We all should be a little embarrassed right now. In a recent court decision, KT Health Inc., the makers of a popular kinesiology tape brand, agreed to pay up to $1,750,000 to settle allegations of false advertising. Like every other kinesiology taping company, KT Health Inc. advertised their tape by suggesting it can treat and prevent sports-related injuries, relieve pain, and improve performance. If you have read my previous posts, it is not surprising to see these claims were found to be false in a court of law. There have been many methodologically sound clinical trials and reviews that have failed to find anything exciting. What does this say about our profession though, considering we have adopted this treatment with open arms? What does it say when in 2014, the APTA partnered with Rocktape, one of the prominent companies providing kinesiology tape and continuing education courses? What does it say that members of our profession are still utilizing taping, despite evidence from almost a decade ago that it doesn’t work, and a court decision affirming the fact that there is no justification for the claims made?
Physical therapy has a “hype” problem. When there is some new and intriguing idea coming out, it is tempting to get on board the hype train; there are blog posts, continuing education courses, patient testimonials, and genuine excitement for a new way we can help our patients. As tempting as it is however, we instead need to calmly buy our ticket for the patience ferry, and ask ourselves a few questions about what we are endorsing and if there is any good reason to believe it works.
The Sources Of Hype
1. One source of hype is undoubtedly the honest desire, by both patients and therapists, for treatments that work. People are suffering, and despite advances in our profession, we simply haven’t figured it all out yet. We are not always successful, and this leads to patients and therapists seeking out anything that looks sufficiently plausible, available, and promising. Therefore, any new treatment that comes out, as long as it has a few specific characteristics, could potentially be built up into something it isn’t.
2. In addition, science can be played up by news reports and popular media, either consciously or subconsciously. Look at any article on the “health benefits” of dark chocolate for example. In 2003, WebMD proclaimed: “Dark Chocolate Is Healthy Chocolate.” Their evidence? A study of 44 people, half of which ate dark chocolate, and the other half ate white chocolate. After two weeks, the group that ate dark chocolate reduced their blood pressure by an average of five points for systolic pressure, and two points for diastolic pressure. I would suspect that five and two are below the measurement variability when taking blood pressure, but even if it isn’t, does any doctor care that you can reduce it by that little? I like dark chocolate as much as the next person, as evidenced by the five dark chocolate bars in my fridge right now, and I am open to the possibility of dark chocolate showing actual, significant health benefits in robust trials and reviews, but can we honestly say it is healthy? I would love nothing more than to eat dark chocolate on the regular, but we need more evidence than this. This is a textbook case of popular media either consciously or subconsciously playing up the minor results of a humble study, for motivations other than communicating the science faithfully.
3. Celebrity and athlete endorsements are arguments from authority and serve to build hype for treatments that don’t deserve it. Kinesiology taping initially gained popularity when Kerri Walsh put some outrageous taping patterns on display in 2008 at the summer olympics. The KT Tape website has an entire page dedicated to the athletes that use it. Ask Tom Brady or Gwyneth Paltrow for advice on any given health treatment and you will most certainly get a response based on nothing but anecdotal evidence and dubious science. I just couldn’t wait for all the social media discussions and conversations with patients after the pictures of Michael Phelps’ bruises from his cupping treatments during the 2016 Olympics came out. The implications of such arguments are clear; the best athletes and the healthiest celebrities use it, and they see results, so you will too. If you don’t see the problem with this line of thinking, you just aren’t thinking carefully enough. Correlation does not, repeat, does not, prove causation, and we have no reason to think that the success these people see is due to the nonsense treatments they utilize. There are too many confounding variables that could be influencing a person’s overall performance or health, and to simply assume it is the product they are endorsing would be a mistake.
My live reaction to the revitalization cupping received after Michaels Phelps’ endorsement:
4. Misinterpretation of scientific research can be another significant source of hype and can result in inaccurate health claims and endorsements that are stronger than warranted. Dissecting a research paper is a skill that requires significant time, practice, and dedication. I have earned my doctorate in physical therapy, where in school we had multiple classes on evidence-based medicine and spent many classes debating a single paper for two hours. I regularly read and appraise research for this blog. For someone that engages in the research on a daily basis, sometimes it is still a chore to read a results section and know what is going on. Many will often simply read a conclusion and not dive deeper into the other aspects of the study, and count it in the win column. Take this noninferiority study, which compared dry needling to cortisone injections for patients with greater trochanteric bursitis. A conservative read suggests that dry needling and cortisone can both equally reduce pain by small amounts over six weeks, but this study was pushed by dry needling advocates as evidence that it may be an effective treatment option. Is this really a study you can hang your hat on, or was the paper misinterpreted and used to pretend dry needling is more effective than it really is? Considering there was no active control or placebo group, no blinding, and pain reduction on the order of only a few points, this was hardly the robust study a dry needling advocate would want, and was only used for building hype.
5. Companies that provide continuing education for the latest treatment du jour, by their very nature, build hype with marketing. It is in a continuing education company’s best interest to promote their treatment as much as possible, bring to light the most encouraging studies, and downplay the most negative ones. This may be done deliberately or unintentionally, as well as subtly or overtly, depending on how cynical you want to be. But every healthcare practitioner that has a new treatment to sell you will tell you it works. It would be a mistake to take claims from a company at face value without evaluating the research independently. For example, the research section on the Graston Technique website seems to be full of research articles of all types, including systematic reviews, randomized controlled trials, and non-clinical studies. But if you actually read and analyze a few of them, as I did here, you will find that the studies are generally weak, have high risk of bias, or have small effects that are of debatable clinical utility. A company with a financial interest in a certain treatment will be biased, and you have to take that into account when assessing it yourself.
Inevitably, there will be some new, trademarked treatment that comes out and it’s important we don’t end up endorsing it without the appropriate justifications. Here are a few things we can do to make sure we don’t fall for the hype.
1. Learn how to correctly read and appraise scientific research. For health claims, scientific research is the best way to sort out what is going on. And since parsing a research article is rarely easily, it is necessary to continually develop our skills and abilities.
2. Scale your beliefs in proportion to the evidence. When interpreting the the scientific evidence, it is never as clear as a thumbs up or a thumbs down for a given treatment. We need to consider basic scientific plausibility, effectiveness and efficacy trials, reviews and meta-analyses, as well as pre-appraised resources and guidelines. In a NYC event where a few panelists discussed the role of science and philosophy in daily life, physicist Lawrence Krauss mentioned that as a scientist, he thinks about things in terms of probability. A given statement or scientific claim is either likely or unlikely, and each subsequent experiment can move the dial one way or the other, in any increment, depending on the design of the study and the results. Physical therapists ought to be thinking like this: as the science trickles in, the confidence in our beliefs about what we do should be continuously modified to reflect the most likely scenarios.
3. Be skeptical and consider who is making the claims. Treatments can be promoted for reasons other than there is a good evidence that they are effective, and we need to make sure we are not fooled. Perform your own literature searches, look at primary sources, and be critical of what is posted on a continuing education company’s website.
I really want our profession avoid any more embarrassment, and to do so, we need to make sure we have reasonable expectations and appropriately scaled judgments regarding new treatments. We have an ethical responsibility to communicate the science effectively, efficiently, and without any spin or hype. Hyped up treatments are a distraction from what we should be known for: targeted motivation, education on pain and injury, and science-based exercise and movement.