Applying a sustainability perspective in the literature on physical therapy in relation to pharmaceuticals: a scoping review

Introduction: Physical therapy encompasses a broad range of treatment options, often utilized in clinical settings where pharmaceutical interventions are standard. The potential for physical therapy to contribute to sustainable healthcare by reducing environmental impact, while maintaining the quality of care, remains underexplored. This study aimed to map existing research comparing physical therapy to pharmaceuticals, with a specific focus on whether these studies address aspects of sustainable development.

Methods: A scoping review was conducted, systematically searching the PubMed, Cinahl, and Pedro databases using keywords related to physical therapy, pharmaceuticals, and comparative studies. Two assessors independently reviewed and selected relevant studies, followed by data extraction and summarization of results.

Results: A total of 27 studies were included, varying in design, population, and healthcare context. The most commonly addressed conditions were osteoarthritis and musculoskeletal pain, with analgesics being the most frequently studied pharmaceutical interventions. While several studies touched upon economic and social dimensions of sustainable development, none examined environmental sustainability. This highlights a critical gap in current research.

Discussion: Future studies are needed to assess how physical therapy, when compared to pharmaceutical treatments, can contribute to sustainable healthcare by offering a low-carbon, resource-efficient alternative without compromising social sustainability through adverse effects. This knowledge could be instrumental in guiding healthcare systems toward more sustainable practices.

Systematic review registration: A study protocol was registered in Open Science Framework 2023-03-31 (Available from: https://osf.io/we58g).

Introduction

Healthcare accounts for a significant share of global greenhouse gas emissions, i.e., carbon footprint, and the largest share is due to the production, transport and consumption of goods and services such as pharmaceuticals and other chemicals, foods and medical equipment (1, 2). Thus, healthcare has a responsibility to actively participate in the transition towards sustainable development (2), defined as ‘development that meets the needs of the present without compromising the ability of future generations to meet their own needs’, involving economic, environmental and social sustainability (3). A sustainable healthcare builds on the three dimensions of sustainable development (2, 4), and is defined as a system that maintains and improves the health of current generations while minimizing damage to the environment and ensuring health for future generations (4). Four key elements have been identified to enable sustainable healthcare (5): disease prevention and health promotion to reduce the need for healthcare; self-management and empowerment of patients to take a greater role in managing their own health and healthcare; lean service delivery and; prioritizing low carbon alternatives (2).

The three dimensions of sustainable development are further described in the business framework the Triple Bottom Line (6). This framework argues that for a business to be sustainable, it needs to consider not only the economic aspect, but also the environmental and social aspects of operations. In other words, it must consider for example air pollution and greenhouse gas emissions, and the health and wellbeing of employees and clients (6). Triple Bottom Line has since its’ introduction been employed in studies (2, 4, 7). The Triple Bottom Line has been found particularly interesting in healthcare since health is directly and indirectly determined by ecological and social aspects (8).

From the perspective of physical therapy (PT), individuals have inherent resources to maintain or improve their health on their own or with the facilitation of others (9). In PT, support for behavioral change, maintenance and resumption of activities, function and abilities, and the promotion of patient empowerment are central concepts (7). The concept of empowerment is based on the idea that people themselves have the ability and resources to define their own problems and devise action strategies to deal with them. Behavior change is an important part of health promotion and disease prevention (10), together with patient education and rehabilitation (10). The fact that PT is a treatment option without the direct environmental impact of, for example, pharmaceuticals (11) implies PT is key for sustainable healthcare.

Pharmaceutical care is the responsible provision of pharmaceuticals (e.g., drugs, medicines) for the purpose of achieving outcomes that improve a patient’s quality of life (12). Pharmaceuticals affect physiological processes in the body, usually by binding to various proteins (13). Pharmaceuticals are usually chemically stable substances, allowing them to withstand a certain passage through the body before they reach their area of action (13). These properties and ways of acting in pharmaceuticals are primarily intended to promote treatment outcomes, but they can also have negative effects through various adverse effects in the user as well as a negative impact on the environment (13).

The adverse effects of pharmaceuticals can vary in severity and depend, among other things, on the substance used, who is using them, and in what dose (3). Side effects of pharmaceuticals have a major impact on society, leading to high costs, increased morbidity requiring care, and risk of death (12). The production and consumption of pharmaceuticals contribute to a global problem of pollution in water and soil (5, 6). These pollutants affect human health and the lives of plants and animals and have been identified as major problems in several countries (14–16). The groups of pharmaceuticals most abundant in the environment are analgesics, specifically Non-steroidal Anti-Inflammatory Drugs (NSAIDs) (17).

