Levels of Evidence in Physical Therapy

August 11, 2018

The Importance of Research and Evidence Levels in Physical Therapy and Fitness


Anyone out there who knows me, knows one thing about me. I love generalizing, and I already know it, it does not work in my favor. I am the type of guy who would tell you that “everyone who does weightlifting is strong” (which is true!). Also I often say things like “all guys like eating salty stuff, and all girls like eating sweet stuff” (yes, I know this is not always the case).


Sound familiar? Let me point out a few specific examples in the fitness and physical therapy fields that may seem familiar to you. A new supplement that promises to turn each pound of body fat into a pound of muscle in less than a week. A new workout that will make you the best weightlifter in the world in less than a year. A new physical therapy modality that will promote the growth of your meniscus after you twisted your knee and tore the meniscus. The examples are endless and it is not uncommon that we are mislead by an “expert”/company for purely for the purpose of them getting our money.


What Does "Levels of Evidence" Mean in Physical Therapy and Fitness?


As a physical therapy professional I am responsible for applying current research findings at work. This helps me to effectively treat my patients/clients as well as to educate other health care professionals and the general public about research findings that are meaningful to the field of physical therapy.

The real question is what research is “meaningful” in the fields of physical therapy and fitness? To answer this question we have to look at the hierarchy of “levels of evidence”. As a therapist I consider the highest level in the hierarchy to be the most useful to look at because they are ranked according to the strength of the research design. Simply put, the higher the research design, the more evidence there is to answer the specific question that is asked in the research study. We must be aware that as the level of evidence decreases, the strength of evidence decreases.


Here is a quick breakdown of the levels of evidence from the lowest level to the highest level:


Ideas/Opinions = are not more than that, be careful in even taking them into consideration.

Case report = as the name suggests, these are based only on one specific individual patient/client.

Case series = based on several cases that are mostly similar in nature (Glossary of Statistical Terms. Centre for Evidence-Based Medicine Web site. http://www.cebm.net/glossary/. Accessed June 27, 2015).

Cross-sectional study = in this kind of study the data is collected at only one point in time and all subjects are tested at the same time. This shows the relationship between a disease and factors that exist in the specified population (Roy S, Wolf S, Scalzitti D. The Rehabilitation Specialist’s Handbook. Forth Edition, F.A. Davis Company. 2013).

Case control study = in this type of study, people with a condition are compared to people without the condition. This way the study can estimate what kind of exposure is significant to people with the condition, compared to people without the condition (Glossary of Statistical Terms. Centre for Evidence-Based Medicine Web site. http://www.cebm.net/glossary/. Accessed June 27, 2015).

Cohort study = an observational study that follows people with a risk factor or exposure over time to compare the occurrence of disease in the exposed group to the unexposed group (Glossary of Statistical Terms. Centre for Evidence-Based Medicine Web site. http://www.cebm.net/glossary/. Accessed June 27, 2015).

Randomized controlled trial = experimental research that examines the effect of an intervention compared to a control condition. This research assigns people with the same conditions to two groups, one that receives no treatment or basic treatment, compared to a second group that receives the specific treatment (Guidelines by Topic. National Guideline Clearinghouse Web site.http://www.guideline.gov/. Accessed June 27, 2015).

Meta-analysis = comprehensive review that uses statistics to derive an estimate of effect size by combining the results of several randomized controlled trails to determine the overall effectiveness of the treatment. Since the information is gathered from several studies, this type of evidence is considered to be very valuable and should be used most often to derive answers to clinical questions (Glossary of Statistical Terms. Centre for Evidence-Based Medicine Web site. http://www.cebm.net/glossary/. Accessed June 27, 2015).

Systemic review = comprehensive review of medical literature. Just like Meta-analysis, this type of evidence is considered to be very valuable since it summarizes all of the literature on a specific issue. (Sackett DL, Straus SE, Richardson WS, Rosenburg W, Haynes RB. Evidence-Based Medicine. How to Practice and Teach EBM. 2nd ed. Edinburgh, Scotland; Churchill Livingstone. 2000).


Conclusion: Become an Expert by Mastering Levels of Evidence


Research is becoming very prevalent in the field of physical therapy, as well as in the field of fitness – especially strength and conditioning. Adhering to these rules of levels of evidence in practice will help you be an expert in the field. Also it will help you avoid buying that future hundred thousand dollar treadmill that promises to help build your leg strength by keeping you up in the air.

