Brazilian Journal of Physical Therapy 27 (2023) 100484

Brazilian Journal of
Physical Therapy
[Link]

SYSTEMATIC REVIEW

Keep posting and following social media profiles about

physical therapy, but be aware! A cross-sectional study
of social media posts on Instagram and Twitter
Bruna Wagecka,b, Iris S. Noalc, Brenda D. Guterresc, Samantha L. Adamic, Daiane Bordinc,
Mauricio Fanfad, Guilherme S. Nunesc,*

a
La Trobe University, Melbourne, VIC, Australia
b
Instituto de Ortopedia e Traumatologia de Santa Maria (IORT), Santa Maria, RS, Brazil
c
Department of Physical Therapy and Rehabilitation, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
d
Department of Communication, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil

Received 17 March 2022; received in revised form 20 January 2023; accepted 9 February 2023
Available online 20 February 2023

KEYWORDS Abstract
Dissemination; Background: Social media is established as a communication channel that is useful to dissemi-
Education; nate scientific information. While social media can disseminate high quality information, it can
Information; also facilitate the spread of false or misleading information. Furthermore, social media is consid-
Knowledge ered a self-promotion environment that can have several aspects related to personal marketing.
translation; Objective: To systematically search and review social media posts verifying whether the posts
Physical therapy about physical therapy interventions reported sources of information; the presence of aspects
suggesting conflicts of interest (COI); whether information was presented to facilitate knowl-
edge acquisition; the reach of information posted; and the use and quality of the cited scientific
references.
Methods: Searches were performed on Instagram and Twitter using #reabilitaç a ~o for Portuguese
posts, and #rehabilitation for English posts. The inclusion criteria were posts including terms
related to physical therapy and presenting interventions along with their purposes. The searches
and screening processes were performed by at least two independent researchers.
Results: Of 1,145 pre-selected posts, 632 posts were included, of which 14% cited references as
source of information, 57% presented potential COI, and 9% facilitated knowledge acquisition.
The posts received the mean § SD of 88 § 593 likes and profiles had a mean of 5,162 § 37,240
followers. Considering the posts that cited references, most posts presented consistent informa-
tion (51%) and 6% presented only positives outcomes (selection bias). Many references were of
poor methodological quality (39%).
Conclusion: The present study enlightens the fact that most posts on Instagram and Twit-
ter regarding physical therapy interventions did not report or use sources to support the

* Corresponding author at: Avenida Roraima, 1000, CEP 97105-900, Santa Maria, RS, Brazil.
E-mail: nunesguilherme@[Link] (G.S. Nunes).
Social media: @DrGuiNunes (G. S. Nunes)

[Link]
1413-3555/© 2023 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier España, S.L.U. All rights reserved.
 B. Wageck, I.S. Noal, B.D. Guterres et al.

information disseminated. Also, most posts were not created to facilitate knowledge
acquisition.
Registration number: PROSPERO register database (CRD42021276941).
© 2023 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier
España, S.L.U. All rights reserved.

