Physical therapists’ perspectives on using contextual factors in clinical practice: Findings from an Italian national survey

Background: Contextual factors (CFs) represent a potential therapeutic tool to boost physiotherapy outcomes, triggering placebo effects. Nevertheless, no evidence about the use of CFs among physical therapists is currently available. Objective: To investigate the use of CFs and the opinion of Italian physical therapists specialized in Orthopaedic Manual Therapy (OMTs) on their therapeutic benefits. Design: An exploratory cross-sectional online survey. Methods: A 17-item questionnaire and 2 clinical vignettes assessed the perspective of OMTs on the adoption of CFs in daily clinical practice. The target population was composed of 906 OMTs. An online survey was performed in 2016 using SurveyMonkey Software. Data were analyzed by descriptive and inferential statistics. Results: A total of 558 volunteers (61.6% of the target OMT population) participated in the study. Half of the participants (52.0%) claimed to use CFs frequently in their practice. More of 50% of OMTs valued the therapeutic significance of CFs for different health problems as determined by a combined psychological and physiological effect. OMTs considered the use of CFs ethically acceptable when they exert beneficial therapeutic effects and their effectiveness has emerged in previous clinical experiences (30.6%). They disagreed on the adoption of CFs when they are deceptive (14.1%). Moreover, OMTs did not communicate the adoption of CFs to patients (38.2%), and CFs were usually used in addition to other interventions to optimize clinical responses (19.9%). Psychological mechanisms, patient’s expectation and conditioning were believed to be the main components behind CFs (7.9%). Limitations: Considering that the data collected were self-reported and retrospective, recall and response biases may limit the internal and external validity of the findings. Conclusions: OMTs used CFs in their clinical practice and believed in their therapeutic effect. The knowledge of CFs, placebo and nocebo mechanisms and their clinical effects should be included in physical therapists’ university studies.