Weekly Literature Review: Starting 2026 on the Right Footing

Introduction

As we enter 2026, physical therapy stands at a crossroads. We have sophisticated frameworks for understanding low back pain, compelling value propositions for our role in healthcare systems, and evolving research methodologies that challenge us to rethink what “evidence” really means. This week’s literature review traces a narrative arc from motor control theory to real-world implementation, examining both the convergence of our clinical models and the gaps that remain in translating research into practice.

The five articles reviewed this week span from 2017 to 2024, covering conceptual frameworks (Hides et al., 2019; Alrwaily et al., 2017), systems-level positioning (Childs et al., 2022), methodological innovation (Cashin et al., 2021), and empirical challenges (Kehl et al., 2024). Together, they paint a picture of a profession grappling with complexity while striving for clarity.

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Monday: Convergence and Divergence in Motor Control Approaches

Hides, J. A., Donelson, R., Lee, D., Prather, H., Sahrmann, S. A., & Hodges, P. W. (2019). Convergence and divergence of exercise-based approaches that incorporate motor control for the management of low back pain. Journal of Orthopaedic & Sports Physical Therapy, 49(6), 437–452. https://doi.org/10.2519/jospt.2019.8451

Key Insights

The Hides et al. paper provides a unifying lens for understanding four major exercise-based approaches to low back pain: Movement System Impairment (MSI), Mechanical Diagnosis and Therapy (MDT), Motor Control Training (MCT), and the Integrated Systems Model (ISM). What makes this article particularly valuable is its recognition that these approaches, while philosophically distinct, share fundamental assumptions about how spinal loading patterns contribute to pain onset, persistence, and recovery.

Convergence points:

• All approaches recognize that motor control,the integration of motor, sensory, and central processes,plays a role in LBP management.

• Each emphasizes individualized assessment and patient-specific treatment.

• Posture and movement retraining are central therapeutic targets.

Divergence points:

• MSI and MCT position motor control as the primary intervention target

• MDT uses motor control principles as adjuncts to directional preference and centralization

• ISM integrates motor control within broader systemic considerations (visceral, neural, musculoskeletal)

Clinical Implications

For practitioners, this convergence creates opportunity. Rather than viewing these approaches as competing paradigms, clinicians can adopt a hybrid model that draws on the strengths of each. The key is matching the approach to the patient’s presentation: someone with clear directional preference might benefit from MDT-guided exercises, while someone with global movement impairments might need the broader lens of ISM.

For the profession, this convergence matters because it moves us beyond technique tribalism toward a shared understanding of mechanism. When PTs align around motor control as a core construct, we strengthen our collective voice in advocating for movement-based interventions in healthcare policy and reimbursement frameworks.

Tuesday: The Movement Control Classification System

Alrwaily, M., Timko, M., Schneider, M., Kawchuk, G., Bise, C., Hariharan, K., Stevans, J., & Delitto, A. (2017). Treatment-based classification system for patients with low back pain: The movement control approach. Physical Therapy, 97(12), 1147–1157. https://doi.org/10.1093/ptj/pzx087

Key Insights

Alrwaily and colleagues advance the treatment-based classification (TBC) system by introducing a movement control schema that emphasizes the balance between local mobility and global stability. This framework recognizes that effective movement requires not just isolated muscle function but coordinated control across multiple systems.

The paper argues that LBP heterogeneity demands stratification,not all patients respond to the same interventions because not all patients have the same underlying impairments. The movement control approach provides clinicians with a structured decision-making tool that goes beyond symptom management to address functional restoration.

Strengths:

• Bridges the biomechanical theory with clinical practice

• Provides clear classification criteria that can guide intervention selection

• Positions PTs as leaders in evidence-based musculoskeletal care

Limitations:

• Lacks large-scale empirical validation across diverse populations

• May require adaptation for different care settings and patient contexts

Clinical Implications

This framework challenges clinicians to think beyond merely reducing pain. If our goal is to restore dynamic control, we must assess and address both mobility deficits (hypomobility in specific segments) and stability deficits (inadequate control during functional tasks). This requires a more nuanced examination process than traditional range-of-motion and strength testing.

For researchers, this paper highlights the need for prospective studies that validate the classification schema and test whether treatment matching improves outcomes compared to non-stratified care.

Wednesday: The Value Proposition of Physical Therapy

Childs, J. D., Fritz, J. M., Wu, S. S., Flynn, T. W., Wainner, R. S., Robertson, L. K., & George, S. Z. (2022). The value proposition of physical therapy in musculoskeletal care. Journal of Orthopaedic & Sports Physical Therapy, 52(12), 1–10. https://doi.org/10.1016/S1526-5900(22)00478-3

Key Insights

This article shifts from clinical mechanisms to systems-level positioning, making the case that PTs should be recognized as first-contact providers for musculoskeletal conditions. The authors synthesize evidence on cost reduction, outcome improvement, and patient satisfaction to articulate a compelling value proposition.

