The premise of this article is to shine a light on the importance of utilizing good evidence and taking the time and energy to apply it to clinical practice. There are many clinicians who struggle to keep up with the research, as was pointed out in an article from 2019 showing only 54% of physiotherapists chose to use treatments recommended by well-established guidelines.1
What’s the big deal with evidence anyways, my patients seem to get better?
Patient outcomes and quality care are central to practice. What the majority of physiotherapists should be using in practice today has been built and modified by research. Unfortunately, physiotherapists struggle to take the current research and apply it into practice.1 Getting past those barriers and putting evidence into practice is important because it gives physiotherapists credibility, respect, and trust in the eye of the public and our peers.
Without evidence informing our practice bed rest would still be recommended for those with acute low back pain, and patients with cerebral palsy would be told not to strength train because it could increase their spasticity. Both of those things we now know have been proven to be poorer forms of care for those patient populations.2,3 The tact of “well this is what I learned” or “I always treat it this way” just doesn’t hold up when we look at how practice has changed in the last 20 years. This can lead to some very challenging decisions and changes by the physiotherapist, but to maintain credibility and do the best for patients evidence is essential.
What is the difference between evidence-based practice and evidence-informed practice?
There is a recent trend leaning more to the adoption of evidence-informed practice (EIP) rather than evidence-based practice (EBP). The differences can be debated but if you look at the most widely accepted version of EBP it “…is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients…”.4
EIP has been suggested as a model that puts the patient in the center rather than the evidence. The critique on EBP for those involved in these debates is that it puts the evidence in the center of the model of care rather than the patient.5 In a recent webinar hosted by the College of Physiotherapists of Alberta, Doug Gross, PhD referenced the analogy of using a funnel model to help understand the role of EBP.6 The model moves away from more traditional models that involved an equal weighing of patient and evidence and instead it is about funneling down the totality of quality evidence through the filter of patient values. It brings in the clinician skills and experiences to come up with a plan that is supported by the research and meaningful and valuable to the patient. This seems to do a great job of capturing the goals of practice in a way that would make sense to most clinicians.
But I found evidence to support using crystals during a full moon for an ACL rupture, does that count?
The biggest pitfall in EBP comes from determining the quality of the evidence you are using. You can potentially find evidence that supports almost any intervention if you search hard enough and ignore the quality of the study. A single randomised control trial has the potential to be inaccurate in its findings so evaluating the quality of that study is important. When looking at systematic reviews and meta-analysis its important to look at the methods as to how they found the studies and ruled them in or out, but generally these will give you stronger conclusions than a single RCT. Evidence you find that supports or negates your treatment plan should be considered as you start to funnel down the options that you present to your patient as part of their proposed plan of care.
What to do about the "guru complex”?
Going onto social media or attending courses you will often hear about this one patient that was experiencing horrible symptoms for years, then they saw this physiotherapist who did this intervention and magically they were cured! Now if you take their course, you too can be this amazing physiotherapist and cure all your patients!
The reality is that patients are more complex than this and what works for one will not always work on others. Take those tools you learned or the information you gathered and apply it as best you can to those patients you think will benefit. The more experience physiotherapists gain the better able they are to be judicious in their decision making. This can be related back to the funnel model discussed earlier.
In researching this article, I came across quite a few online physiotherapists, instructors and clinics touting they were a pain-guru or a posture-guru or a LBP-guru which is an issue unto itself. Generally, people with true expertise in one area or another will point out what they don’t know or don’t understand, so if you are at a course that has all the answers you might want to rethink the value of what you are learning. Attending courses and learning from physiotherapists who dedicate their time to evaluating research and condensing it into a format that you can digest over a weekend or two is great, but you should approach these with some level of questioning. Often the pseudo-science interventions or paradigms that are pushed at us don’t have much evidence at their foundation to support their use in practice. It might be the non-technical skills and therapeutic relationship that you form with your patient that is bringing you success more so than your magic hands.
Sounds swell, but how do I work all this into my day-to-day life?
It is challenging being a clinician who balances work and life responsibilities. Lack of time and a lack of skills to interpret and apply evidence were main themes of barriers to applying evidence.7 However, there are many ways to have evidence put into easily digestible formats.
- PEDro, the physiotherapy evidence database has recently launched a campaign to tackle the barriers to EBP. Check out their website out for more details.
- The University of Alberta has a free Science Literacy course that you can find here.
- The College of Physiotherapists of Alberta have now hosted 3 episodes and 9 separate chapters on EBP.
- Social media platforms like twitter can be a great way to stay up to date by following publications, organizations and other trustworthy sources of information.
Ok so I took the time to find and read good quality evidence but how do I bring this to my patients?
Changing how you practice is challenging. Doing anything outside of your comfort zone or trying to awkwardly add new approaches to practice is intimidating. Most people don’t want to appear uncomfortable or uncertain in front of their patients, so implementing change is also hard. I would recommend a few steps that might make change easier
- Tell your patients that you are working on becoming a better physiotherapist and are trying to implement new research into practice. Being upfront and honest adheres to our Code of Ethical Conduct and patients should appreciate that you are working on improving your practice.
- Use outcome measures to track progress of patients. As you implement new research you can use outcome measures to accurately track your patient’s progress.
- Practice. Do you remember when you were a student or a new grad trying to explain chronic pain or the active cycle of breathing to a patient? It probably wasn’t the smoothest delivery and the patient may have even been searching for your supervisor to help. But, over time and with repetition it got easier and you gained confidence. Don’t give up on it if it doesn’t go smoothly the first few times, it takes time to work the kinks out of any new skill or piece of education.
- Zadro J, O’Keeffe M, Maher C. Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review. BMJ Open 2019;9:e032329. doi: 10.1136/bmjopen-2019-032329
- Scholtes, V.A., Dallmeijer, A.J., Rameckers, E.A. et al. Lower limb strength training in children with cerebral palsy – a randomized controlled trial protocol for functional strength training based on progressive resistance exercise principles. BMC Pediatr 8, 41 (2008). https://doi.org/10.1186/1471-2431-8-41
- Sackett D L, Rosenberg W M C, Gray J A M, Haynes R B, Richardson W S. Evidence based medicine: what it is and what it isn't BMJ 1996; 312 :71 doi:10.1136/bmj.312.7023.71
- Meira, E. (2020, December 10). Understanding evidence-based medicine using a funnel analogy. https://doi.org/10.31236/osf.io/kr6aq
- Scurlock-Evans L, Upton P, Upton D. Evidence-based practice in physiotherapy: a systematic review of barriers, enablers and interventions. Physiotherapy. 2014 Sep;100(3):208-19. doi: 10.1016/j.physio.2014.03.001. Epub 2014 Mar 12. PMID: 24780633.