Clinical PT Talks

The measurement problem in physical therapy: Part 1

A measurement problem exists in the world of physical therapy. In some ways it is subtle, almost unrecognizable, yet pervasive. In others ways, it is clearly structural and perpetuated by systems that diminish or misunderstand its value. Both are harmful to our profession, and to patients. Join me in this 2-part podcast series as I explore what the problem is, how we got here, and what we should do about it.   REFERENCES Kristal A, Gaunaurd IA, Morgan SJ, et al. Use of standardized outcome measures among physical therapists in the United States: A cross-sectional survey study. PLoS One. 2025;20(8):e0330528. Published 2025 Aug 20. doi:10.1371/journal.pone.0330528  McCambridge AB, Nasser AM, Mehta P, Stubbs PW, Verhagen AP. Has Reporting on Physical Therapy Interventions Improved in 2 Decades? An Analysis of 140 Trials Reporting on 225 Interventions. J Orthop Sports Phys Ther. 2021;51(10):503-509. doi:10.2519/jospt.2021.10642 Pires D, Cruz EB, Gomes LA, Nunes C. How Do Physical Therapists Measure Treatment Outcomes in Adults With Chronic Low Back Pain? A Systematic Review. Phys Ther. 2020;100(6):1020-1034. doi:10.1093/ptj/pzaa030 [This study reports spinal mobility is assessed in only 31.8% of studies, and muscle strength and endurance in only 26.7%. Furthermore, measurement targets and tools are not standardized. These findings and more reflect my own observations.]

The fallacy of n-of-1 thinking. How it limits your ability to improve as a clinician, and what to do instead.

Physical therapists love to report the wonderful results they have achieved with their patients. And rightly so. Singular cases stand out. The clinician is happy, the patient is happy, and sharing success with colleagues, patients, and anyone who will listen is fun and can be informative. Inevitably, however, someone is always quick to point out what seems obvious: "But remember, that's only an n-of-1." As if you have cherry-picked your remarkable example from an otherwise unremarkable bunch. How could you be so naive? Join me as I discuss a different perspective on n-of-1 thinking, one that reveals powerful evidentiary options that n-of-1 observations give rise to if properly understood.   REFERENCE https://sites.duke.edu/cemmt/2025/12/24/why-individualized-treatment-effects-matter-more-than-averages-in-musculoskeletal-care/ [https://sites.duke.edu/cemmt/2025/12/24/why-individualized-treatment-effects-matter-more-than-averages-in-musculoskeletal-care/]

Psychopathology and treatment effect interference, PART 2: Are we all now psychotherapists?

Psychological factors are always and irrevocably present in any clinician interaction with patients. They can be a help or a hinderance. In PART 1 of this series I spoke about common distortions of thinking that can get in the way of our understanding examination and treatment of patients and of what to do and why. In PART 2 I discuss a common underlying factor present with all treatments which threatens to undermine our ability to discern mechanisms of action, and more. Consequently, we may find ourselves facing uncertainty regarding both treatment choices and interpretation of our results. Join me as I discuss emerging science, important past works, and linking these ideas together so that we can better understand how to help our patients, as well as ourselves, in the presence of new information.    REFERENCES Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009;14(5):531–538. doi:10.1016/j.math.2008.09.001 Clifford C, Challoumas D, Paul L, Syme G, Millar NL. Effectiveness of isometric exercise in the management of tendinopathy: a systematic review and meta-analysis of randomised trials. BMJ Open Sport Exerc Med. 2020;5:e000760. doi:10.1136/bmjsem-2020-000760 Di Fabio RP. Disablement: the patient's problem no longer matters. J Orthop Sports Phys Ther. 2000;30(6):304-305. doi:10.2519/jospt.2000.30.6.304 Ezzatvar Y, Dueñas L, Balasch-Bernat M, Lluch-Girbés E, Rossettini G. Which Portion of Physiotherapy Treatments' Effect Is Not Attributable to the Specific Effects in People With Musculoskeletal Pain? A Meta-Analysis of Randomized Placebo-Controlled Trials. J Orthop Sports Phys Ther. 2024;54(6):391-399. doi:10.2519/jospt.2024.12126 Filbay SR, Bullock G, Russell S, Brown F, Hui W, Egerton T. No Difference in Return-to-Sport Rate or Activity Level in People with Anterior Cruciate Ligament (ACL) Injury Managed with ACL Reconstruction or Rehabilitation Alone: A Systematic Review and Meta-Analysis. Sports Med. 2025;55(9):2191-2205. doi:10.1007/s40279-025-02268-5 Hancock MJ, Maher CG, Laslett M, Hay E, Koes B. Discussion paper: what happened to the ‘bio’ in the bio-psycho-social model of low back pain? Eur Spine J. 2011;20:2105-2110. Doi:10.1007/s00586-011-1886-3 Harris SR. How should treatments be critiqued for scientific merit?. Phys Ther. 1996;76(2):175-181. doi:10.1093/ptj/76.2.175 Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013;368(18):1675-1684. doi:10.1056/NEJMoa1301408 Lederman E. The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain. J Bodyw Mov Ther. 2011;15(2):131-138. doi:10.1016/j.jbmt.2011.01.011 Nudelman Y, Pincus T, Ami NB. Association Between Physical Therapists' Attitudes and Beliefs and the Functional Outcomes of Patients With Low Back Pain: A Multilevel Analysis Study. Phys Ther. 2025;105(4):pzaf007. doi:10.1093/ptj/pzaf007 Simonetta R, Russo A, Palco M, Costa GG, Mariani PP. Meniscus tears treatment: The good, the bad and the ugly-patterns classification and practical guide. World J Orthop. 2023;14(4):171-185. Published 2023 Apr 18. doi:10.5312/wjo.v14.i4.171 Zadro JR, Ferreira G. Has physical therapists' management of musculoskeletal conditions improved over time?. Braz J Phys Ther. 2020;24(5):458-462. doi:10.1016/j.bjpt.2020.04.002 https://www.scientificamerican.com/article/breakthrough-prize-winner-gerard-t-hooft-says-quantum-mechanics-is-nonsense/

