Challenging Myths in Physical Therapy.

As a young, hospital-based physical therapist in the early 1970s, I vividly recall a middle-aged patient who had undergone a radical mastectomy for treatment of breast cancer. Her chest was sunken and hollow following removal of the pectoral muscles, overlying skin, and supraclavicular lymph nodes. She had a gaping wound in her axilla where the lymph nodes had been cleared, making the range-of-motion exercises that I provided extremely painful. For almost 80 years, the Halsted radical mastectomy was the standard treatment for breast cancer in North America, a procedure that was both physically and psychologically debilitating.

An American surgeon named Bernard Fisher chose to challenge the myth that radical mastectomy was the only viable treatment for breast cancer. Through a series of large randomized controlled trials conducted in the 1970s and 1980s, Fisher's research team demonstrated that a much less invasive surgery--the partial mastectomy (lumpectomy), combined with radiation to the breast--was as effective as the radical mastectomy in prolonging lives of women with early-stage breast cancer.[1,2] As a result, almost 75% of the more than 200,000 women diagnosed with breast cancer in North America each year can opt for a lumpectomy.[3] For those who still require removal of the breast, much less invasive procedures--such as the total mastectomy or modified radical mastectomy--are now standard practice.

A few years after my experience with the patient who had undergone the radical mastectomy, I switched gears and became a pediatric physical therapist. In 1973, I was thrilled to take part in an 8-week course on the neurodevelopmental treatment approach for children with cerebral palsy. During the "Bobath course," we were taught that spastic (or hypertonic) muscles should never be strengthened because strengthening would increase spasticity and decrease overall function. It was more than 20 years before that myth was successfully challenged by US and Canadian physical therapist researchers who showed that strengthening exercises for children and adolescents with cerebral palsy actually enhanced their strength and overall function.[4-6]

According to Webster, a myth is "an ill-founded belief held uncritically, especially by an interested group."[7] During my career as a physical therapist, I have seen a number of myths challenged by my clinical researcher colleagues. In a seminal article published in Physical Therapy in 1994, Wirth-Pattullo and Hayes[8] examined the interrater reliability of craniosacral rate measurements among physical therapists with expertise in craniosacral therapy. Their conclusion was that the reliability attained (ICC=0.02) was "unacceptable for clinical decision making."[8(p916)] Their study was replicated, in part, several years later, with similarly dismal results that were also published in this Journal.[9]

As we all recall from our statistics courses, a measurement that is not reliable cannot be valid. If examiners trained in craniosacral therapy are unable to obtain reliable measurements of craniosacral motion, measurement of this motion is not valid. In fact, we can never be sure if what we're measuring even exists. Imagine if surgical oncologists drew treatment conclusions based solely on the results of mammography! More than 80% of women with abnormal mammograms would undergo needless surgery, at great expense both to the health care system and to the individuals undergoing the surgery.[3] Fortunately, there are reliable and valid measurements that can be obtained following initial screening mammograms, thus enabling surgeons to make informed decisions about who will or will not benefit from surgery. This is not the case, however, for craniosacral measurement. And yet, both in Canada and in the United States, many physical therapists have embraced craniosacral therapy as a primary intervention for patients with a myriad of different complaints.

How can we possibly call ourselves ethical (or evidence-based) practitioners when we fail to adopt evidence that has been published and replicated in our own professional journal? The myth of being able to provide reliable measurement of craniosacral motion has been challenged--and yet many of our colleagues continue to use this technique and to charge for craniosacral assessment and intervention. A recent systematic review of the literature on craniosacral therapy concluded that there is limited research on efficacy, and the research that does exist is of poor quality.[10] In addition, the review noted reports of adverse effects when craniosacral therapy was used for persons with brain injury.[10]

In autumn of 1994, I encountered a different myth--on a very personal level. Following my initial breast cancer surgery (a partial mastectomy with axillary node dissection), I found myself under the care of a physical therapist for the first time in my life. Several weeks after my surgery, I flew home to visit my family in upstate New York. On a beautiful fall day, I raked leaves with my sister and her children under the huge maple trees of our family homestead. I was able to put the threatening specter of cancer behind me and enjoy feeling useful and alive. When I returned to Vancouver and my next physical therapy appointment, I immediately told my therapist how healthy I had felt raking leaves with my family on that lovely autumn day. She responded with alarm. "You did what? You raked leaves? People who are at risk for lymphedema should never do repetitive upper-body motions!" She then measured the circumference of my involved upper arm and announced that it had increased by one half-inch. My renewed joie de vivre disappeared, and my fear of the dreaded lymphedema soared.

Not surprisingly, my physical therapist had never assessed the reliability of her circumferential measurements, nor could she consult the literature because at that time there were no studies on reliability of upper-extremity circumferential measurements. Furthermore, her assumptions about repetitive activity leading to lymphedema were based entirely on anecdotal evidence in medical textbooks. Suddenly, I had my own myth to challenge!

