Pragmatism in manual therapies and psychotherapies : a systematic review
Introduction : Pragmatic trials aim to directly inform about the effectiveness of clinical practices by increasing the comparability between the trials conditions and real-life. Even though the concept of pragmatism has long existed, it remains a minority in clinical trials, even more so in manual therapies. However, pragmatism seems to fit with therapies that assess complex constructs as mental states and somatic dysfunctions.
Methods : A systematic literature review was performed in November 2021 on online databases, including PubMed, about pragmatic clinical trials in manual therapies and psychotherapies. Every article was assessed on the PRagmatic-Explanatory Continuum Indicator Summary 2 tool. Scores were put into perspective with discussions limits if they are mentioned to identify strengths and weaknesses of pragmatism for these therapies.
Results : In manual therapies, trials obtained a mean score of 4.03 (SD=0.98). Three domains obtained weaker scores than the others : flexibility (delivery) (3.73; SD=0.90), flexibility (adherence) (3.45; SD=1.44) and follow-up (2.91; SD=1.22). No study reported blinded patients, one for practitioner, four for outcome assessors and one for statisticians. In psychotherapies, trials obtained a mean score of 4.07 (SD=1.10). Four domains obtained weaker scores than the others : organisation (3.98; SD=1.05), flexibility (delivery) (3.85; SD=0.97), flexibility (adherence) (3.63; SD=1.41) and follow-up (3.24; SD=1.22). One study reported that patients weren’t aware of other intervention groups, no blindness of practitioners, 21 for outcome assessors and three blinded statisticians.
Conclusion : Pragmatism seems to fit for trials in manual and psychotherapies. Flexibility (delivery and adherence) and follow up are the main domains which require attention to stay rather pragmatic. Blinding is usually impossible for patients and practitioners, but assessors could be more systematically blinded to compensate. Researchers should focus on the main reasons for consultation, plan a pragmatic approach, design trials accordingly and improve report of their trials.