Time to stop using the term “conservative treatment” when we actually mean different physiotherapy modalities – Editorial

Reading research papers and practice guidelines, attending conferences and even discussing with colleagues and physiotherapy students, we often hear the term ‘conservative treatment’. Too often, it is used as an umbrella term for physiotherapy modalities. How many times have we read papers where surgical treatment is compared with exercise therapy or other physiotherapy modalities? Exercise therapy might include cardiovascular training, strength training, specific training for coordination, postural control, stabilisation, mobilisation, fatigue or breathing exercises. Others might refer to manipulation, braces, body awareness and stress coping strategies as physiotherapy modalities. Using the term ‘conservative treatment’ to refer all of these modalities risks a confused reader regarding the content of the treatment that actually is evaluated.

Conservative treatment might also be used to describe other non-invasive treatments including medication, immobilisation, cast and bandage or specific interventions administered by occupational therapists, speech therapists, nurse specialists, nutritionists and psychologists. There is an emerging need to be much more specific about the presentation of physiotherapy modalities evaluated in research in order to communicate physiotherapy as the evidence-based profession it is.

A PubMed search for the term ‘conservative treatment’ results in more than 60,000 hits, with the latest one published only some months ago. The first mention of conservative treatment is an editorial from 1891 entitled ‘Melchior on the Conservative Treatment of Haemarthrosis of the Knee-Joint’ [1]. In this article, Prichard was comparing conservative and operative treatment for knee haemarthrosis. The operative treatment was puncture while the conservative treatment was initial immobilisation with ice bags and, after some days, massage. Many things have changed since 1891, and clinical praxis is different. For example, operative treatment after knee haemarthrosis is most probably repair or reconstruction of the injured tissues. Contemporary ‘conservative treatment’ of knee haemarthrosis can be a comprehensive rehabilitation protocol with clear and distinct progression and discharge criteria. It can also be crutches and recommendation for some days of rest.

In relation to physiotherapy the term ‘conservative treatment’ is troublesome and counterproductive. What does the term really mean? According to medical dictionary [2], conservative treatment is defined as ‘treatment designed to avoid radical medical therapeutic measures or operative procedures’. Sometimes, the term conservative surgery can be found meaning restricted or smaller surgery aiming to keep as much as possible as it is without substantially disrupting surrounding structures. ‘Conservative’ indicates that the treatment is aimed at retaining something by using, usually, well-established methods. In other words, implying the notion of stagnation, of not moving forward.

Can we accept defining physiotherapy modalities as ‘conservative treatment’?

Physiotherapy is services provided to individuals and populations to promote health and decrease illness and suffering. It includes developing, maintaining and restoring maximum movement and functional ability throughout the lifespan [3]. Physiotherapy practice is dynamic and changes depending on the individual and societal needs. Most often, physiotherapy includes physical activity and therapeutic exercise, supporting the individual in relevant behavioural changes to reach that target, with the understanding that movement is central to what it means to be healthy and to reach health. The importance of collaboration between physiotherapist and person with needs is essential. You cannot ‘get’ physiotherapy – you do it. How does the term ‘conservative treatment’ correspond with that?

Since the genesis of the physiotherapy profession, movement has been a central concept. From the latter part of the 19th century, the ‘medical regimen’ was developed in Sweden as one part of gymnastics (the others being military, pedagogic, and to some extent aesthetic gymnastics). Medical regimen included treatment by movement and massage that emphasised the use of natural means to reach health. Interventions with movement, either manual or mechanical, has been the hallmark of physiotherapy ever since. Nowadays, physiotherapy includes, but is not limited to, health-promoting activities such as active behavioural changes of lifestyle habits, coping strategies of stress and sleep disorders, therapeutic interventions for pain disorders, cardiovascular and neurological diseases. Physiotherapy includes primary and secondary prevention, habilitation and rehabilitation. We even prescribe physical activity today!

There is now substantial evidence that active exercise therapy, guided by physiotherapists should be a treatment for many different diseases. The increased research within physiotherapy also highlights that the therapy has to be specific, well defined and individualised to each patient’s needs. Physiotherapy is active, therapeutic and behavioural interventions through which the inherent resources of the individual are activated to reach increased health. People are referred to or seek physiotherapy when they need a change. Even a slowing down of a deterioration is a change and not ‘conservation’. In most cases, physiotherapy implies an active patient who has to do something and not only receive a passive treatment. It could be exercises, a change in behaviour, in mind-set or interpretation of a situation.

The term ‘conservative treatment’ conserves and limits both brain and body when the focus and aim of physiotherapy is instead to challenge and move the limits. The inherent power of words for our mind-set has more than proven truth. Just imagine you have the choice between ‘movement therapy’, and ‘conservative treatment’. Hand-on-heart, which one would you choose? Using the right words, defines physiotherapy as an evidence-based profession both for the patient and the other professions within health care.

To further develop physiotherapy, we need to be more specific and describe what we are doing and what we mean. We cannot accept to use an outdated umbrella term that does not adequately describe physiotherapy. Ask your closest relative or friend what they understand by ‘conservative treatment’ and note the answers.

We did. They said: It must be something traditional, old-days treatment.

In conclusion, a consensus is required among physiotherapists in order to be more specific when communicating the physiotherapy subject and profession. Physiotherapy education programmes within Universities and physiotherapy schools should banish the conservative treatment descriptor, and teach the students to be specific about physiotherapy. Likewise, scientific journals should not allow a publication with it, and at congresses the attendants should be specific in their messages, describing what they are talking about.