10 Papers Every Physical Therapist Should Read

I originally thought this blog would be a way for me to discuss current physical therapy research and help new graduates like myself navigate the complex world of evidence-based medicine. However, I took a slightly different, but equally important route by discussing the role of philosophy and science in healthcare and critically evaluating concepts in physical therapy. I want this post to fulfill my original goal and highlight some interesting papers that I have come across in my two years as a physical therapist and health writer. Each one of these papers has made me think, showed me a new perspective, or changed the way I practice. They were worthy of my time, and I think they will be for you too. I would suggest reading each paper in full if you can.

(small disclaimer: I am not the first to talk about these papers and you may have seen them before)

1) “Why Do Ineffective Treatments Seem Helpful? A Brief Review” by Steve Hartman (2009)

In this paper, author Steve Hartman reviews the reasons why we all need to be skeptical of anecdotal reports of success from other healthcare practitioners and patients with any given treatment. In addition, he discusses why we need to be careful trusting ourselves or our own patients when judging our treatments. Hartman argues one main thing that warrants skepticism is that many conditions that we see can improve with other factors besides an effective treatment. These include the natural history of the disease, regression to the mean, and placebo effects. And therefore, after performing a treatment that has no true effects (whether anyone knows it or not), it may seem like it is helping.

In addition, other concepts from psychology help to explain our and our patients’ biases that lead us to believe treatments are actually effective. Confirmation bias (detecting the pattern you want to see) and cognitive dissonance (avoiding inconsistent thought patterns) combine and allow us to better see our successes and forget our failures. In our patients, their beliefs about the treatment they are getting, the person giving it, and other confounding variables like adopting other healthy behaviors at the same time of seeking treatment, can impact their impressions of the effects of a treatment. Hartman concludes that rigorous, placebo-controlled trials are the only way to control for these effects an until we have them, we have good reasons to be skeptical.

“Without science, healthcare still would involve little more than applying tourniquets, setting bones, and administering placebos. After many centuries as socially sanctioned, organized magical thinking, healthcare has been transformed by scientific inquiry into a powerful service profession. In fact, science has become integral to everything healthcare providers do. If you see patients, I hope you now will be suspicious about all assumptions of therapeutic success, including your own.”

Main Takeaway: Until we have some good science, we ought to be skeptical of the appearance of success with any given treatment due to the natural history of disease, regression to the mean, placebo effects, confirmation bias, cognitive dissonance and other confounding variables.  

2) “An Epidemiological Examination Of The Subluxation Construct Using Hill’s Criteria Of Causation” by Timothy A Mirtz, Lon Morgan, Lawrence H Wyatt and Leon Greene (2009)

My sister-in-law’s boyfriend had a bout of low back pain a few months ago and went to a chiropractor. He was diagnosed with multiple subluxations and obviously needed to come regularly and get adjusted. Questioning this recommendations, they asked me what I thought. I had a lot to say. It is upsetting to see people continuing to believe in the myth of subluxations.

This paper sought to determine if there was any evidence to support the subluxation theory of chiropractic, utilizing a set of conditions proposed by Austin Bradford Hill designed to determine causation. Determining if one thing causes another may sound like a trivial problem, but philosophically and scientifically, it is not easy as you would think. The authors succinctly sum up Hall’s criteria and searched the evidence for any studies that could fulfill them. They were unable to find any evidence suggesting subluxations were the cause of any disease state or related to health.

“There is a significant lack of evidence in the literature to fulfill Hill’s criteria of causation with regards to the chiropractic subluxation. No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention. Regardless of popular appeal this leaves the subluxation construct in the realm of unsupported speculation. This lack of supportive evidence suggests the subluxation construct has no valid clinical applicability.”

Main Takeaway: The subluxation theory should be left in the graveyard of dead medical ideas. But more importantly, what supposed causes of pain and disability in the physical therapy world deserve the same scrutiny? Do we have strong causal links to pain and disability for muscle weakness? Trigger points? Rotated pelvises? Flat feet? The list goes on and we should take extra care to ensure we aren’t doing the same thing as chiropractors.

3) “The Traditional Mechanistic Paradigm In The Teaching And Practice Of Manual Therapy: Time For A Reality Check” by Frédéric Wellens (2010)

In this paper, author Frédéric Wellens critiques the biomechanical model of manual therapy and then briefly points to the emerging research favoring a neurophysiological model. Wellens writes that many of the assumptions made by manual therapy paradigms are not supported by the current research or are completely unsubstantiated. Wellens argues there is no strong consensus on what manual therapy actually does, mechanical dysfunctions haven’t been shown to correlate with pain or the resolution of pain, our tests to determine biomechanical dysfunctions are not reliable, manual treatments are generally not specific to the problem supposedly being corrected, and the effects of manual therapy are modest, but transient.

The research thus far showing beneficial effects does not validate the mechanisms proposed. The emerging research on the neurophysiological model of manual therapy seems to be more promising and acknowledges the complex nature of pain, the psychological and social components that can influence it, and may be more plausible to explain what we see. The author recommends that manual therapy schools ought to start shifting their teaching to better reflect the problems with the biomechanical model and incorporate new information from the neurophysiological model.

