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| INVITED EDITORIAL |
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| Year : 2023 | Volume
: 5
| Issue : 1 | Page : 4-7 |
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The paradox of ineffective treatments: unraveling the illusion in physiotherapy practice
Prashant Mukkannavar
Department of Orthopedic Physiotherapy, KLE College of Physiotherapy, Hubballi, Karnataka, India
| Date of Submission | 24-May-2023 |
| Date of Decision | 10-Jul-2023 |
| Date of Acceptance | 19-Jul-2023 |
| Date of Web Publication | 11-Aug-2023 |
Correspondence Address:
Dr. Prashant Mukkannavar
KLE College of Physiotherapy, Kotagundshi, Gabbur, Hubballi - 580 028, Karnataka
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijptr.ijptr_160_23
How to cite this article:
Mukkannavar P. The paradox of ineffective treatments: unraveling the illusion in physiotherapy practice. Indian J Phys Ther Res 2023;5:4-7 |
How to cite this URL:
Mukkannavar P. The paradox of ineffective treatments: unraveling the illusion in physiotherapy practice. Indian J Phys Ther Res [serial online] 2023 [cited 2023 Oct 1];5:4-7. Available from: https://www.ijptr.org/text.asp?2023/5/1/4/383671 |
| Introduction | |  |
An important part of rehabilitation and recovery, physiotherapy has long been recognized for its role in restoring movement and function. Physiotherapists use a wide range of techniques and modalities to treat disorders of the musculoskeletal and nervous systems. As evidence-based practice guides the field, the emergence of seemingly ineffective treatments with putative efficacy raises interesting questions. This article addresses the paradox of ineffective treatment in physiotherapy practice and highlights the factors contributing to this complex phenomenon through notable examples supported by evidence and guidelines.
| The Enigma of the Placebo Effect in Physiotherapy | | |
The unexplained mechanisms underlying the placebo effect offer a plausible explanation for the apparent effectiveness of ineffective treatments. This phenomenon occurs when a patient believes in a treatment and experiences improvement in symptoms, even though the treatment lacks effective therapeutic properties. Studies in various areas of medicine, including physiotherapy, have shown a significant impact of the placebo effect. For instance, a study by Bingel et al.[1] showed that chronic pain patients reported pain relief even when receiving placebo treatment, highlighting that patient expectations and perceptions influence treatment outcomes.
| Natural History and Regression to the Mean | | |
The perception that ineffective treatment is effective can be influenced by the natural history of the disease and regression to the mean. The term “natural history” pertains to the inherent progression of a condition without any intervention, whereas “regression to the mean” characterizes the tendency of extreme measurements to move closer to the average over time.
To illustrate this concept, let us consider the study carried out by Hancock et al.,[2] which investigated the effectiveness of manual therapy in treating nonspecific low back pain. The study found that patients who received manual therapy reported better outcomes than those who received sham treatment initially. However, both groups experienced similar improvements over time, suggesting that the initially perceived efficacy may be due to the natural history of the disease.
| Contextual Factors and Therapeutic Alliance | | |
The context of treatment and the therapeutic alliance between physiotherapist and patient can have a significant impact on treatment outcomes. Contextual factors such as treatment setting, therapist's behavior, and communication style may increase patient expectations and contribute to perceptions of treatment efficacy.
A study by Rossettini et al.[3] investigated the use of contextual factors in clinical practice. The researchers discovered that contextual factors play a prominent role in the realm of clinical practice, with certain factors being more commonly employed than others. Verbal communication, a patient-centered approach, and the establishment of an empathetic therapeutic alliance emerged as the most frequently utilized contextual factors. Notably, physiotherapists hold the belief that these contextual factors possess the potential to yield favorable treatment effects on patient outcomes. This finding highlights the importance of the therapeutic relationship and the treatment context in shaping and influencing patient outcomes.
| Expectations and Positive Reinforcement | | |
Patients' expectations have a significant impact on how they perceive and react to physiotherapy interventions. A recent study[4] published in the European Journal of Pain found that patients with patients' expectations play an important role in predicting short-term treatment outcomes for low back pain. This means that clinicians should consider and address patients' expectations at the start of treatment to optimize the chances of a successful outcome.
