Earning your doctorate in physical therapy isn't easy. You spend three years in extremely challenging classes, learning an enormous amount of material. You have probably spent many nights at the library or mornings at Starbucks studying this information... and for many, it will be ingrained in your brain for a long time.
Mastering the content in each course is a must for getting through school and subsequent pass the boards and start your professional life, things change.
Once you start the challenging, yet exciting dive into the physical therapy literature, you realize things are much more gray than they seem in school. The information you learn is subject to doubt and criticism.
The research often tells a different story. This certainly isn’t going to be an article bashing my professors or suggesting everything I learned in school was a lie, but it will highlight an unfortunate fact: the truth in musculoskeletal rehabilitation is often hard to come by.
Here are 8 lies I learned in physical therapy school.
1. The sacroiliac joints can move out of place, be detected, and then be corrected with muscle energy techniques.
In a few of our classes, we had learned that pain in the sacroiliac joints may be related to misalignments of the pelvic bones, and that physical therapists can detect these misalignments and ultimately correct them with a few sexy techniques that were specific to each “dysfunction” we could find. It was rewarding to know we could learn how to find sacral torsions and innominate rotations and subsequently “fix” our patients in a few minutes. While this has some biological plausibility to it, there are some problematic aspects.
First, it is questionable how much the sacroiliac joints even move.
A systematic review exploring the sacroiliac joint’s movement with 3D modeling came to the conclusion that the joint just doesn’t move that much. The amount of movement was on the order of a few degrees in each plane; small enough to make any serious palpation difficult. The authors suggest “motion of the SIJ is limited to minute amounts of rotation and of translation suggesting that clinical methods utilizing palpation for diagnosing SIJ pathology may have limited clinical utility” (Goode, 2008).
Overall, the sacroiliac joint moves about two degrees in all planes...an amount that is certainly beyond the precision a human being can feel with their hands (Vleeming, 2012).
In addition, the manual tests that we utilize to detect these movements are largely unreliable. We learned to palpate bony landmarks, as well as a few special tests including the standing flexion test, the seated flexion test, the sit-slump test, the marchers test, and the long-sit test.
O’Sullivan and Beales sum it up nicely:
“...adherence to [Pelvic Girdle Pain] paradigms based on intra-pelvic movement dysfunction, positional faults and pelvic instability is not evidence based. The tests have no validity and very poor reliability, and therapists frequently report losing confidence in their manual therapy skills because of a self-perceived inability to ‘feel intra-pelvic motion’ like the experts who teach them” (2013).
We were also taught complicated manual techniques for correcting these dysfunctions, and spent many nights studying for practicals and the potential clinical scenarios we would encounter on them. Putting doubts about sacroiliac movement and our ability to detect them aside, is there any reason to believe that these techniques actually correct sacroiliac joint dysfunctions? If a sacroiliac joint can move out of place, what is to stop it from happening again? If it can’t move, and we can’t decide which way it needs to be corrected, why bother with muscle energy techniques in the first place?
When researchers actually assessed the position of the sacroiliac joints after manipulation, they found it does not get repositioned (Tullberg, 1998). While there is always more research on sacroiliac joint pain to explore, a more reasonable approach may include pain provocation testing, graded exposure, building load tolerance, pain science education, and manipulations; with the explicit goal of pain relief and not for any repositioning.
Something of clinical interest may be happening with the traditional, biomechanical approach to SI joint dysfunction, but it is unlikely to be due strictly to the misalignment and correction of the pelvic bones.
2. Kinesio taping is a useful adjunct technique to add to your toolbox.
The popularity of kinesio taping has exploded, and it is easy enough to find various brands of elastic tape in any drug store. The claims surrounding the benefits of kinesio taping range from humble to outrageous, but most commonly include:
- Reducing pain
- Improving muscular strength
- Regulating tone
- Improving circulation
- Reducing swelling
- Increasing performance.
We learned an assortment of different taping techniques, each varying the positioning, cutting, and tension of the tape, in order to facilitate a certain goal. It seemed like a cheap, easy way to improve patient outcomes. While my professors were careful not to overstate the benefits, it was presented as something with worthwhile effects.