In 1996, I joined a hardy band of 24 middle-aged women, all of whom had been treated for breast cancer and who, under the direction of an exercise physiologist/sports medicine physician, were embarking on the very vigorous and repetitive upper-body sport of Dragon Boat racing. As part of that adventure, another physical therapist and I measured the arm circumferences of our teammates at the beginning of our training sessions, again at the international races, and finally at a specified time point 5 months later. In addition, we established interrater reliability of our measurements. Our results showed that there were no clinically important increases in arm circumference and no new cases of lymphedema. That research was published in the Journal of Surgical Oncology and was titled "Challenging the Myth of Exercise-Induced Lymphedema in Breast Cancer: A Series of Case Reports."[11] As a result of our challenge to that long-held myth, there are now more than 35 Dragon Boat teams of women living with breast cancer around the world.

Based on Sackett's rules,[12] our study represented a low level of evidence; however, it debunked a universally held myth and was the first study on vigorous exercise and lymphedema to be published in the peer-reviewed literature. Our research was incredibly simple to conduct, with no associated costs and very little time involved in collecting three sets of serial measurements. Any physical therapist who can obtain reliable arm-circumference measurements could easily replicate this study on women with breast cancer who are engaged in any vigorous sport or recreational activity.

We have many myths yet to challenge in physical therapy regarding the measurements we use and the interventions we recommend for our clients. Does the W-sitting posture preferred by children with spastic diplegia really lead to hip dislocation? Can we enhance the cardiovascular fitness of individuals with developmental disabilities? Is it possible that upper-body exercise might minimize the impairments associated with lymphedema? Thanks to pioneers such as Damiano,[4,5] MacPhail and Kramer,[6] and Wirth-Pattullo and Hayes,[8] we have clinical researcher role models to emulate.

References

[1] Fisher B, Redmond C, Poisson R, et al. Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med. 1989;320:822-828.

[2] Fisher B, Anderson S, Redmond CK, et al. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med. 1995;333:1456-1461.

[3] Olivotto IA, Gelmon K, Kuusk U, eds. Intelligent Patient Guide to Breast Cancer. 2nd ed. Vancouver, BC: Intelligent Patient Guide; 1998.

[4] Damiano DL, Abel MF. Functional outcomes of strengthening in spastic cerebral palsy. Arch Phys Med Rehabil. 1998;79:119-125.

[5] Damiano DL, Kelly LE, Vaughn CL. Effects of quadriceps femoris muscle strengthening on crouch gait in children with spastic diplegia. Phys Ther. 1995;75:658-671.

[6] MacPhail HE, Kramer JF. Effect of isokinetic strength training on functional ability and walking efficiency in adolescents with cerebral palsy. Dev Med Child Neurol. 1995;37:763-775.

[7] Webster's Seventh New Collegiate Dictionary. Springfield, Mass: G & C Merriam Co; 1963.

[8] Wirth-Pattullo V, Hayes KW. Interrater reliability of craniosacral rate measurements and their relationship with subjects' and examiners' heart and respiratory rate measurements. Phys Ther. 1994;74:908-916.

[9] Rogers JS, Witt PL, Gross MT, et al. Simultaneous palpation of the craniosacral rate at the head and feet: intrarater and interrater reliability and rate comparisons. Phys Ther. 1998;78: 1175-1185.

[10] Green C, Martin CW, Bassett K, Kazanjian A. A Systematic Review and Appraisal of the Scientific Evidence on Craniosacral Therapy. B.C. Office of Health Technology Assessment. Vancouver, BC: University of British Columbia, 1999.

[11] Harris SR, Niesen-Vertommen SL. Challenging the myth of exercise-induced lymphedema in breast cancer: a series of case reports. J Surg Oncol. 2000;74:95-99.

[12] Sackett DL. Rules of evidence and clinical recommendations for the use of antithrombotic agents. Chest. 1989;95:2S-3S.

As Editor Jules Rothstein prepares to present the Thirty-Second Mary McMillan Lecture at Physical Therapy 2001: Annual Conference and Exposition of APTA, the Journal will publish Guest Notes. Dr Rothstein will resume his Editor's Notes in the September issue.

In her Note, Harris mentions upper-extremity exercise for women with lymphedema as a result of breast cancer treatment and muscle strengthening in patients with cerebral palsy. In this issue, the Journal publishes two articles on these topics: Development and Validation of a Telephone Questionnaire to Characterize Lymphedema in Women Treated for Breast Cancer" (page 1192) and "The Eject of Quadriceps Femoris Muscle Strength ening Exercises on Spasticity in Children With Cerebral Palsy" (page 1215).

Susan R Harris, PhD, PT, FAPTA Dr Harris is Professor, School of Rehabilitation Sciences, University of British Columbia, Vancouver, BC.