Introduction Methods
The quick dissemination of information through social Design
media, and its widespread availability to the public in gen-
eral, may help shorten the implementation gap between sci- This study is a cross-sectional study using a systematic
entific research and clinicians, patients, and health approach to search and review social media posts about
institution managers.1,2 If this information is of a high-qual- physical therapy interventions. Therefore, the study fol-
ity, it could encourage evidence-based clinical practice lowed the Cochrane Collaboration recommendations14 to
implementation in a wider range of health services.3 systematically select information, reported the finding fol-
While social media can disseminate high quality infor- lowing recommendations for systematic review report,15
mation, it can also facilitate the spread of false or mislead- and was prospectively registered with the PROSPERO regis-
ing information.4,5 This problem was made evident during ter database (CRD42021276941).
the COVID-19 pandemic where dissemination of fake news
was treated as an infodemic.6 Furthermore, social media is
considered a self-promotion environment that can have Search strategy
several aspects related to personal marketing.7 Social
The searches were performed on the social media platforms
media platforms have lowered entry levels and heightened
Instagram and Twitter during the month of October 2021
the potential reach of self-branding strategies, enhancing
(14th and 15th October for searches in Portuguese, and 18th
the internalization of marketing strategies by individuals.8
and 19th October for searches in English) by two independent
Thus, professionals use the reach of social media to adver-
researchers (Fig. 1). A new user profile was created just for
tise their services and endorse products9 using physical
the searches in this study to minimize the influence of the
therapy-related posts to capture the attention of an inter-
social media algorithm for targeting content. The searches
ested audience.
were performed using the hashtag “#reabilitaç a~o” for posts
Self-promotion is not an issue; in contrast, it could be a
in Portuguese, and “#rehabilitation” for posts in English. No
form of self-motivation for experts to keep posting about
limit for publication period was applied.
scientific matters to maintain social engagement.10 How-
As we intended to include at least 100 posts per platform
ever, in professional fields, such as physical therapy, self-
in each language, we reran the search on Twitter for posts in
promotion may combine practices of micro-influencers
Portuguese on 26th October 2021, considering we included
endorsing products with practices used for content making
just 86 posts from the first search (Fig. 1).
in science communication, such as knowledge translation.
The act of stimulating consumption or profit from products
and services likely includes potential conflicts of interest Eligibility criteria
(COI) when selecting information to be disclosed.11 The
appealing and lucrative aspects of a service or product may To be included, the posts had to (i) be written in Portuguese
contradict scientific evidence or favor selection bias. Even or English; (ii) include, in any location of the post (caption,
unintentionally, information disseminators may ignore high- text, hashtags, or images), the terms “fisioterapia”, “fisio-
quality scientific information against their products or over- terapeuta” and/or “fisio” for posts in Portuguese, and
state weak information that favors the endorsed product.11 “physical therapy”, “physical therapist”, “physiotherapy”,
In addition, many information disseminators are the same “physiotherapist” and/or “physio” for posts in English; (iii)
professionals who reported difficulties in interpreting scien- suggest, explain, or present at least one physical therapy
tific findings or understanding the language in which scien- intervention; and (iv) report some objective, purpose, or
tific reports were published,12 resulting in a chain of focus of the discussed intervention targeting a condition or
misinformation.4,5 One study evaluated 200 most popular an outcome. Posts were excluded if they (i) were expressly
YouTube videos with information about rehabilitation for intended to endorse, sell, or offer services, products, or lec-
low back pain and found that only half of the proposed inter- tures/courses; (ii) presented interventions outside the phys-
ventions were in accordance with relevant clinical guide- ical therapy scope, e.g. prescription of medication or
lines.13 Therefore, this study aimed to systematically review surgery techniques; (iii) were from scientific journals pro-
posts on social media that disclose information related to files; (iv) and/or only shared links from other social media.
physical therapy interventions and verify (i) whether the In the case of reposts, the original post was searched and
posts reported sources of information to support the con- analyzed for eligibility. English language was selected con-
tent; (ii) the presence of aspects that could suggest COI; (iii) sidering that the majority of scientific evidence is published
whether the information was presented to facilitate knowl- in this language, and a secondary language (Portuguese) was
edge acquisition; (iv) the reach of information posted; and included because language is an important barrier for the
(v) the use and quality of the cited scientific references. understanding of scientific information12 and the language

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 Brazilian Journal of Physical Therapy 27 (2023) 100484

Fig. 1 Flow diagram of post selection process.