Looking at the literature regarding kinesio taping tells a different story, however. There are multiple, well-controlled studies that suggest kinesio taping can in fact reduce pain, but not much better than sham taping (Gonzales-Iglesias, 2009; Simsek, 2012; Castro-Sanchez, 2012; Parreira, 2014; Kocyigit, 2015; Wageck, 2016). In addition, the studies undertaken to assess inhibitory or facilitatory effects of kinesio taping found disappointing results; suggesting taping does not do much to inhibit or facilitate muscle function (Gomez-Soriano, 2013; Anandkumar, 2014; Fernandez De Jesus, 2015; and Cai, 2016). Lastly, kinesio taping was not shown to be effective for the reduction of ankle swelling (Nunes, 2015).
Many systematic reviews and meta-analyses also failed to find any significant effects for anything beyond short term pain relief (Mostafavifar, 2012; Williams, 2012; Morris, 2013; Csapo, 2014; Montalvo, 2014; Parreira, 2014; Kalron, 2015; Lim, 2015; Nelson, 2016). Parreira et.al. writes:
“When used for a range of musculoskeletal conditions, Kinesio Taping had no benefit over sham taping/placebo and active comparison therapies,the benefit was too small to be clinically worthwhile, or the trials were of low quality. Therefore, current evidence does not support the use of Kinesio Taping for musculoskeletal conditions” (2014).
When compared to sham taping, other interventions, or nothing, the effects are small and not clinically worthwhile for any outcome measure. With an honest look at the literature, it is clear that kinesio taping is a low value intervention, and the claims regarding its benefits are exaggerated. This questions its value as a tool in our collective toolbox.
3. Frozen shoulder progresses through freezing, frozen, and thawing phases, with full resolution.
In school, we learned that frozen shoulder, a condition characterized by limited active and passive movement, typically progresses through a few different phases. The “freezing” phase is distinguished by a decline in range of motion, followed by a “frozen” phase, distinguished by extremely limited range of motion and general stiffness, and a subsequent “thawing” phase, where range of motion would improve.
After progressing through these phases, shoulder function would begin to return to normal. A recent paper by Wong et.al. calls this progression into question. The authors assessed four cohort studies and three randomized controlled trials that looked at the progression of range of motion and functional ability over time for patients diagnosed with frozen shoulder. They found that there was no evidence for the progression of a frozen shoulder through the aforementioned stages and that frozen shoulder is not a self-limiting condition that ultimately resolves on it’s own.
“The lack of primary research beyond the lowest level of evidence to support the natural history theory of frozen shoulder, especially combined with stronger evidence to the contrary, leads to a recommendation that reference to the theory that frozen shoulders progress through stiff to recovery phases leading to full resolution without supervised treatment should be discontinued” (Wong, 2016)
4. Ultrasound therapy is beneficial for patients with musculoskeletal disorders.
This may be a bit of a low-hanging fruit, but it is a bit upsetting that this is something that still comes up. In our modalities class, we got a long lecture on all things ultrasound: theory, mechanisms, benefits, safety risks, terminology etc. In my second clinical, the ultrasound machine was well used, as was the custom in this facility, and I spent many treatment sessions making sure I kept the ultrasound head moving and not going outside the treatment area.
I absolutely spent many hours memorizing the ultrasound settings for the boards and making sure I knew the difference between 1 Mhz and 3 Mhz. A few weeks ago, I had a patient rave about the benefits of ultrasound for her previous knee replacement and was wondering why I wasn’t doing it for her current one. Ultrasound is still a “thing” in physical therapy and that is extremely unfortunate.
Before even looking at the research, ultrasound has questionable biological plausibility, is proposed as a treatment that can accomplish a broad range of therapeutic goals, and is used for almost every condition that we treat. These facts should raise a red flag for you, but the research behind it confirms its lack of utility. A systematic review of ultrasound for musculoskeletal conditions found nothing exciting:
“...in conclusion, the large majority of 13 randomized trials with adequate methods do not confirm the existence of statistically significant or clinically important differences between true and sham ultrasound. The magnitude of the reported treatment effects appeared to be small, and are probably of little clinical importance” (van der Windt, 1999)
Two other reviews found similar conclusions for lower extremity conditions and chronic back pain, respectively (Shanks, 2010; Ebadi 2014). In many of these studies, ultrasound was compared to sham ultrasound; i.e. they leave the machine unplugged or don’t turn it on, and there are no appreciable differences in outcome measures.
While the tide is turning, as seen with the APTA formally recommending against using passive agents like ultrasound for long term treatment, ultrasound will persist. Ultrasound is the quintessential example of the discordance between scientific research and clinical practice, and as new graduates, we ought to be staying on the cutting edge of the best evidence available.
