Evidence-based physical therapy (EBPT) has been defined as "physiotherapy informed by relevant high quality clinical research" (Herbert, Jamtvedt, Mead & Hagen, 2005, p. 1). "The practice of evidence-based physiotherapy should be informed by the integration of relevant high quality clinical research, patients' preferences and physiotherapists' practice knowledge" (Herbert, p. 2). In the event that high quality clinical research is not available, good practice must make use of other sources of information such as peers, practice guidelines, practice knowledge, and any other lower quality research to inform action in practice.
The practice of EBPT really comes from making the "cost effectiveness of physiotherapeutic intervention in comparison with other ... treatment, or no treatment at all" make clinical sense (Koes, 1997). Another reason for the existence of EBPT, is because it is "the best strategy clinicians can use to cope with the potential chaos and uncertainty of modern clinical practice, and to meet the ethical imperative of providing the best possible care for our patients" (Sherrington, Moseley & Herbert, 2001, p. 125).
Since the early 1990's, following the rise of Evidence-Based Medicine (EBM), the concept of evidence-based practice has been associated with physical therapy. The first publication on this topic came out of the Department of Epidemiology at the University of Maatricht, Netherlands. Today, the major study center is the Centre for Evidence-Based Physiotherapy based in the School of Physiotherapy at the University of Sydney, Australia.
1. Ask: Convert the need for information into an answerable question.
A question is considered well-built if it addresses the most pertinent parts of your information need and will lead to a focused answer for your clinical question:
EB-PT (or OT) uses the PICO model for formulating a clinical question:
P = Population or Problem - recipients or potential beneficiaries of a service or intervention, or the situation being examined
I = Intervention or exposure - the service or planned action to be delivered to the population
C = Comparison - an alternative service or action that may or may not achieve similar outcomes
O = Outcome - the ways in which the service or action can be measured to establish whether it has had a desired effect
2. Find: Track down the best evidence with which to answer that question.
Steps in a Good Search
Think about the keywords for each part of the clinical question:
For the question: Is prophylactic physical therapy for patients undergoing upper abdominal surgery effective in preventing post-operative pulmonary complications?
A search strategy might include:
|Parts of the Question||Clinical Scenario||Search Strategy (keywords)|
|Patient Population||patients undergoing upper abdominal surgery||upper abdominal surgery|
|Intervention||prophylactic physical therapy||prophylactic physical therapy|
|Comparison (if any)||Selective prophylactic physical therapy||none|
|Outcome||post-operative pulmonary complications||pulmonary complications|
|Type of Study||RCT||randomized controlled trial
3. Appraise: Critically appraise that evidence for its validity and applicability.
(From Most Valuable to Least Valuable)
Evaluation criteria are:
Credibility: looks at truth and quality and asks, "Can you believe the results?"
Some questions you might ask are: Were patients randomized? Were patients analyzed in the groups to which they were (originally) randomized? Were patients in the treatment and control groups similar with respect to known prognostic factors?
Transferability: looks at external validity of the data and asks, "Can the results be transferred to other situations?"
Some questions you might ask are: Were patients in the treatment and control groups similar with respect to known prognostic factors? Was there a blind comparison with an independent gold standard? Were objective and unbiased outcome criteria used? Are the results of this study valid?
Dependability: looks at consistency of results and asks, "Would the results be similar if the study was repeated with the same subjects in a similar context?"
Some questions you might ask are: Aside from the experimental intervention, were the groups treated equally? Was follow-up complete? Was the sample of patients representative? Were the patients sufficiently homogeneous with respect to prognostic factors?
Confirmability: looks at neutrality and asks, "Was there an attempt to enhance objectivity by reducing research bias?"
Some questions you might ask are: Were 5 important groups (patients, care givers, collectors of outcome data, adjudicators of outcome, data analysis) aware of group allocations? Was randomization concealed?
4. Apply: Integrate the critical appraisal with clinical expertise and with the patient's unique biology, values, and circumstances.
Guidelines for applying evidence in clinical practice can be found in the classic text:
Guyatt, G., Rennie, D., Meade, M., and Cook, D. (2008) Users' guides to the medical literature: a manual for evidence-based clinical practice (2nd ed.). New York, NY: McGraw-Hill Professional.
Chapters in this guide are organized by type of clinical question: therapy, harm, diagnosis, and prognosis.
Other good resources for both appraisal and applying evidence in clinical practice can be found on these two websites:
KT Clearinghouse/Centre for Evidence-Based Medicine, Toronto:
Centre for Evidence Based Medicine, University of Oxford:
5. Evaluate: Evaluate the effectiveness and efficiency in executing steps 1-4 and seek ways to improve them both for next time.
AbleData provides objective information on assistive technology and rehabilitation equipment available from domestic and international sources to consumers, organizations, professionals, and caregivers within the United States. We serve the nation's disability, rehabilitation, and senior communities. ABLEDATA is sponsored by the National Institute on Disability and Rehabilitation Research (NIDRR), part of the Office of Special Education and Rehabilitative Services (OSERS) of the U.S. Department of Education.
Government site providing access to evidence reports, technology assessments, outcomes research, and the National Guidelines Clearinghouse's database of evidence-based clinical practice guidelines.
Mount Sinai Hospital and University Health Network, Toronto
Hooked on Evidence is an online database of research evidence produced by the American Physical Therapy Association. Unfortunately, access to this database is by paid subscription. Hooked on Evidence contains articles, abstracts from research, and articles from peer-reviewed journals. Each abstract contains the purpose, study design, participants, method, interventions and outcomes. One of the useful features of this database is the inclusion of measures of effect size, which is useful in determining treatment effectiveness in terms of achieving an outcome.
Searchable practice guidelines from various, states and government
(NARIC)Instant Disability Information Center
The information resources at this site include the NARIC Knowledgebase; RehabData, a database of disability and rehabilitation literature abstracts; the NIDRR (National Institute on Disability and Rehabilitation Research) Program Directory which lists disability and rehabilitation research projects in the United States; and the Knowledge Dissemination and Utilization page which links to additional research databases funded by NIDRR.
Compiled by the Centre for Evidence-Based Physiotherapy; contains abstracts of randomized controlled trials, systematic reviews and clinical practice guidelines in physiotherapy. Most trials have been rated for quality.
A site intended to support an increase in clinical activity in medical rehabilitation.
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