Fisioterapia.

2016;38(2):57---59

www.elsevier.es/ft

EDITORIAL

Literature review and research in physiotherapy

curriculum: Some reflections
Revisión de la literature e investigación en los estudios de Fisioterapia:
algunas consideraciones

Being invited to write an editorial for the Fisioterapia is an the literature. One is that the patient will have direct access
honor. Before formally accepting the invitation we analyzed to physiotherapy in many countries and the physiothera-
the possibilities to write something that might be useful pist will act as a primary care provider for musculoskeletal
for the readers of this journal. Discussion with physiothera- ailments and perhaps other diseases.3,4 The other is that
pists over the years, teaching physiotherapists at all levels physiotherapy schools or departments are formed at uni-
of education and some recent articles that reflects these versities belonging to the faculty of medicine or health
discussion helped us to make our decision. One article is sciences. Belonging to a university faculty necessitates
rather historical,1 and another describes the difficulties and research and physiotherapists have shown to be excellent
hurdles with performing or integrating research expressed researchers in a team or alone. In this new environment
by practicing licensed physiotherapists.2 come also a responsibility in surveying and analyzing the
The article by Hansson and Ottoson1 visits the origin of literature as clinician and/or researcher of excellence. This
‘‘physical therapy concepts and the profession of physi- editorial will focus on change to discuss literature searches,
cal therapist’’ in Sweden and the US within the context of methodology and education.
the Nobel Prize awarding procedure. The article by Janssen There are methodologies and new technologies deal-
et al., from New Zealand and still in press,2 explores the ing with performing a good bibliography search in the
‘‘perceptions of physiotherapists toward the use of and vast amount of peer-reviewed publications. Our experience
participation in research’’. We recommend all faculty and shows that the education to perform searches and synthe-
educators in charge of the future professionals physiother- sizing the literature is not optimal for physiotherapists at
apists to read and enjoy these two papers. undergraduate level but even at graduate level, a must in
During the last decades we have assisted to a major today’s clinical and research environment. The new physio-
evolution in the education of physiotherapists in many therapist graduates are excellent at e-communication and
countries. The education moved from a diploma to the cur- are able to contact authors and/or mentors worldwide, with
rent Bachelor, Master and PhD system and in the USA and little efficacy as a basic search of the literature has not
some other countries to the DPT (Doctor of Physical Ther- always been performed before the contact is made.
apy) degree. Programs that have implemented mandatory We receive demands from physiotherapy students from
research requirements as part of the curriculum for the stu- different countries and levels in education ranging from
dents will be less dependent on the personal motivation a reprint of an old publication, a bibliography search,
or willingness of the student to learn research methodol- electronic copies of references of a poorly defined topic.
ogy. Physiotherapy students have been confronted with a Quite often, in our exchanges, we had the firm conviction
hurdle of difficulties (for example inexperienced faculty, that there was no clear question for research behind the
ethical approval, lack of mentors) that stems from volun- requests. Moreover, the data from New Zealand2 suggest
tary research requirement. Therefore, a basic knowledge in that most participants ‘‘perceived good research to con-
research methodology and literature review is necessary and sist of RCTs (randomized controlled trials) and reviews’’
not always available in the education. However, times are which is a narrow definition of research. This statement
changing and so are curricula. may have been influenced by PEDro (Physiotherapy Evidence
There are two main changes in the physiotherapy envi- Database), a free database of randomized trials, systematic
ronment that have pushed the necessity to keep abreast with reviews and clinical practice guidelines in physiotherapy,

http://dx.doi.org/10.1016/j.ft.2015.11.001
0211-5638/© 2016 Asociación Española de Fisioterapeutas. Published by Elsevier España, S.L.U. All rights reserved.
58 EDITORIAL