5. Your palpation skills will get better over time.
I distinctly remember learning about the importance of the multifidus during spinal stability tasks, and we were taught how to palpate for appropriate timing and activation. We had our lab partners in quadruped and asked them to perform opposite arm and leg extensions, while palpating for the multifidus to come on. Never mind we would have to palpate through layers of skin, muscle, and fat.
I certainly felt like a novice because I couldn’t feel a damn thing.
We were told that eventually we would be able to detect tiny variations in spinal positions, trigger points, altered muscle activation patterns, passive intervertebral motion, and many more. One of my professors even suggested he can palpate multiple levels of intervertebral motion with simultaneously using one hand. For many of our assessments we were told that as you get better and have more experience, your palpation skills will improve to an acceptable level. The literature suggest something slightly different.
While experience may help improve clinical skills, palpation is simply not that reliable for many of the things we do as physical therapists. In a systematic review of PSIS palpation, the authors write “although claims have been made that palpatory procedures can detect subtle misalignments, fixations, and soft tissue changes in patients with neuromusculoskeletal disorders, and that the requisite skills take a considerable amount of time to acquire, there is little evidence at this time in support of these contentions with regard to PSIS palpation” (Cooperstein, 2016).
In another systematic review of spinal palpatory tests, the authors mention that more experienced examiners did not fare better than less experienced ones.
“The level of clinical experience of the examiners did not improve the reliability of the procedures; i.e., experienced clinicians fared no better than students in terms of palpatory test reliability. Contrary to common belief, examiners’ consensus on procedure used, training just prior to the study, or use of symptomatic subjects, did not consistently improve reliability of spinal palpatory diagnostic tests, confirming conclusions made previously by other researchers.” (Seffinger, 2004)
In addition, two reviews concluded that manual palpation of trigger points is largely unreliable (Myburgh, 2008; Rathbone, 2017). We have good reason to think that things we were taught to palpate are just not reliable enough to be useful and we ought to be looking elsewhere for making diagnoses.
Before older clinicians take this the wrong way, let me suggest that yes experience does matter, and no doubt can help put you at an advantage. But I and many other students had the perception that as we accumulated real-life experience, we would become body detectives with incredible palpation skills.
6. The effects of manual therapy are biomechanical and specific.
Right before my third clinical, I remember wanting to be a manual therapist. I loved the idea of being a biomechanical detective; assessing the scene, gathering evidence, finding the culprit. We were taught many manual techniques to address what we found, and these techniques were sexy, elaborate, and sophisticated.
It was exciting to find out that I would eventually be able to detect a rotated vertebrae or an elevated first rib, and then quickly correct it within session. It was implied that manual therapy can be targeted specifically to the tissues being treated; you can manipulate the cervicothoracic junction, find that trigger point and eliminate it, or mobilize a rotated rib back into position.
First, all therapeutic interventions, manual therapy included, are subject to contextual mediators and psychobiological factors that can affect outcomes (Testa, 2016). These include, but are not limited to professional reputation and appearance, the beliefs and behaviors of the therapist, the patient’s expectations, preferences, and previous experience, the therapeutic relationship, verbal and nonverbal communication, and the layout, cleanliness, and aesthetics of the clinical setting (Testa, 2016). A certain percentage of the effects our manual treatments have is due to these factors, and while the an exact percentage would be hard to quantify, it is arguably higher that we initially thought.
Second, we have good evidence to suggest that our manual treatments are not changing biological structure or altering biomechanics in any significant way. In regards to treatment effects of manual therapy. Bialosky et.al. writes:
“lasting structural changes have not been identified, clinicians are unable to reliably identify areas requiring MT, the forces associated with MT are not specific to a given location and vary between clinicians, choice of technique does not seem to affect outcomes, and sign and symptom responses occur in areas separate from the region of application. The effectiveness of MT despite the inconsistencies associated with a purported biomechanical mechanism suggests that additional mechanisms may be pertinent” (2009).
The position of the sacroiliac joint doesn’t change after manipulation (Tullberg, 1998), multiple vertebrae are mobilized with specific spinal techniques (Ross, 2004), and you can mobilize segments above or below the “dysfunctional” one, and get similar results (Cleland, 2005). No literature to date has demonstrated any long lasting biomechanical effects resulting from manual techniques (Wellens, 2010). For fans of myofascial released, the amount of force to deform fascia is well beyond a human’s capability to give or receive (Chaudhry, 2008).
