[ evidence in practice ]

STEVEN J. KAMPER, PhD1

Blinding:
Linking Evidence to Practice
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J Orthop Sports Phys Ther 2018;48(10):825-826. doi:10.2519/jospt.2018.0705

S
ingle blind, double blind, triple blind—what about blinding than the control group, then they may
makes it so important that it becomes a stamp of superiority have more positive expectations about
on a clinical trial? Blinding isn’t remotely a part of clinical how they will do, or report better out-
comes to please their treating therapist.
practice, as it plays no role in day-to-day treatment of patients.
On the other hand, if a patient knows
So why should it concern us so much when it comes to research? that he or she is in the control group, then
Blinding (sometimes called “mask- in the Methods section to find out who he or she might have lower expectations
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

ing”) is usually referred to in the context
of a clinical trial and denotes that 1 or
more of the groups of people involved
in a trial do not know whether the trial
participants received treatment A or a
control. Practically speaking, this means
that the patients in the trial don’t know
whether they are in the treatment or
control group (participant blinding), the
Journal of Orthopaedic & Sports Physical Therapy®
is blinded.
Studies that don’t blind the partici-
pants, therapists, and assessors are at
higher risk of bias; they are more likely
to report an effect that differs from what
can be expected in practice. That is why
all study-quality scales, such as the Co-
chrane risk-of-bias tool and the Phys-
iotherapy Evidence Database (PEDro)
or be disappointed by what is other than
the real/best/latest treatment and conse-
quently report poorer outcomes.
Therapists bring their own beliefs
about treatments to clinical trials and so
may be more enthusiastic and do a better
job delivering one treatment compared to
another. They may also transfer their ex-
pectations about the different treatments

therapists delivering the interventions scale, include items about blinding. to the patients in the study. For example,
don’t know (therapist blinding), and/or consider a trial in which one group re-
the researchers measuring the outcomes Why Is Blinding Important? ceives manual therapy and exercise, and
don’t know (assessor blinding). There Lack of blinding can introduce bias into the other receives detuned ultrasound
are several groups of people involved in study results in different ways, depend- and nonspecific information. Imagine the
the study (TABLE) that can be blinded, ing on which people involved in the study difficulty of a physical therapist in pro-
and no standard terminology for single, are not blinded. If participants know that viding these 2 interventions with equal
double, or triple blind; you have to look they are in the treatment group, rather enthusiasm, confidence, and conviction.
Because practically all measures (in-
cluding more objective ones) involve
TABLE Who Can Be Blinded in a Trial and Why some degree of influence of the person
reporting and/or the person doing the
assessing, unblinded outcome assess-
Who Why ment can introduce bias. This occurs
Participant So people receiving treatment engage to the same extent, regardless of whether they receive treatment when the interpretation or scoring of
or a control
the outcome is skewed toward better
Therapist So people delivering treatment do so with the same effort and enthusiasm, regardless of whether they
results in the treatment group than in
are delivering treatment or a control
the control group, and happens because
Assessor So outcomes are measured in exactly the same way in treatment and control groups
the assessors have a pre-existing belief
Statistician So decisions about how to deal with unclear or missing data and analysis methods are made only on
the basis of the most efficient use of available data or desire to show that treatment is more
Writer So interpretation of the results is not influenced by personal biases and beliefs of the study team effective than a control. Another thing
to note here is that when the outcome is

School of Public Health, University of Sydney, Camperdown, Australia; Centre for Pain, Health and Lifestyle, Australia. t Copyright ©2018 Journal of Orthopaedic & Sports Physical
1

Therapy®

journal of orthopaedic & sports physical therapy | volume 48 | number 10 | october 2018 | 825

patient reported (eg, pain or quality-of-
life questionnaire), the assessor is often
only considered blinded when the par-
ticipant is blinded.
It is important to note that the biases
mentioned above are not (necessarily)
due to dishonesty on the part of the peo-
ple involved in the trial; they happen at
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[ evidence bites ]
blinded. This second definition of blind-
ing leads us to consider the issue of treat-
ment credibility. The argument is that if
patients in both groups think they are
getting a real intervention and both in-
terventions are equally credible, then the
participants can be considered blinded.
There is merit to this viewpoint when we
pants, therapists, and assessors is not pos-
sible for most trials in physical therapy.
While it is relatively straightforward to
create a placebo pill or injection to blind
a patient, and even a therapist, in drug tri-
als, the same isn’t true when we are talk-
ing about manual treatments, education,
exercise programs, etc. This has led some

the subconscious level.
Defining Blinding
Blinding can be defined in slightly differ-
ent ways, especially participant blinding.
By the strictest definition, patients can
only be blinded when they do not know
which group they are in (eg, treatment or
control) and are not able to tell the dif-
ference between the 2 interventions. This
means that patients in the hypothetical
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
think about the source of bias that comes
with nonblinded participants. If credibil-
ity and expectations associated with the
2 interventions are more or less equal,
then the risk of bias associated with non-
blinded patients is probably quite small.
Treatment credibility can also influence
the risk of bias associated with the thera-
pist. A trial of a treatment versus a pla-
cebo (for example, manual therapy versus
detuned ultrasound) is at higher risk of
to suggest that blinding items shouldn’t
be considered when assessing the quality
of rehabilitation trials. But that is missing
the point. The aim of appraisal of study
quality is to determine the risk of bias
as it applies to the results of a particular
trial, and the risks associated with lack of
blinding are real, regardless of how diffi-
cult (or impossible) blinding may be.
Blinding is one of those issues that is
more complex than at first glance, and

trial of manual therapy versus detuned
ultrasound cannot be blinded.
Blinding might be less strictly defined
by saying that patients are blinded if,
when asked, they do not know whether
they received treatment or a control.
So, in the case of the hypothetical trial
above, participants may be considered
Journal of Orthopaedic & Sports Physical Therapy®
bias due to lack of therapist blinding than
a trial that compares 2 contemporary
treatments (for example, manual therapy
versus exercise).
Blinding in Trials of Physical Treatments
It might be obvious that, based on the
strict definition, the blinding of partici-
even more so in the context of the sorts of
trials relevant to physical therapists. Tri-
als in which participants, therapists, and/
or assessors are not blinded are at risk of
bias, but that is not the end of the story.
The magnitude of the risk also depends
on the types of interventions and the na-
ture of the outcomes. t

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826 | octobber 2018 | volume 48 | number 10 | journal of orthopaedic & sports physical therapy