translation is likely a factor influencing the consistency of Data analysis

information.16
The analyses and classifications were performed by two
independent researchers, and when consensus was not
reached, a third researcher was consulted.
Screening process
Presentation of information sources
~o/#rehabili-
- 1st step: the posts reached using #reabilitaç a We analyzed whether the posts cited scientific references as
tation were sorted by publication date (most recent to basis for their information.
oldest), and each independent researcher pre-selected
the most recent 150 posts for both social media plat- Potential conflict of interest (COI)
forms, and both languages, applying the eligibility crite-
ria (Fig. 1). Twitter was the exception, each reviewer We considered a potential COI if the analyzed post included
pre-selected 100 posts in Portuguese (Fig. 1). This plat- professional contacts for selling products or services; or if in
form presented less eligible content in Portuguese, so we the past two years, the profile had published posts endors-
reached outdated posts (early 2000s). Therefore, we ing, advertising, or encouraging the consumption of products
included fewer posts to try and maintain a chronological or services offered by them or in partnerships with organiza-
uniformity. tions or other professionals. We also considered the pres-
- 2nd step: another two independent researchers confirmed ence of a potential COI in posts presenting only the positive
the eligibility of pre-selected posts and excluded dupli- outcomes from the cited reference, omitting negative and/
cates. In cases of inconsistency in the selection, a fifth or non- significant results (selection bias).
researcher was consulted to resolve the differences. Dur-
ing this step we also verified the number of posts per pro- Type of dissemination
file. We set a limit of a maximum of four most recent
posts per profile to reach a greater diversity of content The feature of the publication regarding information dissem-
authors. ination was classified as:

- Facilitated information: when the profile was not consid-

Data extraction ered to have COI, and the post content was developed to
facilitate knowledge acquisition of the referenced scien-
Data extraction was performed by two independent tific information. For this, the posts could use different
researchers and coordinated to be realized in the same day. tools, such as infographics, illustrations, or videos.
Conflicts were resolved by consensus. Data extracted from - Facilitated information with potential COI: the post con-
the post were: publication date; number of likes, comments, tent was developed to facilitate knowledge acquisition of
and shares (when available); description of the interven- the referenced scientific information; however, the post
tions; objective of the intervention; references cited sup- or profile presented indications of having potential COI.
porting the information; presence of endorsement or - Simple dissemination: the post or profile did not present
advertisement of products or services. Data extracted from indications of having potential COI, yet it did not facili-
the profile which posted the content were: number of fol- tate knowledge acquisition of the referenced scientific
lowers; professional information disclosed in the profile information; or it facilitated the understanding, but the
description; and presence of endorsement or advertising in content was not based on scientific references.
other posts in the last two years from the date of the post - Simple dissemination with potential COI: the post or pro-
selected. file presented indications of having potential COI and did

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 B. Wageck, I.S. Noal, B.D. Guterres et al.