“The BMM for the effectiveness of manual therapy in the treatment of pain makes many unproven assumptions, has many obvious demonstrated flaws and lacks prior biologic plausibility and thus, should seriously be questioned. An emerging NPM should be considered instead and gradually developed as new knowledge and evidences are gathered.”

Main Takeaway: The current literature on manual therapy does not adequately support the traditional biomechanical mechanisms used to justify manual therapy treatments, despite clear evidence of benefit. We need to change how we explain manual therapy to patients and shift our focus towards new models.

4) “Science And The Sources Of Hype” by T. Caulfield and C. Condit (2012)

Unjustified hype about the latest and greatest treatments triggers me. So much so that a wrote an entire blog about it. This 2012 paper by authors Caulfield and Condit evaluates the scientific “hype pipeline” and goes into detail about how for a new scientific discovery, there are pressures at each step of the way that shape and pull the news coverage of it.

Multiples sources of hype can contribute to exaggerated claims, and these include pressure to publish interesting research from scientific journals, pressure to commercialize new scientific ideas, inaccurate coverage from the media, marketing excitement generated by companies selling the products they are studying, and misplaced enthusiasm and expectations from the general public.

“As we noted in the introduction, hype is not without consequences. At the very least, it misallocates resources to inappropriate projects and creates a model of the future that may be not only unattainable, but undesirable. In the long run, then, too much hype focused on the wrong dimensions of genomics can’t be a good thing – not for researchers or for the public who fund and hope to benefit from research results.”

Main Takeaway: The fields of physical therapy and healthcare more broadly, are vulnerable to scientific hype, i.e. unjustified excitement for a new treatment or a new trend. As healthcare professionals it is our duty to be able to identify these sources of hype and provide accurate counter-narratives that are appropriately scaled to the strength of the current scientific evidence.

5) “Is A Positive Clinical Outcome After Exercise Therapy For Chronic Non-Specific Low Back Pain Contingent Upon A Corresponding Improvement In The Targeted Aspect(s) Of Performance? A Systematic Review” by F. Steiger, B. Wirth, and E. D. de Bruin (2012)

No one can seem to agree on what causes back pain. Poor posture, underperforming transverse abdominis muscles, rotated pelvises, spinal subluxations, weak paraspinal muscles, low trunk muscle endurance…the list goes on. But when people with back pain get better, do any of those things change? The goal of the authors here was to answer this question, specifically with respect to sagittal plane mobility, rotational and lateral mobility, trunk extension strength, trunk flexion strength, and trunk muscle endurance. The authors found that for the majority of the studies they saw, positive outcomes for patients with CNSLBP were not associated with changes in any of these parameters.

So when people get better after physical therapy, what actually changes? The authors suggest it may have something to do with “side effects” of exercise like the modified fear-avoidance and catastrophizing beliefs, and improved self-efficacy. Overall, this paper highlights the need to shift our focus away from “issues with tissues” and towards a more holistic and neuropsychological view of pain and disability.

“Based on the findings of our review and on similar information from other systematic reviews and studies, we suggest that changes in physical function are largely unable to explain changes in the clinical condition in cLBP patients, and that the important ‘‘side effects’’ of exercise therapy (including, amongst other things, changes in psychological variables such as fear-avoidance beliefs, catastrophizing and self-efficacy regarding pain-control) should be more specifically emphasised and investigated in future rehabilitation programs.”

Main Takeaway: When patients with chronic low back pain get better, it is probably not related to changes in core strength, endurance or mobility. This should change the way you think about exercise prescription, the language we use with patients, and the overall goals of our treatment.

6) “What Do Physical Therapists Think About Evidence-Based Practice? A Systematic Review” by Tatiane Mota da Silva, Lucíola da Cunha Menezes Costa, Alessandra Narciso Garcia and Leonardo Oliveira Pena Costa (2015)

Here, the authors sought to answer exactly the question in the title. Specifically they investigated beliefs about what EBP is, its overall value to physical therapy, their literature search habits and frequency, and, most importantly, the barriers they face when implementing EBP. The most commonly cited barriers were lack of time, inability to understand statistical data, lack of support from their employers, lack of resources, colleagues not favorable to EBP implementation, lack of interest, and lack of generalization of results.

This study suggests that a certain percentage of physical therapists don’t employ an evidence-based approach because they don’t have the time, don’t have adequate training in statistical interpretation, or they or their employers don’t value it. I hope that my blog highlights the need for evidence-based practice and makes things easier and quicker for my fellow healthcare practitioners.

“Physiotherapists need to improve their knowledge, skills and behaviour towards EBP, however, they have a positive opinion of EBP. Additionally, the main barriers that hinder the implementation of EBP in physiotherapy are lack of time, inability to understand statistical data, lack of support from employer, lack of resources, lack of support from colleagues for EBP implementation, lack of interest, and lack of generalisation of results.”

Main Takeaway: In order to better implement EBP, we need to make evidence utilization easier, quicker, and more accessible to clinicians.