There are a few things therapists can do to help manage patient expectations. First, physiotherapists should ask patients about their expectations for improvement at the start of treatment. This information can help clinicians tailor treatment plans to each patient's needs and expectations. Second, physiotherapists should provide patients with information about the expected course of treatment and the potential for improvement. This can help manage patients' expectations and avoid disappointment. Ultimately, physiotherapists should focus on building relationships with patients and providing them with positive reinforcement to maximize their chances of success.
A study by Foster et al.[4] focused on patients with chronic low back pain and investigated the impact of the therapeutic context on treatment outcomes. The study found that patients who received positive reinforcement and were informed about the benefits of a particular treatment experienced significant improvements in pain and function. Despite the lack of compelling evidence supporting the treatment itself, these results reinforce the importance of communication and constructive reinforcement in enhancing treatment success.
| Patient Engagement and Active Participation | | |
Patients are frequently asked to actively participate in physiotherapy, with exercises and therapeutic activities serving as a key component of treatment plans. Engaging patients in their own recovery process gives them a sense of control and optimism. Even when specific techniques lack strong supporting evidence, the overall therapeutic relationship and encouragement provided by the physiotherapist can enhance patient outcomes.
A review by Teo et al.[5] studied the factors affecting “patient engagement” in exercise rehabilitation. The article identified three key domains that influence patient engagement: capability, opportunity, and motivation (COM-B framework). Capability refers to the patient's knowledge, skills, and beliefs about exercise. Opportunity refers to the patient's lifestyle, social support, and access to resources. Motivation refers to the patient's goals, values, and perceived benefits of exercise. Clinicians and researchers should consider all three domains of the COM-B framework when designing and evaluating exercise rehabilitation programs. In addition, clinicians should work with patients to codesign exercise programs that are tailored to their individual needs and preferences. This review showed that patient engagement is essential for achieving the desired treatment outcomes of rehabilitation.
| Subjectivity of Patient-Reported Outcomes | | |
Patient-reported outcomes serve as key indicators in evaluating treatment efficacy. However, they are subjective in nature and can be affected by a variety of factors, including patient expectations, mood, and treatment context.
Patient-reported outcome measures are used to assess the results of an intervention. It is important to remember that outcome measures measure outcomes, not the effects of intervention.[6] This means that a change in an outcome measure does not necessarily mean that the intervention caused the change. It is, therefore, important to distinguish between outcomes and effects of intervention. This distinction is important for clinical practice, as it can help clinicians determine whether or not an intervention is effective. For example, if an outcome measure shows a significant improvement in pain after an intervention, it is not possible to say for sure whether the intervention caused the improvement. The improvement could have been caused by other factors, like the natural course of the disease. Therefore, it is important to recognize that outcome measures primarily evaluate the outcomes of interventions rather than directly assessing the effects of the intervention itself. Physiotherapists should be aware of this distinction when interpreting the study results.
| Publication Bias and Selective Reporting | | |
Publication bias and selective reporting contribute to perceived effectiveness in physiotherapy practice. Positive treatment results are more likely to be published and reported, while negative or ineffective results are likely to be omitted or unpublished. This may lead to a biased representation of treatment effectiveness in the literature.
A recent literature review conducted by Komukai et al.[7] highlights the importance of addressing publication bias and selective outcome reporting in randomized controlled trials related to rehabilitation. The authors noted that a significant number of RCTs related to rehabilitation were not published and that many of the published RCTs did not report all of the primary outcomes. This publication bias and selective outcome reporting of results can lead to misleading conclusions about the effectiveness of interventions. The authors recommend a number of strategies to address these biases, including preregistration of research protocols, mandatory reporting of all primary outcomes, and increased transparency in the publication process. These recommendations are important for ensuring that the evidence base is more complete and accurate and that clinicians can make informed decisions about clinical practice.
| Ethics, Transparency, and Evidence-Based Practice | | |
While the obvious benefits of ineffective treatments may seem encouraging, it is important to adhere to the principles of ethics, transparency, and evidence-based practice in physiotherapy. Physiotherapists must continually update their knowledge and skills and stay up to date with the latest research, guidelines, and best practices. This commitment guarantees that patients receive treatment options that are backed up by scientific evidence and have a better chance of attaining their desired outcomes.