not facilitate knowledge acquisition of the referenced and ‘partial’ when the information agreed with the refer-
scientific information; or it facilitated the understanding, ence, however, the post (i) did not present all the pri-
but the content was not based on scientific references. mary results of the study; (ii) presented only image from
- Self-promotion: posts which presented scientific infor- manuscript omitting important parts; or (iii) did not pres-
mation (or not), with or without facilitation of the under- ent all the results that fulfill the aims mentioned in the
standing, and directly associated professional contacts original reference, when primary outcomes were not
with the content disclosed, such as clinic/clinician name determined.
and/or brand, telephone, e-mail, etc. Posts presenting
pre-post treatment performed by the profile’s owner Statistical analysis
were also considered self-promotion.
Data were analyzed descriptively using measures of central
Reach of information posted tendency and variability, or frequencies, percentages, and
absolute values. After checking the primary data, in a post
To verify the reach of the posts and engagement of fol- hoc analysis, we aimed to verify whether (i) posts using sci-
lowers, the absolute number of followers, likes, comments entific references reach more people or engage more fol-
and shares were analyzed. lowers compared to posts without references; (ii) posts of
profiles with potential COI reach more people or engage
Reference analysis more followers compared to posts of profiles without COI;
(iii) the non-use of scientific reference is related to profiles
We analyzed the following aspects: with COI; and (iv) facilitation of knowledge acquisition is
related to scientific references of good quality. Therefore,
- Level of evidence regarding intervention: the Oxford the Mann-Whitney test was used to verify whether there
centre for Evidence-based Medicine scale was applied were differences regarding the number of followers and
considering the methodological design used in the likes between posts that cited or not scientific reference
references.17 and between profiles with or without COI. Data were ana-
- Methodological quality: the scales were applied accord- lyzed using R statistical software 4.1.1 (packages stats and
ing to the methodological design. Randomized controlled pairwiseCI). Additionally, a Pearson’s chi-square test was
trials were assessed using PEDro scale (good-quality 6 used to verify the association between the use of scientific
points, low-quality 5 points)18-20; Systematic reviews reference and presence of COI, and between the type of
were assessed using the tool AMSTAR II (good- dissemination and the quality of reference used. Data were
quality = none, one or more non-critical weakness, low- analyzed using SPSS version 26.0 (IBM SPSS Inc., Chicago,
quality = one or more critical flaws)21; Observational IL, USA). The confidence level was set at 5% for all the anal-
studies were assessed via Epidemiological Appraisal yses.
Instrument (EIA) (good-quality >1 point; low-quality 1
point)22,23; and Clinical guidelines were assessed via the
tool AGREE II (good-quality 50% at domain 3, low-qual- Results
ity <50% at domain 3).24,25 Other designs were not
assessed considering the low relevance for intervention Post selection and characteristics
evidence.
- Impact of the references: was assessed using the greater From 1,145 pre-selected posts, 632 posts were included in
citation numbers on Scopus or Web of Science database, the analysis, of which 339 posts were in English and 293 in
and the Altmetric score. Portuguese (Fig. 1). The included posts were published
- Consistency of the information: verified whether the post between June 2011 and September 2021. The most cited
information was consistent with the cited reference. intervention was exercise (Fig. 2A), and the main target of
Posts were classified as ‘accurate’ when the post infor- the interventions was pain management (Fig. 2B). The data-
mation matched the reference; ‘inaccurate’ when the set used in the analyses is available in the supplementary
post information was not supported by the reference; material 1.

Fig. 2 A Interventions included in social media posts; B Targets of the interventions included in social media posts.

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 Brazilian Journal of Physical Therapy 27 (2023) 100484

Fig. 3 Data on use of references, potential conflict of interest and communication aspects (n = 632).

Citation of information sources Reference analysis

From 632 posts, 14% (n = 89) cited references in which their One hundred and one references were cited as source of
information was based, and 86% (n = 543) did not cite any information. We could not access the full text of six referen-
source of information (Fig. 3A). ces (three original manuscripts, two books, and one under-
graduate thesis). The characteristics of references used in
the included posts are presented in Fig. 4 and supplementary
Potential conflict of interest (COI)
material 2 (Table 2.C).
We identified that 57% (n = 362) of the posts/profiles pre- The most frequent methodological design was systematic
sented materials which suggest potential COI (Fig. 3B and reviews (33%) (Fig. 4A). In addition, the most frequent level
supplementary material 2 [Table 2.A]). For selection bias, of evidence based on the Oxford scale was 1a (20%) which
6% (n = 6) of the posts presented only the positive results indicates results from systematic reviews (Fig. 4B).17
from the cited references (supplementary material 2 [Table Regarding the methodological quality, most references were
2.C]). of poor quality (39%) (Fig. 4C). The average number of cita-
tions on Scopus or Web of Science was 25 (SD=58, median=2,
min-max values=0 417) and the average Altmetric score
Type of dissemination was 152 (SD=558, median=31, min-max values=0 5,188).
When comparing the information presented in the posts
Most included posts were characterized as self-promotion with the information from references, half of the posts pre-
post (43%; n = 270), with only 9% (n = 51) using approaches sented accurate information (51%) (Fig. 4D).
to facilitate knowledge acquisition of the scientific informa-
tion disclosed (Fig. 3C and supplementary material 2 [Table
2.A]).
Post hoc analysis