7) “Enhance Placebo, Avoid Nocebo: How Contextual Factors Affect Physiotherapy Outcomes” by Marco Testa and Giacomo Rossettini (2016)

In this paper, authors Testa and Rossettini discuss the role of placebo and nocebo effects in physical therapy practice, as well as other non-specific effects that can influence outcomes in the clinic, like the features of the clinic, the characteristics of the staff, the patient-therapist relationship, and the type and features of a given treatment. They discuss many of these non-specific treatment elements and suggest reasonable ways to take advantage of them in Table 2.

“From a clinical point of view, placebo and nocebo elements are always present during a therapeutic intervention. Every healthcare intervention is formed by two factors: a specific/active biological component and a contextual/psychosocial one. These contextual elements interact with the specific effect of the therapy by either increasing or decreasing the global effect of treatment…For PTs it is essential to transfer this knowledge in clinical practice to improve therapy application and outcome.”

Main Takeaway: Every treatment we provide has non-specific effects and we need to pay attention to them to maximize outcomes.

8) “Debunking: A Meta-Analysis Of The Psychological Efficacy Of Messages Countering Misinformation” by Man-pui Sally Chan, Christopher R. Jones, Kathleen Hall Jamieson, and Dolores Albarracin (2017)

I originally started this blog because I wanted to counter the messages I heard being given by fellow clinicians to some of my patients during one of my clinicals. “Debunking” has become a big part of this blog, and when I came across this psychology paper I knew it would be relevant. In this meta-analysis, the authors sought to understand what are the components of a successful debunking message.

The authors make a few recommendations that are vital to countering misinformation. First, we need to create and foster a culture of healthy skepticism, counter-argument, and debate. Second, a detailed argument with new information is more likely to be effective than one that simply labels misinformation as such, which often strengthens the erroneous belief. Lastly, misinformation can persist, despite debunking messages, and therefore it is vital to have resources for people to go utilize like fact-checking organizations.

“Misinformation on consequential subjects is of special concern and includes claims that could affect health behaviors and voting decisions. For example, the rumor that genetically modified mosquitoes caused the Zika virus outbreak in Brazil is misinformation, a claim unsupported by scientific evidence. Despite retraction of the scholarly article making the causal link between autism and the measles, mumps, and rubella vaccine, some people are still convinced of this unfounded claim.”

Main Takeaway: To protect the health and safety of our patients, we have a duty as healthcare professionals to be able to effectively counter health misinformation, and this paper provides some recommendations on how to do it effectively.

9) “Key Concepts For Informed Health Choices: A Framework For Helping People Learn How To Assess Treatment Claims And Make Informed Choices” by Iain Chalmers, Andrew D Oxman, Astrid Austvoll-Dahlgren, Selena Ryan-Vig, Sarah Pannell, Nelson Sewankambo, Daniel Semakula, Allen Nsangi, Loai Albarqouni, Paul Glasziou, Kamal Mahtani, David Nunan, Carl Heneghan, Douglas Badenoch (2018)

The Informed Health Choices project aims to help people improve their health science and research literacy and make better decisions. In this paper, the authors lay out 36 different concepts in regards to maintaining healthy skepticism about treatment claims, understanding medical literature, and the nature of scientific research itself. The list provided provides a great starting point for your discussions with our patients on evidence-based healthcare, popular treatment claims, and countering misinformation.

“Many claims about the effects of treatments, though well intentioned, are wrong. Indeed, they are sometimes deliberately misleading to serve interests other than the well-being of patients and the public. People need to know how to spot unreliable treatment claims so that they can protect themselves and others from harm. The ability to assess the trustworthiness of treatment claims is often lacking.”

Main Takeaway: Our job is not just limited to direct patient care; we need to serve as advocates for our patients and work to improve their healthcare literacy and comprehension.

10) “Prevention And Treatment Of Low Back Pain: Evidence, Challenges, And Promising Directions” by Nadine E Foster, Johannes R Anema, Dan Cherkin, Roger Chou, Steven P Cohen, Douglas P Gross, Paulo H Ferreira, Julie M Fritz, Bart W Koes, Wilco Peul, Judith A Turner, and Chris G Maher (2018)

The Lancet, one of the most well-respected medical journals, released this paper on back pain earlier in the year. The authors sought to provide the most up-to-date evidence on all things back pain: prevention, treatment, evidence implementation, public policy recommendations, and future directions for back pain research.

Much to the delight of physical therapists everywhere, exercise and education was found to have moderate quality evidence showing it can be effective for the prevention of back pain. In addition, remaining active, education, exercise therapy and cognitive behavioural therapy were recommended as first-line treatments for back pain. Massage, acupuncture, and spinal manipulation were considered to be second-line or adjunctive treatments. The majority of other back pain treatments like medications, surgery, or injections were not recommended, had insufficient evidence, or only had limited use.

“The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation.”

Main Takeaway: This paper highlights an opportunity for physical therapists to move away from antiquated passive care and be the leading practitioners managing patients with back pain.

Every single one of these papers has had impact on my approach to physical therapy and healthcare broadly. So I just want to take a moment to thank all of the authors who undoubtedly spent much of their time, money, and attention performing their job and making things clearer for all of us.

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