Publication of randomised trials and systematic reviews in physiotherapy has increased spectacularly over the past few years. There are more than 2700 randomised trials and systematic reviews in physiotherapy, of which more than 800 have been published since 1997.1 The evidence from the best of these trials confirms the value of some current physiotherapy practices and the ineffectiveness of others. Some little used interventions have been found to be remarkably beneficial. This article describes some advances in our understanding of physiotherapy that have arisen from recent clinical trials.
Methods
With the help of several organisations and many volunteers, we have produced a web based database of randomised trials and systematic reviews in physiotherapy (PEDro).1 Trials on the database are rated for methodological quality by using a modification of the Delphi list.2 To produce this article, we scanned the database looking for recent systematic reviews or high quality clinical trials with clear conclusions and with potential to improve quality of life. We present selected findings of these trials and reviews.
Chronic musculoskeletal pain
Musculoskeletal disorders are the most common cause of chronic incapacity in industrialised countries.3Fortunately, some of the most important advances in physiotherapy have been in the management of these problems, particularly chronic low back pain, osteoarthritis of the hip and knee, and rheumatoid arthritis.
There is strong evidence from recent studies that simple interventions provided soon after onset of symptoms can prevent the development of chronic back pain. For example, reassuring patients about the self limiting nature of most low back pain and advice to return to normal activity as soon as possible increases the rate of return to work for workers with low back pain.4 On the other hand, encouraging rest is probably harmful.4,5
Traditionally, the mainstays of physiotherapy management of musculoskeletal pain have been massage, manual therapy (that is, manipulation and joint mobilisation), electrotherapy (such as therapeutic ultrasound, shortwave diathermy, and low energy laser), and therapeutic exercise. Current evidence paints a mixed picture of the effects of these interventions. There has been little rigorous research into the effects of massage,6 so the clinical benefits of massage, if any, remain unsubstantiated. Manual therapy is more effective than placebo in relieving low back pain, but it is not clear if it is more effective than other physiotherapy treatments.7 Most electrotherapies probably have little more than placebo effects.8
The most positive findings come from recent studies of therapeutic exercise. Many trials and several systematic reviews have shown that exercise can produce clinically worthwhile reductions in the disability and handicap associated with chronic low back pain, osteoarthritis of the hip and knee, and rheumatoid arthritis.7,9,10
The exercise programmes most often shown to be effective in contemporary clinical trials differ from traditional exercise in two important ways. Firstly, formal exercise programmes are considered to be part of a more global process of “activity prescription” involving a structured return to normal home, work, and social activities. Secondly, the programmes are based on evidence from behavioural sciences as well as the biological sciences. Many exercise programmes now explicitly incorporate principles of cognitive-behavioural therapy.11 With this approach, patients are taught to exercise to quotas rather than as symptoms permit, specific rewards are provided when exercise quotas or activity goals are met, and pain behaviours are not rewarded by attention from the therapist.
Urinary incontinence
About a quarter of women experience involuntary loss of urine, and about 2.5% report this causes much bother or a great problem.12 The problem of urinary incontinence in women, including genuine stress urinary incontinence, can be treated effectively with training of the pelvic floor muscles.13 For example, training pelvic floor muscles with weighted vaginal cones (weights inserted into the vagina) substantially increases the probability of cure or improvement compared with no exercise.14 An important recent trial of the effects of training pelvic floor muscles in women with genuine stress urinary incontinence has shown that doing eight near maximal pelvic floor muscle contractions three times a day for six months produces large reductions in the risk of incontinence related problems with social life, sex life, and physical activity.15 In this sample (mean duration of symptoms 10 years), absolute reductions in risk of each of these problems exceeded 35%, implying that at least a third of women experience each of these benefits from exercise. It is not clear if training with weighted cones, biofeedback (electromyographic feedback of pelvic floor muscle activity) or electrical stimulation produces better outcomes than pelvic floor muscle training alone.13,15
Movement dysfunction resulting from stroke
In terms of disability adjusted life years, stroke ranks as the sixth highest cause of burden of disease worldwide and is the single most important cause of severe disability in people living in their own homes.16Multidisciplinary rehabilitation programmes reduce the odds of death or institutionalised care and the odds of death or dependency after stroke (odds ratios of 0.76 and 0.75), probably partly by reducing physical disability.17 There is some evidence that physical training reduces disability, and that more training produces better outcomes.18,19 Some specific methods of training show promise, although the evidence relating to these methods is limited to a few high quality trials. One simple strategy is to constrain the unaffected upper limb to “force” use of the affected upper limb.20 Another effective strategy is to suspend patients in a harness above a treadmill to enable them to practice walking with partial body weight support.21
Acute and chronic respiratory disease
The role of physiotherapy in prevention and management of pulmonary disease has been debated for decades. Several recent important systematic reviews and clinical trials have helped clarify the situation.
Prophylactic chest physiotherapy before and after surgery reduces morbidity after major abdominal surgery.22 For example, Olsen showed that prophylactic chest physiotherapy reduced the incidence of pulmonary complications after major abdominal surgery from 27% to 6%.22 This implies that, on average, one pulmonary complication is prevented for every five patients treated. It is not clear which interventions are most effective. Prophylactic chest physiotherapy has little effect when routinely administered after coronary artery bypass surgery or minor abdominal surgery, or during intubation after routine cardiac surgery.23 This is consistent with the view that prophylactic chest physiotherapy is of most benefit to patients at the highest risk of postoperative complications.22
Pulmonary rehabilitation programmes typically involve upper and lower body exercise (usually treadmill walking or stationary cycling), and may include ventilatory muscle training, counselling, and education. Such pulmonary rehabilitation programmes can increase walking distance and health related quality of life in people with asthma and chronic obstructive pulmonary disease.24 A recent trial indicates that rehabilitation may also reduce duration of hospital stay but not the number of medical consultations.25
An important and relatively new intervention is the application of nocturnal ventilatory support to patients with sleep disordered breathing, particularly patients with chronic obstructive pulmonary disease, neuromuscular diseases or injury, or cystic fibrosis. Nocturnal assisted ventilation greatly reduces one year mortality and hypoventilation related symptoms in people with neuromuscular diseases.26
Prevention of falls in elderly people
One in three older people fall at least once a year.27 There is strong evidence that multifaceted interventions targeting identified risk factors reduce falls risk in older people.28 Well designed studies suggest that it is necessary to prescribe such interventions for about eight people to prevent one fall per year in a community setting.29
Known risk factors for falls such as weakness of lower limb muscles and poor balance are potentially modifiable by exercise, so physiotherapists and others have provided exercise programmes for older people at risk of falling. Several trials and reviews conclude that exercise can reduce risk of falls.28,30 One individually tailored home based strength and balance training prescribed by trained health professionals has been found effective in four trials.31
Isometric exercise for back extensor muscles: exercise can reduce disability associated with chronic low back pain
Pulmonary rehabilitation can increase quality of life for people with asthma and chronic obstructive pulmonary disease
Acknowledgments
We acknowledge helpful discussions with Elizabeth Ellis, Mark Elkins and Pauline Chiarelli. The Centre for Evidence-Based Physiotherapy is funded by the Motor Accidents Authority of New South Wales and the New South Wales Physiotherapists Registration Board.
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