Reach of information posted Details of the post hoc analysis are presented in the supple-
mentary material 2 (Tables 2.D G). The post hoc analysis
The social media profiles posting information on physical indicated that posts using scientific references as source of
therapy interventions had a mean § SD of 5,162 § 37,240 information did not reach more people via the number of
followers (Table 1). In total, the posts received a mean of followers compared to posts without references (median dif-
88 § 593 likes, 2 § 9 comments, and 1 § 7 share (Table 1). ference= 73 followers, 95% CI: 297, 302). In contrast,
The results for each language and social media are pre- posts without references caught more attention of the audi-
sented in supplementary material 2 (Table 2.B). ence receiving more likes than posts which used references

Table 1 Number of followers, likes, comments, and shares of the included posts (n = 632).
Followers Likes Comments Shares
5,162 § 37,240 88 § 593 2§9 1§7
485 [0 834,000] 7 [0 10,073] 0 [0 141] 0 [0 80]
*Data are presented as mean § SD and median [min-max].

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 B. Wageck, I.S. Noal, B.D. Guterres et al.

Fig. 4 Data on references analysis.

as source of information (median difference= 6 likes, 95% sites is based on trustful sources. We found that the majority
CI: 8, 2). of social media posts regarding physical therapy interven-
Profiles presenting potential COI did not reach higher num- tions did not cite a source of information. Information from
bers of followers (median difference= 201 followers, 95% CI: social media posts without references might be accurate
2,356) or receive more likes (median difference= 0 likes, and based on strong evidence. However, without cited refer-
95% CI: 4, 3) compared to profiles without evident COI. ences, we should consider the information as a personal
Posts with no reference as source of information were opinion. The evaluation of information quality is therefore,
associated to the presence of a potential COI (Chi-Square, limited to other aspects, such as the public knowledge or
p<0.001; Phi=0.248), and posts which used some approach subjective perception about the personal characteristics of
to facilitate knowledge acquisition were associated to infor- whom disseminated the information.
mation based in studies with good methodological quality Expert opinion is considered a level of evidence28 and
(Chi-Square, p = 0.02, Phi=0.288). social media is a good channel to share expert opinions to a
broader audience.10 But, the person disseminating scientific
or health information may not have proper knowledge or
Discussion understanding of the topic; social media logic facilitates the
personification of an “expert.”29 We can determine the
The present study found that most posts on social media potential lack of knowledge about scientific methodology by
regarding physical therapy interventions did not present a checking the study designs used to base information about
source of information. Additionally, most profiles presented interventions; in our study less than half of posts with refer-
information with a possible COI. Most posts were not ences based their information on randomized controlled tri-
designed to facilitate knowledge acquisition, focusing only als or systematic reviews. Furthermore, people may post
on author/profiles’ self-promotion. Although several cited information or ideas based on motivations with potential
references presented poor methodological quality, most COI, as confirmed in the present study. The non-use of refer-
references were considered as high level of evidence based ences was associated with profiles presenting potential COI.
on methodological design (systematic reviews) and rele- Also, more than half of the included profiles present some
vance to the literature based on the number of citations and content suggesting a COI, mainly related to the offer of
Altmetric scores. physical therapy services.
Although social media has been noted as a valuable tool One could affirm that social media users should know how
to engage students,26 the use of information from social to select information or profiles to follow, but it seems that
media to build academic and technical knowledge requires followers are unaware of potential COI or the veracity of
caution. Kyung-Sun et al.27 reported that almost 100% of information. We observed that posts without references
their undergraduate students sampled from different disci- received more engagement from followers compared to posts
plines used posts from social media as a source for academic with references. The act of not citing references is likely a
works; and almost 60% of the students reported that they choice based on the creator’s purposes, indicating their inter-
never check if the information acquired from social media ests are more related to self-branding than to knowledge