i.e. the content of the database is limited for a specific the results from the literature search. This is not a small
purpose. There are many other designs of importance for task. Some and increasingly more physiotherapy academic
example cohorts for prediction of outcomes or qualitative departments and schools allow time for improving the
research to look at patient centered important values. The knowledge of literature reviews and searches. Reviewing
research question asked decides the study design. It is pos- and understanding the literature must be taught and
itive and encouraging that students and physiotherapists curricula are slowly changing, but in our opinion too slow.
make contact, however a search of the literature was sel- The basis for proposing a good study is a literature review
dom done perhaps because it was not part of the curriculum and showing the knowledge and limitations of what is
in the education. known from the literature in the topic proposed. What
As an example we are considering only one of our topic of is not answered in the literature should preferably be
interest, i.e. juvenile low back pain, and searching only one studied.
database. The results of PubMed yields with a brief search We would like to make some suggestions to the faculty
cross-matching different synonymous of lower back pain like and the future physiotherapists responsible for the current
the following (low back pain OR lumbago OR backache OR and future education.
lumbar pain OR spinal pain OR vertebral pain) and several
terms defining the age group of interest (children OR ado-
1. Research is important for physiotherapists, and the
lescent OR teenager OR juvenile OR infant OR pediatric),
methodology for a literature review and research prin-
ends up with 14,759 publication hits. Of those, 3625 articles
ciples have to be taught. There are excellent research
were published within the last 5 years, and in 22% of the arti-
courses, developed by the best researchers, method-
cles published (N = 795) physiotherapy skills were involved
ologists and professionals, which should be integrated
(at least searching with physiotherapy OR physical therapy
stepwise in the students’ curriculum from undergraduate
OR rehabilitation and cross-matching again). Reviewing 795
to graduate studies.
articles is a major task and cannot be done at undergradu-
2. Defining the research question(s) is fundamental to
ate level. However starting with two systematic literature
decide the appropriate design for the question asked and
reviews or two articles that gives opposite recommenda-
the study to be performed.
tions for treatment or diagnostics is a good exercise. Why
3. Dealing with the huge amount of bibliography available
did this happen and which review or article should the stu-
requires a good to excellent search strategy for the lit-
dent believe? At graduate level a literature review should
erature. Learning this means to be exposed to a librarian
be a must for every graduate student in a specific topic,
and to understand the complexity of a search in today’s
this takes time and the curriculum must allow it. Under-
world.
standing how to review the literature according to proper
4. Synthesizing the literature is exciting but takes time
methodology is important for the whole carrier as physio-
and effort, therefore starting with a few articles on the
therapist. Of course, getting in contact with the authors
same topic may be wise and gradually expand to larger
of relevant articles may obtain some useful information
searches must be part of the curriculum and a continuum.
and advice, but authors may be biased toward their own
5. There are ethical and even legal limitations to what
results.
can be done in an e-world. The authors sign a copyright
Weather becoming a physiotherapy clinician or
transfer and thus the publisher becomes the legal
researcher, physiotherapy education must include the
owner of the intellectual property of the work. As
methodology to build a research question by using available
an example this journal, accepts some ‘‘scholarly
tools such as FINER criteria (Feasible, Interesting, Novel,
sharing’’ (http://www.elsevier.com/about/company-
Ethical, Relevant).5,6 Other helpful tools are for example:
information/policies/sharing). We recommend everyone
Preferred Reporting Items for Systematic Reviews and Meta-
visiting the website of the publisher before making any
Analyses (PRISMA), PICO criteria (Population, Intervention,
decision of sharing. Unlimited sharing is allowed if an
Comparison and Outcome), GRADE (Grades of Recommen-
article is published as ‘‘open access’’.
dation, Assessment, Development and Evaluation), SIGN
(Scottish Intercollegiate Guidelines Network) available to
facilitate research of high quality.6 These tools are not new In conclusion understanding research has become
but have been developed in the last decades. The tools unavoidable for all health professionals, reading and syn-
must be taught at the educational institutions or schools thesizing the literature is a must. Consequently, learning
for the physiotherapists involved in clinical care and/or how to read scientific articles, how to perform and manage
research. As pointed out in the article by Janssen et al.2 literature searches must be integrated early in the educa-
not all professionals with higher leadership responsibilities tion. The fundamentals of research methodology in this case
have a uniform positive attitude toward research. At the review of the literature should become part of the basic
educational level the physiotherapy undergraduate or grad- and advanced curriculum stepwise for all future physiother-
uate student has to be introduced and learn how to pose apists. This will enable physiotherapists to pose the best
a question, formulate key words for the literature search, question in the field, to contribute to essential research and
contact a librarian on how to perform a library search, to early discover the satisfaction of being able to understand
understand study designs, review articles and accept or the successes and limitations of a study as well as better
reject them due to quality criteria. The most difficult is translate findings into practice. The physiotherapy depart-
still left that is the synthesis of the results from the articles ments and schools that have already integrated mandatory
published in peer-reviewed journals, to summarize and to and stepwise research requirements into the curriculum are
resolve controversies between results and finally write up to be congratulated.
EDITORIAL 59

Funding 4. Ojha HA, Snyder RS. Direct access compared with referred phys-
ical therapy episodes of care: a systematic review. Phys Ther.
2014;94:14---30, http://dx.doi.org/10.2522/ptj.20130096.
The authors have not received any grant or other financial
5. Farrugia P, Bradley A, Forough F, Mohit B. Research questions,
support.
hypotheses and objectives. J Can Chir. 2010;53:278---81.
6. Websites: FINER: http://www.fmdrl.org/group/index.cfm?event
Conflict of interest =c.showWikiPage&pageId=413; PICO: http://learntech.physiol.
ox.ac.uk/; GRADE: http://www.gradeworkinggroup.org/;
The authors do not declare any conflict of interest. PRISMA: http://www.prisma-statement.org/; SIGN: http://
www.sign.ac.uk/1.

References F. Balagué a,b,c,∗ , M. Nordin d,e

a
Department of Rheumatology, HFR Fribourg-hôpital
1. Hansson N, Ottosson A. Nobel prize for physical therapy? Rise, cantonal, 1708 Fribourg, Switzerland
fall, and revival of medico-mechanical institutes. Phys Ther. b
Faculty of Medicine, University of Geneva, Geneva,
2015;95:1184---94.
Switzerland
2. Janssen J, Hale L, Mirfin-Veitch B, Harland T. Perceptions of c
physiotherapists towards research: a mixed methods study. Department of Orthopedic Surgery, NYU Hospital for
Physiotherapy. 2015;17, http://dx.doi.org/10.1016/j.physio. Joint Diseases, New York University, New York, NY, USA
d
2015.04.007. pii:S0031-9406(15)03788-8 [Epub ahead of print] Department of Orthopedic Surgery, OIOC, NYU Hospital
PMID: 26209908. for Joint Diseases, New York University, New York, NY, USA
e
3. Bury TJ, Stokes EK. Direct access and patient/client self- World Spine Care, Santa Ana, CA, USA
referral to physiotherapy: a review of contemporary practice
within the European Union. Physiotherapy. 2013;99:285---91, Corresponding author.
∗

http://dx.doi.org/10.1016/j.physio.2012.12.011. E-mail address: Federico.Balague@h-fr.ch (F. Balagué).