Key points:

• PTs can triage patients effectively, reducing unnecessary imaging and surgical referrals.

• PT-led pathways demonstrate cost savings without compromising outcomes.

• Patient satisfaction scores are high when physical therapists serve as the entry point for musculoskeletal care.

Critical success factors:

• Payer incentives must align with PT-led models.

• Electronic health record systems need to support PT triage workflows

• PTs must be integrated into care delivery teams, not siloed as downstream providers.

Clinical Implications

For individual practitioners, this article underscores the importance of developing diagnostic reasoning skills that go beyond rehabilitation prescription. If we are to serve as gatekeepers, we must be confident in ruling out red flags, identifying patients who need surgical consultation, and managing complex comorbidities.

For health system leaders and policy advocates, this paper provides ammunition for advocating direct access legislation and value-based payment models that recognize PT’s role in bending the cost curve.

Thursday: Disentangling Contextual Effects

Cashin, A. G., McAuley, J. H., Lamb, S. E., & Lee, H. (2021). Disentangling contextual effects from musculoskeletal treatments. Osteoarthritis and Cartilage, 29(2), 297–299. https://doi.org/10.1016/j.joca.2020.12.011

Key Insights

This editorial tackles a fundamental question in rehabilitation research: when a treatment “works,” how much of the benefit is due to the specific intervention versus contextual factors like patient expectations, therapeutic alliance, and clinical environment?

Cashin and colleagues note that only about 4% of RCTs in low back pain use placebo controls, making it difficult to isolate specific treatment effects. While pragmatic trials remove non-specific effects (like natural history and regression to the mean), they leave contextual effects intact. This creates ambiguity about the mechanism.

The proposed solution: causal mediation analysis, which allows researchers to partition variance and estimate how much of the treatment effect is mediated by contextual variables versus the direct effect of the intervention itself.

Case example: In the Back Skills Training Trial, mediation analysis showed that only 5% of the benefit of cognitive behavioral treatment was mediated by patient satisfaction,meaning 95% was due to the specific intervention.

Clinical Implications

For researchers, this is a call to embed mediation analyses in pragmatic trials. Understanding the balance of specific versus contextual effects helps clarify which components of an intervention are active and which are setting-dependent.

For clinicians, this research validates the importance of therapeutic alliance while also challenging us not to over-rely on contextual factors. If most of the benefit comes from the specific intervention, we need to ensure we’re delivering that intervention with fidelity, not just creating a positive clinical environment.

For the profession, this work highlights a critical gap: we need more placebo-controlled trials in physical therapy. While logistically challenging, such trials are essential for understanding mechanism and defending our interventions in an increasingly evidence-driven healthcare landscape.

Friday: Pain-Related Fear and Movement Variability

Kehl, C., Suter, M., Johannesdottir, E., Dörig, M., Bangerter, C., Meier, M. L., & Schmid, S. (2024). Associations between pain-related fear and lumbar movement variability during activities of daily living in patients with chronic low back pain and healthy controls. Scientific Reports, 14, 22889. https://doi.org/10.1038/s41598-024-73430-8

Key Insights

This study examined whether pain-related fear (measured via the Tampa Scale of Kinesiophobia and task-specific PHODA scales) was associated with lumbar spine movement variability during walking, running, stair climbing, and lifting in 49 patients with chronic LBP versus 51 healthy controls.

Surprising finding: Despite higher task-specific fear scores in the LBP group, there were no significant associations between pain-related fear and movement variability.

Important methodological observation: Movement variability indices were weakly correlated with each other and highly dependent on the calculation method used and the activity being performed.

Authors’ interpretation: The lack of association may reflect the relatively young sample with moderate disability and low overall pain and fear levels. Alternatively, it may suggest that the relationship between fear and movement is more nuanced than traditional fear-avoidance models suggest.

Clinical Implications

This study serves as a cautionary tale about measurement. Movement variability is not a unitary construct, how you calculate it matters, and what task you’re examining matters. This has implications for comparing findings across studies and for using movement variability as a clinical outcome.

For practitioners, the disconnect between subjective fear and objective movement patterns raises questions about how we assess and address fear-avoidance. If patients report high fear but don’t demonstrate corresponding changes in movement variability, what does that tell us? Are our movement assessment tools insufficiently sensitive? Are patients’ fears not actually influencing their motor control? Or is the relationship between fear and movement more task-specific and context-dependent than we’ve appreciated?

This study also highlights the need for more sophisticated psychological assessment. General fear measures (like the TSK) may miss task-specific fears that are more relevant to functional impairment.

Synthesis: Where Are We in 2026?

These five papers, spanning nearly a decade of scholarship, reveal both progress and persistent challenges in physical therapy’s evolution.