Evidence-based guidelines from organizations such as the American Physical Therapy Association (APTA),[8] the Chartered Physical Therapy Association (Chartered Society of Physiotherapy [CSP]),[9] and the World Confederation for Physical Therapy (WCPT)[10] are valuable resources for guiding the practice of physiotherapy. These guidelines were developed through a rigorous process of reviewing existing literature and synthesizing the best available evidence. Following these guidelines allows physiotherapists to reduce dependence on ineffective treatments and ensure that patients receive the most appropriate evidence-based care.
In addition, professional accountability and transparency are essential to maintain the integrity of physiotherapy practice. Physiotherapists should openly discuss the limitations of a particular treatment, explain the level of evidence supporting the intervention, and engage in shared decision-making with the patient. Involving patients in the decision-making process creates realistic expectations, eliminates misconceptions, and promotes trust and collaboration.
| Conclusion | | |
The paradox of ineffective treatments presents challenges within physiotherapy practice. Factors such as the placebo effect, positive reinforcement, patient engagement, and subjective measures of improvement contribute to this paradox. In order to effectively address the challenges posed by the ineffective treatment paradox, physiotherapists must align interventions with the best available evidence, adhere to guidelines, and engage in shared decision-making with patients. Furthermore, it is essential for physiotherapists to consistently enhance their knowledge and refine their skills through continuous updates. These actions are important in navigating the complexity and uncertainty inherent in physiotherapy practice, ensuring that treatments are based on solid evidence and ethical considerations.
As the field of physiotherapy evolves, further research is needed to delve into the underlying mechanisms and psychological factors that influence treatment outcomes. By cultivating a culture of critical thinking, professional accountability, and adherence to evidence-based practice, physiotherapists can successfully navigate the paradox of ineffective treatments. Ultimately, this commitment to ongoing education and a patient-centered approach allows them to provide optimal care and achieve positive outcomes for their patients.
| References | | |
| 1. | Bingel U, Wanigasekera V, Wiech K, Ni Mhuircheartaigh R, Lee MC, Ploner M, et al. The effect of treatment expectation on drug efficacy: Imaging the analgesic benefit of the opioid remifentanil. Sci Transl Med 2011;3:70ra14.  |
| 2. | Hancock MJ, Maher CG, Latimer J, McLachlan AJ, Cooper CW, Day RO, et al. Assessment of diclofenac or spinal manipulative therapy, or both, in addition to recommended first-line treatment for acute low back pain: A randomised controlled trial. Lancet 2007;370:1638-43. |
| 3. | Rossettini G, Palese A, Geri T, Fiorio M, Colloca L, Testa M. Physical therapists' perspectives on using contextual factors in clinical practice: Findings from an Italian national survey. PLoS One 2018;13:e0208159. |
| 4. | Eklund A, De Carvalho D, Pagé I, Wong A, Johansson MS, Pohlman KA, et al. Expectations influence treatment outcomes in patients with low back pain. A secondary analysis of data from a randomized clinical trial. Eur J Pain 2019;23:1378-89. |
| 5. | Teo JL, Zheng Z, Bird SR. Identifying the factors affecting 'patient engagement' in exercise rehabilitation. BMC Sports Sci Med Rehabil 2022;14:18. |
| 6. | Herbert R, Jamtvedt G, Mead J, Hagen KB. Outcome measures measure outcomes, not effects of intervention. Aust J Physiother 2005;51:3-4. |
| 7. | Komukai K, Sugita S, Fujimoto S. Publication bias and selective outcome reporting in randomized controlled trials related to rehabilitation: A literature review. Arch Phys Med Rehabil 2023:S0003-9993(23)00362-3. |
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