Although the scientific literature and a wealth of anecdotal evidence suggests manual therapy has positive and clinically worthwhile effects, we still do not know exactly how it works. However, it is clear that overly mechanical explanations suggesting we alter specific tissues and change biomechanics is no longer sufficient. There is more to the story, and integrative models have been proposed that takes these considerations into account.
7. Capsular patterns describe patterns of motion loss for stiff joints.
This one even surprised me. Capsular patterns were the bane of my existence in school. Here you go young physical therapy student, please memorize seemingly-arbitrary patterns of motion loss for every joint in the body.
Having to to go through all the capsular patterns via flashcards for the boards time after time probably elevated my blood pressure a solid ten points. Capsular patterns of motion loss were originally described by orthopedic surgeon James Cyriax, in a noble attempt to categorize different injuries and conditions. The thought was that if a person has an issue going on with a joint capsule, they would have specific patterns of motion loss that would indicate it.
The problem is there is very little research to back up these claims.
An investigation of the validity of Cyriax’s rule for hip and knee osteoarthritis and found that the typical patterns of motion loss for these patients do not follow the rules consistently (Dekker, 1998). A similar study was performed to investigate the consistency of motion loss patterns for patients diagnosed with adhesive capsulitis and found that while external rotation was typically most limited, the limitations in abduction and internal rotation were not significantly different (Mitsch, 2004). In an attempt to determine a clinical prediction rule for diagnosis of hip osteoarthritis, researchers found that the traditional pattern as described by Cyriax did not assist in diagnosis (Sutlive, 2008). Serious investigation into capsular patterns for other joints remain to be seen. Chasing references back ultimately gets you to Cyriax’s own text, and not to any thorough research.
How often does a test have to be right for it to be useful? Undoubtedly you will see patients that, by chance or not, will have motion loss in a joint that matches the rule as predicted by Cyriax. Does that mean that the patient truly has a capsular issue? I don’t think we have enough evidence to say that with any certainty at this point.
Ultimately, the research thus far leaves me in a position to doubt the validity and utility of capsular patterns, and to be a little upset about all the time I spent memorizing them.
8. The vertebrobasilar artery insufficiency test can screen those at risk prior to cervical manual therapy.
Prior to performing manual therapy on the cervical spine, we were taught we needed to clear the vertebral artery of any potential issues; some of the interventions we do would place the neck into various positions, and given that the vertebral arteries take blood to the brain, we needed to make sure there would be sufficient blood flow throughout the treatment. Even on practicals, we were required to perform the VBI screen and assess our patients for dizziness and any other potential symptoms.
We have a few reasons to doubt the utility of this test.
Ideally, a test of this nature would be highly sensitive; it would accurately label the people with VBI as positive. This way, if we get a negative on the test, we can confidently assume that the patient doesn’t have vertebrobasilar insufficiency, and we can carry on with our manual treatments.
A systematic review of the literature in regards to the sensitivity and specificity of the VBI test revealed there were not enough strong studies to make firm conclusions. But, methodological flaws aside, the sensitivity values they found ranged from 0-57%, which is too low to be useful (Hutting, 2013). To be most charitable, as far as we can tell scientifically, the traditional VBI test as performed by physical therapists is at least of questionable utility.
By now, I hope you feel uncomfortable...
After spending some time reading research paper after research paper, and treating patients in the real world, I realized that things are much less certain than they appeared to be while in school. In science, we seek to constantly be less wrong; that is we may not arrive at truth in a deep epistemological sense, but we can at least strive to always challenge our beliefs, be open to evidence, and be willing to change our minds when the science points in a new direction.
A new graduate from 25 years ago might have written a completely different list. The same thing will undoubtedly happen with new graduates 25 years from now. The purpose of this article was not to complain about the education I received or explore the biases of my professors, but to show that physical therapy is a constantly evolving profession.
We need to ensure that we are evolving in the right direction. Being a physical therapist means having a commitment to lifelong learning; education does not stop after you get that diploma and the “PASSED” email from the FSBPT. It is up to us, new graduates, to stay current with the research, question physical therapy dogma, and abandon antiquated treatments.
We owe it our patients and to ourselves to be a generation of skeptical, inquisitive, and reflective physical therapists that always seek to be less wrong.
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