Progress We Can Celebrate

1. Conceptual Maturity in Motor Control
The convergence identified by Hides et al. (2019) and operationalized by Alrwaily et al. (2017) shows that our profession has moved beyond simplistic biomechanical models. We now recognize that motor control is multifactorial, integrating local and global factors, sensory and motor processes, and even psychosocial influences.

2. Systems-Level Recognition
The Childs et al. (2022) value proposition demonstrates that PTs are increasingly recognized not just as post-surgical rehab providers but as first-contact gatekeepers who can improve outcomes while reducing costs. This is a significant professional advancement.

3. Methodological Sophistication
The Cashin et al. (2021) editorial reflects growing awareness of the importance of mechanism research and the need to disentangle specific from contextual effects. This methodological maturity will strengthen our evidence base.

Challenges That Remain

1. The Evidence-Practice Gap
Despite sophisticated frameworks, we lack large-scale validation studies showing that classification-based treatment matching improves outcomes. The gap between conceptual models and empirical validation remains substantial.

2. Measurement Inconsistency
The Kehl et al. (2024) study exposes a fundamental challenge: our movement and psychological measures are not standardized. This makes it difficult to compare studies, replicate findings, or build cumulative knowledge.

3. Implementation Science
Even when we know what works, we struggle with how to implement it at scale. The Childs et al. value proposition is compelling, but actual adoption of PT-led triage pathways remains limited due to reimbursement structures, referral patterns, and system inertia.

A Call to Action for 2026

As we start this new year, these articles collectively issue several challenges to the profession:

For Clinicians:

• Move beyond technique tribalism. Draw eclectically from multiple frameworks based on patient presentation.

• Develop diagnostic reasoning skills that position you as a first-contact provider, not just a downstream rehabilitator.

• Recognize that contextual effects matter, but don’t over-rely on them. Ensure intervention fidelity.

For Researchers:

• Conduct large-scale validation studies of classification systems.

• Standardize movement and psychological assessment tools.

• Embed mediation analyses in pragmatic trials to understand the mechanism.

• Conduct more placebo-controlled trials, despite the logistical challenges.

For Leaders and Advocates:

• Use the value proposition evidence to advocate for direct access legislation and value-based payment models.

• Push for EHR systems that support PT-led triage workflows.

• Invest in implementation science to bridge the evidence-practice gap.

Conclusion

Physical therapy in 2026 stands on solid conceptual ground. We have sophisticated frameworks for understanding movement disorders, compelling evidence for our value in healthcare systems, and growing methodological sophistication in our research.

But sophistication without implementation is just an intellectual exercise. The challenge ahead is not to develop more models or conduct more trials, but to translate what we know into scalable systems that improve patient outcomes at the population level.

That requires not just clinical excellence but also leadership,the kind of leadership that navigates payer negotiations, that redesigns care pathways, that advocates for policy change, and that invests in the implementation science needed to close the evidence-practice gap.

As the APTA mission reminds us, our profession exists to transform society by optimizing movement to improve the human experience. These five articles show us both how far we’ve come and how much work remains to fulfill that transformative promise.

Here’s to starting 2026 on the right footing,with clear eyes about our challenges and renewed commitment to the hard work of implementation.

References

Alrwaily, M., Timko, M., Schneider, M., Kawchuk, G., Bise, C., Hariharan, K., Stevans, J., & Delitto, A. (2017). Treatment-based classification system for patients with low back pain: The movement control approach. Physical Therapy, 97(12), 1147–1157. https://doi.org/10.1093/ptj/pzx087

Cashin, A. G., McAuley, J. H., Lamb, S. E., & Lee, H. (2021). Disentangling contextual effects from musculoskeletal treatments. Osteoarthritis and Cartilage, 29(2), 297–299. https://doi.org/10.1016/j.joca.2020.12.011

Childs, J. D., Fritz, J. M., Wu, S. S., Flynn, T. W., Wainner, R. S., Robertson, L. K., & George, S. Z. (2022). The value proposition of physical therapy in musculoskeletal care. Journal of Orthopaedic & Sports Physical Therapy, 52(12), 1–10. https://doi.org/10.1016/S1526-5900(22)00478-3

Hides, J. A., Donelson, R., Lee, D., Prather, H., Sahrmann, S. A., & Hodges, P. W. (2019). Convergence and divergence of exercise-based approaches that incorporate motor control for the management of low back pain. Journal of Orthopaedic & Sports Physical Therapy, 49(6), 437–452. https://doi.org/10.2519/jospt.2019.8451

Kehl, C., Suter, M., Johannesdottir, E., Dörig, M., Bangerter, C., Meier, M. L., & Schmid, S. (2024). Associations between pain-related fear and lumbar movement variability during activities of daily living in patients with chronic low back pain and healthy controls. Scientific Reports, 14, 22889. https://doi.org/10.1038/s41598-024-73430-8