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 Brazilian Journal of Physical Therapy 27 (2023) 100484

dissemination. A recent study reported that the majority of make clinical decisions,30 and official government websites
popular videos on YouTube about low back pain do not follow present inaccurate content about the management of low
strong recommendations about its management.13 Therefore, back pain.31 Therefore, during the process of knowledge
our and previous findings call the attention of the public to acquisition and clinical making decisions, it is crucial to
the need to be cautious about physical therapy content on search for trustful sources with complete information. This
social media, of content producers to the need to base their does not mean that social media should be disregarded.
posts on high-quality sources and cite their references, and of However, consuming information on social media requires
social media platform content moderators, community man- caution. Readers should check the presented information
agers, and guideline makers to the quality management of references and be aware of the methodological quality, COI,
the content circulating on their platforms. studied population, intervention description, comparators,
Our results suggest that knowledge translation was not outcomes, clinical meaningfulness, harms, and
the main motivation for posting content about physical ther- others.30,32,33 Hence, it is advisable to look for high-quality
apy interventions. Only 9% of the posts handled the informa- studies and read the full-text version. We acknowledge that
tion in a way that facilitated its understanding, and most the access and interpretation of scientific papers are impor-
posts citing references, disseminated information from stud- tant barriers mentioned by physical therapists.34 Neverthe-
ies with questionable quality. Perhaps content producers are less, there are valuable sources, such as PEDro database
unaware of the process of knowledge translation and its ([Link] that provide the tools to facilitate
effectiveness. Thus, our results highlight the need for edu- the understanding of research and trials in physical therapy.
cating content producers about the knowledge translation
methodology. Therefore, encouraging them to keep posting
valuable information about physical therapy using means to Conclusion
facilitate the understanding and reducing the gap between
research and clinical practice. A positive finding was that Our analysis of physical therapy social media posts found
posts which handled the information facilitating its under- that most posts did not present a source of information to
standing were associated with the use of studies with good base their content on interventions; most profiles presented
methodological quality, indicating that good methodological aspects indicating potential COI; very few posts reported sci-
quality is valued and this scenario of contestable informa- entific information in a way that facilitates knowledge
tion can be changed in the future. acquisition; the included posts reached thousands of fol-
lowers who seemed to not engage with them; and most posts
Limitations that mentioned their references presented information from
studies with poor methodological quality. Therefore, our
We cannot affirm that the search strategy was specific
results reinforce the importance of physical therapists being
enough to capture all posts regarding physical therapy inter-
cautious about the physical therapy content they consume
ventions on the platforms. Our decision regarding the search
on social media.
terms was based on a pilot study: i) we searched different
hashtags, and #rehabilitation/#reabiltitaç a~o presented the
greatest number of linked posts; ii) posts linked to #rehabili-
~o were most likely to fulfill the eligibility
tation/#reabilitaç a Conflicts of interest
criteria; and iii) most posts linked to abbreviated hashtags,
such as #physio, presented content related to activities of The authors declare that they have no competing interests
daily living without technical information. Therefore, we and no financial affiliation or involvement with any commer-
chose the search strategy to facilitate a systematic search cial organization that has a direct financial interest in any
and improve our chances to reach posts that discussed physi- matter included in this manuscript.
cal therapy interventions. The used metrics to check social
media engagement is another potential limitation, and we
acknowledge that they do not necessarily represent real Acknowledgements
engagement with the presented information. We included
posts from two social media platforms, and the non-inclusion This research did not receive any specific grant from funding
of others, such as Facebook, is likely another study limita- agencies in the public, commercial, or not-for-profit sectors.
tion. Nevertheless, besides the limitations, our results prop-
erly reflect the content which is available for general
population of physical therapists. Supplementary materials

Implication Supplementary material associated with this article can be

found in the online version at doi:10.1016/[Link].2023.100484.
Most of the analyzed posts were missing vital information
needed to be trustworthy and to report useful information
for supporting clinical decision. The lack of important infor- References
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