Cupping Therapy

August 12, 2024
Cupping therapy is an ancient technique that has been integrated into modern physical therapy to help alleviate pain, reduce inflammation, and enhance overall recovery. In my practice, I use cupping as part of a holistic approach to treat muscle tightness, improve blood flow, and accelerate the healing process. How Cupping Works: Cupping involves placing specialized cups on the skin to create suction. This suction helps to lift the skin and underlying tissues, promoting increased circulation to the affected area. The improved blood flow aids in reducing muscle tension, breaking up scar tissue, and encouraging the body’s natural healing processes. Benefits of Cupping Therapy: – Pain Relief: Cupping can help reduce muscle soreness and pain by releasing tightness and promoting relaxation. – Enhanced Recovery: By improving blood circulation, cupping accelerates the removal of metabolic waste from tissues, leading to quicker recovery times. – Flexibility and Mobility: Regular cupping sessions can improve joint and muscle flexibility, making it an excellent addition to your rehabilitation or performance enhancement program. What to Expect: During a cupping session, you may feel a pulling or stretching sensation as the cups create suction. It’s normal to experience some mild bruising or redness at the treatment sites, which typically fades within a few days. I ensure that each session is tailored to your specific needs, targeting areas that will most benefit from the therapy.

Blood Flow Restriction Training

August 10, 2024
Blood Flow Restriction Training (BFRT) is a rehabilitation technique used to enhance muscle strength and growth by applying a cuff to partially restrict blood flow to a muscle during exercise. This method allows patients to gain the benefits of muscle hypertrophy and strength gains using low-intensity exercises. In physical therapy BFRT is particularly advantageous in settings where patients are recovering from injuries or surgeries, as it reduces the mechanical load on joints and tissues, minimizing the risk of re-injury.  The benefits and advantages of BFRT include: Muscle Strength and Growth : BFRT promotes muscle hypertrophy and strength gains even with low-intensity exercise, which is crucial for patients who cannot engage in high-intensity workouts. Accelerated Recovery : By enabling effective training at lower intensities, BFRT helps maintain muscle mass and strength during periods of limited mobility, aiding faster recovery. Reduced Joint and Tissue Stress : BFRT allows for significant muscle engagement without the high loads that could strain joints and soft tissues, making it suitable for patients with orthopedic issues or those recovering from surgeries. Versatility : BFRT can be applied to various body parts and adapted to different exercise modalities, making it a flexible tool in a therapist’s toolkit. Enhanced Safety : The low-intensity nature of exercises performed with BFRT reduces the risk of overtraining and injury, providing a safer rehabilitation option for patients at different fitness levels.

Force Plates

August 10, 2024
Force plates are a valuable tool in physical therapy, offering a range of benefits that enhance the quality of care and outcomes for patients. Here’s a detailed explanation of their advantages: – Objective Data Collection Force plates provide objective, quantitative data on ground reaction forces, which are essential for understanding how a patient’s body interacts with the ground during various activities. This data is critical for accurately assessing biomechanical performance and movement patterns, such as gait, balance, and jump dynamics. Unlike subjective assessments, force plates offer precise measurements, which lead to more accurate diagnoses and treatment plans. – Enhanced Assessment and Diagnosis With the detailed information force plates provide, physical therapists can identify subtle imbalances and asymmetries that might not be visible to the naked eye. For example, discrepancies in how much force each leg produces can indicate underlying issues, such as muscle weakness, joint instability, or improper technique. Early detection of these issues allows for timely intervention, potentially preventing more severe injuries. – Personalized Treatment Planning The data from force plates enables the creation of highly individualized rehabilitation and training programs. By understanding a patient’s specific movement deficiencies, therapists can tailor exercises and interventions to target these areas. This personalized approach increases the effectiveness of therapy, as interventions are specifically designed to address the patient’s unique biomechanical profile. – Progress Tracking and Outcome Measurement Force plates facilitate the objective tracking of a patient’s progress over time. By regularly assessing changes in force production, symmetry, and other key metrics, therapists can evaluate the effectiveness of treatment interventions. This ability to measure outcomes quantitatively helps in refining treatment plans and ensures that patients are making measurable improvements. – Injury Mitigation and Performance Enhancement For athletes and active individuals, force plates are particularly valuable for optimizing performance and preventing injuries. By analyzing the forces involved in specific sports movements, therapists can identify risky movement patterns that may predispose an athlete to injury. Interventions can then be designed to correct these patterns, enhance performance, and reduce the risk of future injuries. – Comprehensive Documentation and Communication The data collected from force plates can be documented and shared with other healthcare providers, coaches, or trainers, fostering a collaborative approach to patient care. This comprehensive documentation supports a continuum of care, ensuring that all parties involved have a clear understanding of the patient’s condition and progress. – Patient Education and Engagement Visual and numerical data from force plates can be a powerful tool in educating patients about their condition. When patients see the objective data, such as force distribution and asymmetries, they often gain a better understanding of their issues and the rationale behind their treatment plan. This understanding can enhance patient compliance and engagement in their rehabilitation process. Incorporating force plates into physical therapy practice elevates the standard of care by providing precise, objective data that enhances assessment accuracy, personalizes treatment plans, and tracks progress. This technology not only aids in injury prevention and performance enhancement but also fosters better communication and education, ultimately leading to improved patient outcomes.