Physical therapists as leaders rather than followers with reference to clinical practice guidelines for management of individuals with heart failure – an editorial/commentary

In their various mission and position statements, physical therapist associations around the world have long purported to value physical therapists serving as leaders (World Confederation for Physical Therapy, 2022). Leadership is cited as an essential attribute within the profession as a means to advancement and serving the public to the highest degree possible, in the interests of individual patient health and public health (American Physical Therapy Association, 2022). Professional leadership is also associated with the multi-directional flow and exchange of information with other established health professionals and their associations. For decades, the physical therapist profession worked hard to break free of medicine’s grip on the profession and duly earned our autonomy, at least in most western countries. We need to remain true to this conviction.

To this end, I write this editorial/commentary directed at the next generation of physical therapists. We rely on you to ensure that this hard-earned autonomy and leadership competency is upheld to effect change and continue to advance the profession and health care overall. Practicing autonomy requires bravery. It requires being ever guided by evidence rather than other factors including our biases. As our experience below demonstrates leadership can slip away right before our eyes.

In August 2021, we submitted a manuscript titled ‘A Health and Lifestyle Framework: Basis for Contemporary Physical Therapist Clinical Practice Guidelines with Special Reference to Individuals with Heart Failure.’ This manuscript was in response to two companion articles published in the Physical Therapy Journal titled ‘Physical Therapist Clinical Practice Guideline for the Management of Individuals with Heart Failure’ (Shoemaker, Dias, Lefebvre, Heick, and Collis, 2020) and ‘A Knowledge Translation Framework for Optimizing Physical Therapy in Patients with Heart Failure’ (Dias, Shoemaker, Lefebvre, and Heick, 2021). Given the extensive literature on cardiovascular health that has been accruing, these guidelines fell short as they largely reflected the status quo, the traditional biomedical disease orientation. In our submission, we made an evidence-based case for contemporary physical therapist clinical practice guidelines to be grounded within a health and lifestyle framework with special reference to the construct of cardiovascular health in these particular physical therapist clinical practice guidelines for heart failure. With a focus on cardiovascular health as well, heart disease progression can be mitigated and even reversed based on lifestyle change. The seminal work of Ornish et al. (1990) published in Lancet three decades before and considerable supportive evidence in the intervening years, were pivotal to our position. After two revision cycles, we withdrew the manuscript when requested to recraft it in a way that would have substantially compromised the message. The literature called for more.

On July 2, 2022, the American Heart Association (AHA) released ‘Life’s Essential 8: Updating and Enhancing the American Heart Association’s Construct of Cardiovascular Health: A Presidential Advisory from the American Heart Association’ (). This position paper that focuses on cardiovascular health constitutes a major paradigm shift in the management of heart disease, hence promises to be revolutionary in the field. The first major paradigm shift in the management of heart disease in one hundred years.

On the one hand, I am elated that the AHA had finally translated the well-documented knowledge base about factors contributing to cardiovascular health as a foundation for care for the multitude of patients with heart disease. It goes well beyond simply remediating signs and symptoms; an approach that fails to address the underlying problem which a focus on cardiovascular health does. This constitutes a bold shift from the traditional working biomedical construct of disease management that has been the dominant paradigm, by complementing and extending its foundation to one of health.

On the other hand however, I am disheartened. I appreciate that science is not a competition or race, but the profession of physical therapy had an opportunity to lead, to be on the forefront, to offer a platform to the AHA on which to build their work further, rather than the reverse.

In retrospect, this may appear moot given that our work has been published elsewhere (Dean and Lomi, 2022) in an international peer-reviewed journal without revision which expedited its publication but not in sufficient time. Had it been published in Physiotherapy Theory and Practice it would have sufficiently predated the AHA position statement, and enabled the AHA working group to build further on original ideas for which our profession would have received appropriate credit. As it turns out, we still have made an impact as the AHA position paper does not go as far as it should based on the totality of evidence.

Nonetheless, now that the presidential advisory group of the globally respected and established AHA has decreed cardiovascular health as a bona fide construct, this construct undoubtedly will be embraced by the physical therapist profession, particularly by the Academy of Cardiovascular and Pulmonary Physical Therapy. We’ll be all over it. Alternatively, we could have accepted this position from within, in turn leading other health professions including medicine to take note of physical therapy’s evidence based, innovative contribution. Now sanctioned by the AHA, reference to cardiovascular health will appear everywhere within the specialty and in future iterations of the existing physical therapist clinical practice guidelines for individuals with heart failure (Dias, Shoemaker, Lefebvre, and Heick, 2020; Shoemaker, Dias, Lefbvre, Heick, and Collis., 2020) with credit appropriately given to AHA. But, why not us? We need to assert ourselves as leaders, be ever true to our profession’s vision, and based on the evidence not be afraid or hesitant to do so. We have worked long and hard to free ourselves from being medicine’s little sister and simply its followers.

To the next generation of physical therapists who are committed to the profession’s advancement, I implore you to lead, be bold, be rigorous, do what’s right. Challenge the status quo. Follow the science, trust the science, even when others aren’t. Value yourselves. You do not need the approval of medicine before you can advance your profession as well as health care overall. Think of yourselves not just as leaders, but practice leadership not simply be followers as we have largely done for one hundred years. I have complete trust in you.

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