) contribution to the “Choosing Wisely” initiative of the American Board of Internal Medicine addressed “Five Things Physical Therapists and Patients Should Question.”¹ Of these, one stated that therapists should not “use passive physical agents except when necessary to facilitate participation in an active treatment program.” The lack of clarity in this statement was questioned by several including Belanger et al² and Bjordal et al,³ leading the APTA to redact its original statement to “don’t use (superficial or deep) heat to obtain clinically important long-term outcomes in musculoskeletal conditions” with additional recognition that electrophysical agents were not intended to be included in the original recommendation.⁴ While this redacted statement vastly differed from the broader original statement, significant bias was introduced against the more encompassing field of therapeutic modalities. Since these statements, the greater scrutiny of therapeutic modalities has been both damaging and encouraging—damaging in that many clinicians simply stopped or greatly limited their use of therapeutic modalities and encouraging in that the accountability to substantiate use of therapeutic modalities became a greater driving force for researchers, educators, and clinicians.

The reality is that therapeutic modalities, when appropriately used, remain a viable and skilled intervention that are part of multiple disciplines within rehabilitative medicine. In keeping with these thoughts, this text is written to present the use of therapeutic modalities as supported by the collective body of evidence and in the context of how therapeutic modalities should be used when the clinical decision is made to do so.