Psychology and treatment effect interference, PART 1: It's you, not me ... and other tales of woe.

Psychological factors are always and irrevocably present in any clinician interaction with patients. They can be a help or a hinderance. When problematic, they can negatively interfere with intended treatment effects. However, they can also be present in clinicians as well. This can lead to distortions of thinking that alter our ability to properly interpret what we are doing, why, and what our results are like. Recognizing such issues is helpful in deciding what to do about them. Join me in this first part of a 2-part podcast as I discuss these aspects of psychologically informed practice and more.     REFERENCES Ballengee LA, Zullig LL, George SZ. Implementation of Psychologically Informed Physical Therapy for Low Back Pain: Where Do We Stand, Where Do We Go?. J Pain Res. 2021;14:3747-3757. Published 2021 Dec 7. doi:10.2147/JPR.S311973 Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378 (9802):1560–1571. doi:10.1016/S0140-6736(11)60937-9 [Study design flaws lead to overestimation of beneficial result.] Rogers JS, Witt PL, Gross MT, Hacke JD, Genova PA. Simultaneous palpation of the craniosacral rate at the head and feet: intrarater and interrater reliability and rate comparisons. Phys Ther. 1998;78(11):1175-1185. doi:10.1093/ptj/78.11.1175 Rosa L, Rosa E, Sarner L, Barrett S. A close look at therapeutic touch. JAMA. 1998;279(13):1005-1010. doi:10.1001/jama.279.13.1005 [9 year-old girl’s science fair project debunks therapeutic touch.]

What to do when your patient is lying to you? A perspective.

Not everyone lies, but patients lie more than we might expect. And we’re not good at detecting it. So, what is one to do, as a healthcare provider, when faced with this reality? Afterall, lies and failure to disclose vital health information can dramatically and disastrously impact our ability to provide quality care. Join me in this podcast as I discuss these issues and provide a perspective on what’s known from the published scientific literature blended with the pragmatism of clinical practice. NOTE: Patient examples in this podcast episode are representative. They are drawn from composites of multiple clinical cases modified to protect identities and protected health information.    REFERENCES Embattled Harvard honesty professor accused of plagiarism | Science | AAAS https://www.science.org/content/article/embattled-harvard-honesty-professor-accused-plagiarism [https://www.science.org/content/article/embattled-harvard-honesty-professor-accused-plagiarism] Levy AG, Scherer AM, Zikmund-Fisher BJ, Larkin K, Barnes GD, Fagerlin A. Prevalence of and Factors Associated With Patient Nondisclosure of Medically Relevant Information to Clinicians. JAMA Netw Open. 2018;1(7):e185293. Published 2018 Nov 2. doi:10.1001/jamanetworkopen.2018.5293 Palmieri JJ, Stern TA. Lies in the doctor-patient relationship. Prim Care Companion J Clin Psychiatry. 2009;11(4):163-168. doi:10.4088/PCC.09r00780