The use of pharmaceuticals leads to negative environmental impact and possible negative side effects for the individual. PT as a treatment has been shown to have an effect in several areas where pharmaceuticals are commonly used, such as high blood pressure, depression, diabetes, and osteoarthritis (11, 18). However, there is a lack of collective knowledge about the areas in which PT could influence pharmaceutical use. This is an important area, as this knowledge could contribute the transition to sustainable healthcare. The aim of this study was to investigate what research, in form of scientific articles, is available that study PT in relation to pharmaceuticals. The aim was also to investigate whether this research relates their results to sustainable development regarding environmental-, social- or economic aspects.

Methods

Study design

This study utilized a scoping review methodology to investigate the extent and type of available research. The methodological framework proposed by Arksey and O’Malley (19) was followed, with some additions from Levac et al. (20). A study protocol was registered in Open Science Framework 2023-03-31 (Available from: https://osf.io/we58g) and the PRISMA ScR Checklist was used when reporting the results (21).

Research questions

The research questions guiding this scoping review were formulated as follows:

1. What research exists that compares PT and pharmaceutical treatments, or that assesses pharmaceutical use/prescription as outcomes from PT?

2. To what extent are aspects of sustainable development addressed, in articles on PT in relation to pharmaceuticals?

Literature search

A comprehensive literature search was conducted on 2023-02-20 to identify relevant studies. PubMed, Cinahl, and PEDro databases were searched using combinations of keywords related to PT, pharmaceuticals, and comparative studies, with no limitation on the date (Table 1). The search strategy was adjusted based on sample searches, and consultations with a librarian, to optimize search results.

Table 1

Table 1. Overview of the search strategy.

Study selection

Based on the following inclusion and exclusion criteria, studies were selected from the search result:

Inclusion Criteria:

• Original articles and study protocols that in some way compare PT and pharmaceuticals as treatment options, with PT explicitly mentioned as PT by the authors, or interventions performed or supervised by a physical therapist, or performed in a PT clinic.

• Studies that evaluate pharmaceutical consumption as an outcome measure via either intake or via prescription, or by evaluating a pharmaceutical treatment as an intervention.

Exclusion Criteria:

• Articles involving animal studies.

• Articles not available in English.

The selection process was performed by two assessors independently (PS and MJ), with the help of Rayyan.ai software, and started with screening of titles and abstracts. Relevant articles were further assessed by reading their full texts. Inclusion and exclusion criteria were applied individually by the authors. The selection was based on agreement and discrepancies were identified and resolved through discussion within the author group, until consensus was reached.

Data charting

Data from the included studies were extracted and organized into a table. The collected information included author details, year of publication, study location, study design, intervention type, study population, research purpose, methodology, outcome measures, significant results, and aspects of sustainable development.

Collating, summarizing, and reporting the results

The included articles were analyzed and presented in relation to the research questions, in terms of their characteristics, physical therapy interventions, types of pharmaceuticals, pharmaceutical consumption as an outcome measure, and discussions related to sustainable development. The scoping review aimed to provide an overview of the available research rather than conducting a synthesis of the evidence.

Results

The search in PubMed, Cinahl and PEDro resulted in 1254 articles (Figure 1) of which 45 duplicates were detected and deleted, leaving 1,209 unique articles for title screening. Out of 1,209 articles, 68 were selected for further review of abstract after the title screening based on the study’s inclusion- and exclusion criterium. The abstracts were then reviewed, and 66 studies were selected for full-text review. Finally, 27 articles (22–48) were included after the study selection process, the most common reason for studies not being included was that they did not address PT explicitly as treatment (Figure 1).

Figure 1

Figure 1. Flow chart of main search and inclusion process.

The included studies (22–48) were published between 1998 and 2022 and conducted in 15 different countries, with the most studies conducted in Turkey (23, 37, 39–41, 47, 48) and the USA (24, 25, 34, 46) (Table 2). Most of the studies (17 out of 27) were randomized controlled trials (23, 24, 28–31, 35, 39–42, 44–48), and another four had a randomized design (26, 27, 37, 38), three of the studies where retrospective (25, 34, 36), one was a prospective observational study (43), one was an open-label alternate patient treatment allocation study (33) and two were study protocols (27, 32). The most common diagnoses in the included studies were osteoarthritis (OA), back pain and shoulder pain. The other studies commonly included musculoskeletal diagnoses, but also respiratory and gynecological diagnoses.

Table 2

Table 2. Characteristics of included studies.

In the included studies, many different types of PT interventions were described, comprising various exercise interventions (20 of 27) (22–36, 38, 42–44, 46) and interventions where the patient passively received treatment (15 of 27) (22–24, 27, 36–42, 45–48) (Table 2). Other interventions found in the included studies were patient education (22, 26, 27, 31, 34, 35) and organizational health care changes (Table 2) (34, 43, 44).

Of the pharmaceuticals that appeared in the studies, the most common type was analgesics; primary NSAIDs, followed by cortisone or other injections, muscle relaxants, and pharmaceuticals for depression and anxiety. Other pharmaceuticals that occurred were blood pressure lowering substances, anti-choleric, and pharmaceuticals to facilitate breathing (Table 2).

Twelve of the studies (24, 25, 28–35, 43, 44) had pharmaceutical use- or prescription as an specified outcome measure. Of these studies, nine compared PT with treatment as usual (25, 27–30, 34, 35, 43, 44), one study compared PT with pharmaceutical review (31) and two studies compared PT with pharmaceutical interventions (32, 33). Of the studies that compared PT with usual treatment, three (34, 43) compared PT at the ED with either no-PT ED care or PT at a later stage. Two studies (29, 30) compared PT with standard treatment by a physician, one with standard treatment by physical therapist (27), one compared fast-track rehabilitation with rehabilitation according to routine (28), and two studies (25, 35) compared multimodal therapy and educational programs containing PT with treatment as usual and routine PT.

Fifteen studies compared PT interventions, without pharmaceutical treatment, with pharmaceutical interventions but did not specify pharmaceutical use as a direct outcome measure (22, 23, 26, 36–42, 45–48). In one of these studies the participants still reported their pharmaceutical intake, which was presented in the results (22). Of the 15 studies, nine compared PT with some type of injection (22–24, 36, 39–41, 46, 48) (cortisone, hyaluronic, NaHa, or steroid). The types of pharmaceuticals in the other six studies were: anticholinergics (26), NSAIDs or other analgesics (37, 38, 42, 45), muscle relaxants (37, 42), blood pressure lowering pharmaceuticals (38) and antidepressants (47).

None of the included articles discussed sustainable development, and none performed evaluations from a Triple Bottom Line since environmental aspects of sustainable development were not addressed in any study. Eight of the studies did not address any aspect of sustainable development (22, 23, 29, 30, 36, 39, 41, 45). Economic aspects of sustainable development related to costs and healthcare utilization, were discussed in 17 of the included studies (24, 26–28, 31–35, 37, 38, 40, 42–44, 46, 48). Six of those studies compared costs and utilization between their intervention and control groups (2, 24, 27, 28, 35, 44). One study (26) suggests for future studies that cost analyses should be carried out. Social aspects of sustainable development were addressed in 12 of the included studies (25–27, 31–34, 38, 40, 42, 44, 47). One study (33) addresses poverty, education level and unequal access to care. Quality of life or physical and mental health were included as outcome measures in eight studies (26, 27, 31–33, 40, 44, 47), but they were not discussed from a sustainable development perspective. Three studies discussed patient abilities and active participation in care (31, 42, 44) and two discussed risks to patients, such as overmedication (25, 34). In one study, TENS was suggested as an alternative for pain management if pharmaceutical treatments where contraindicated (38). Negative effects of prolonged NSAID use, and the positive effects on coping through active patient engagement in PT were highlighted (42). Empowerment and self-management was discussed as possible reasons for lowered use of health care services and resources in PT treatment (44).

Discussion

This scoping review found that investigations on PT in relation to pharmaceuticals as treatment hold a variation of characteristics with different study designs, study samples and in a range of areas within healthcare. The perspective of sustainable development was not applied in any of the included studies, and environmental aspects were not considered at all. However, several studies did consider economic or social sustainability to some extent.

Among the 27 included studies, many different types of interventions were described as PT. Physical exercise in different forms, was the most frequent type of PT treatment in the studies and TENS was the second most frequent form of PT intervention. In most of the included articles PT was referred to as specific rehabilitation exercises (22–36), in some it was referred to as TENS (36–43) and, in one study, PT was referred to as electromagnetic field treatment (45). These examples mirror the diversity of interventions within the PT discipline, highlighting the importance to mention PT in the title, abstract or keywords when addressing an intervention within the wide scope of PT, when applicable. Nevertheless, to describe an intervention solely as ‘physical therapy’ would not be of sufficient detail (49). Thus, we argue that a clear description of the intervention, including if it is delivered within the PT discipline is necessary to facilitate systematic study of interventions delivered within the PT profession.

None of the included studies were found to address all three dimensions of sustainable development, i.e., the Triple Bottom Line. That absence of evaluations regarding environmental sustainability in any study, can be considered a missed opportunity as the high carbon footprint and pollution from pharmaceuticals is a well-known problem where an effective PT alternative could pose an important contribution to sustainable healthcare. The environmental impact of PT on for example facilities and water use should not be ignored, but could be considered minor compared to the total emissions from health care, especially when compared to pharmaceuticals (2). However, some studies did discuss economic and social aspects of sustainable development. Economic evaluations mainly concerned costs and utilization of health care resources where evaluations of social aspects involved patient participation and empowerment as means for reduced healthcare utilization over time. The importance of patient empowerment for sustainable healthcare has been recognized by the WHO and is proposed by the Centre for Sustainable Healthcare as a cornerstone for sustainable healthcare (2, 4). Another aspect of sustainability that was addressed in the included studies was over medication (25) and the negative consequences from side effects were discussed in another (38). In line with this, the inconvenience of side effects from pharmaceuticals compared with PT interventions has been described previously in research of pain management (50), and patients have previously been found to prefer non-pharmacological pain management over opioids as treatment (51). Hence, increasing societal knowledge and awareness of PT as a non-pharmacological, non-invasive pain treatment is essential (52). Evaluation from the triple bottom line has been suggested in PT research (53). For such evaluations, cooperation between physical therapists, environmental scientists and economists could be of great value for assuring that all parts of the triple bottom line are considered in a holistic perspective on sustainable healthcare.

A strength of our study is the systematic methodology and following the stepwise process described by Arksey and O’malley with additions by Levac et al. (19, 20). Combining these two when conducting a scoping review is recommended for a structured methodology (54). The choice of study design was appropriate to be able to chart in which areas comparisons of PT and pharmaceuticals exist, in order to address gaps in knowledge and identify areas where systematic reviews would be possible. There have also been at least two reviewers of all articles at all stages. Making the selection of studies in a team is something recommended by Levac et al. (20).

One limitation of this study is that grey literature was not included. The primary reason we only searched databases is because we were mainly interested in scientific sources. This could have led to publications bias and a possible lack of included studies with non-significant results. Another limitation is only including articles in English, which may have meant that we missed interesting research that could have contributed to our results; the reduction in linguistic and cultural variation could have led to lower generalizability. The result could also be limited due to the choice to only include three databases in the search strategy, as well as the specific choice of databases. Further, the decision to only include studies that used certain terminology concerning PT, it was noted during the exclusion process that many potentially interesting studies were to be excluded. By only including studies where PT was mentioned explicitly, many studies that involved exercise interventions, TENS, acupuncture, and other interventions that may well be referred to as PT were excluded. This is problematic since similar interventions would be stated as PT in the included studies but were excluded due to the lack of mentioning of PT. However, it would not have been appropriate to define PT by naming all possible interventions, considering the wide range shown already in this study. Therefore, we emphasize the importance of carefully consider terminology in studies evaluating PT interventions, to facilitate future systematic research in the field of PT.

Conclusion

There is a need for further research on the role of PT interventions in relation to pharmaceuticals as treatment. Studies are lacking that consider sustainable development, and studies comparing PT and pharmaceuticals that evaluate outcomes from a perspective of sustainable development could contribute with knowledge about how PT can be a low-carbon, resource efficient alternative to pharmaceuticals, without their negative impact on social sustainability in terms of adverse effects, and thus contribute to sustainable healthcare.

Data availability statement

The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author.

Author contributions

PS: Conceptualization, Data curation, Project administration, Formal analysis, Investigation, Methodology, Software, Writing – original draft. MJ: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Writing – original draft. AP: Conceptualization, Supervision, Validation, Writing – review & editing. EL: Conceptualization, Supervision, Writing – review & editing, Data curation, Project administration.

Funding

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Acknowledgments

We would like to acknowledge Mathias Andersson, at the School of Health and Welfare, Dalarna University, for supporting the idea of the study and for contributing to the initiation of this work.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The authors declare that Generative AI was used in the creation of this manuscript. During the preparation of this work the authors used OpenAI in order to edit language. After using this tool, the authors reviewed and edited the content as needed and takes full responsibility for the content of the publication.

Publisher’s note

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