Evidence-based Physical Therapy
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).
- Ensure that all decisions made for patient care take "the best available evidence" into account
- Better plan and evaluate service delivery
- Better analyze research studies and direct those findings to better care
- Take better measurement and do interpretation of outcomes to provide the best care possible
- Provide better patient information.
- Better understand the reasons for lack of compliance by patients in relation to their PT care
- Accurately gauge the relationship between patients and physical therapists and its effect on health-related outcomes
- Develop theories based on evidence in practice
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.
5 Steps of EBPT or EBOT
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
- Construct the question (see previous section).
- Select the best resource (see Resources for some places to start).
- Formulate the search strategy.
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 | randomized clinical trials (RCT) | RCT |
3. Appraise: Critically appraise that evidence for its validity and applicability.
(From Most Valuable to Least Valuable)
- Meta-analyses: methods of synthesizing the data from more than one study, in order to produce a summary statistic
- Systematic Review: attempts to answer a clear question by finding and describing all published, and if possible, unpublished work, on a topic. [It] uses explicit methods to perform a thorough literature search and critical appraisal of individual studies and uses appropriate statistical techniques to combine these valid studies (Booth & Brice, 2004).
- Randomized Controlled Trials (RCT): also called "randomized clinical trials." They involve the random assignment of subjects to groups that are then given different interventions to assess the effects of the interventions.
- Controlled Comparison or Case Control Study: an observational study in which the cases have the issue of interest
- Descriptive Surveys: studies aimed at describing certain attributes of a population, specifying associations between variables, or searching out hypotheses to be tested, but which are not primarily intended for establishing cause-and-effect relationships or actually testing hypotheses.
- Case Studies: describe a particular service or event, often focusing on unusual aspects of the reported situation or adverse occurrences, commonly have exploratory, descriptive, or explanatory purposes.
Evaluation criteria are:
- Credibility (Internal Validity)
- Transferability (External Validity)
- Dependability (Reliability)
- Confirmability (Objectivity)
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 the 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. (2015) Users' guides to the medical literature: a manual for evidence-based clinical practice (3rd ed.). New York, NY: McGraw-Hill Education.
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
5. Evaluate: Evaluate the effectiveness and efficiency in executing steps 1-4 and seek ways to improve them both for next time.
Ask yourself:
- Did you ask an answerable clinical question?
- Did you find the best external evidence?
- Did you critically appraise the evidence and evaluate it for its validity and potential usefulness?
- Did you integrate critical appraisal of the best available external evidence from systematic research with individual clinical expertise in personal daily clinical practice?
Handbook of Qualitative Health Research for Evidence-Based Practice by
This progressive reference redefines qualitative research as a crucial component of evidence-based practice and assesses its current and future impact on healthcare. Its introductory section explains the value of sociocultural context in case conceptualization, and ways this evidence can be integrated with quantitative findings to inform and transform practice. The bulk of the book's chapters review qualitative research in diverse areas, including pain, trauma, heart disease, COPD, and disabling conditions, and examine ways of effectively evaluating and applying qualitative data. This seismic shift in perception moves the healing professions away from traditional one-size-fits-all thinking and toward responsive, patient-centered care. Among the topics in the Handbook: ·Examining qualitative alternatives to categorical representation. ·The World Health Organization model of health: what evidence is needed? ·Qualitative research in mental health and mental illness. ·Qualitative evidence in pediatrics. ·The contribution of qualitative research to medication adherence. ·Qualitative evidence in health policy analysis. The Handbook of Qualitative Health Research for Evidence-Based Practiceoffershealth and clinical psychologists, rehabilitation specialists, occupational and physical therapists, nurses, family physicians and other primary care providers new ways for understanding patients' health-related experiences and opens up new ways for developing interventions intended to improve health outcomes.
ISBN: 1493929208Publication Date: 2015-10-12
Orthopaedic Clinical Examination by
Evidence-based practice is becoming an increasingly important topic in physical therapy clinical practice, especially as the cost of health care continues to accelerate. As a result, evidence is now being incorporated into all aspects of physical therapy patient/client management including examination, evaluation, diagnosis, prognosis, and intervention. Designed as a handy, quick-reference guide, ORTHOPAEDIC CLINICAL EXAMINATION: AN EVIDENCE-BASED APPROACH FOR PHYSICAL THERAPISTS takes a uniquely visual, evidence-tables approach to make it easy for clinicians to locate relevant evidence of the diagnostic utility of commonly utilized tests and measures. Features 281 evidence-tables with essential information clinicians need to make appropriate decisions on clinical tests for their patients. Provides information specific to the diagnostic accuracy of specific tests ... measures that have been investigated in controlled studies ... and each test's sensitivity, specificity, and likelihood ratios. In addition, each table offers an easy-to-follow guide to the performance and scoring of every test and measure. Offers information on the patient population and reference standard that was utilized in the corresponding study, with an overview of the study results and their applicability to the clinician's environment. Includes 169 Netter and Netter-style images and 173 photographs assure that clinicians have an understanding of the relative anatomy, arthrology, myology, and neurology behind the examination process.
Call Number: Stacks; WE39 C624o 2005ISBN: 9781929007875Publication Date: 2005-06-01
Rehabilitation Research by
Written to help rehabilitation students and professionals change and improve their practices on the basis of the evidence, this edition provides a practical framework for understanding and applying the systematic process of research. Highlighting both traditional research methods and emerging approaches, this book keeps the reader apprised of the current and future focus of rehabilitation research and emphasizes the importance of the joint effort of the producers and consumers of research. It uses straightforward language and relevant examples to capture the diversity and complexity of research that is of interest to rehabilitation professionals. 4th edition due September 2010, and can be found under Carter: Rehabilitation Research 4e. Provides a solid grounding in traditional research design and analysis and an introduction to emerging research topics, all in the context of physical therapy research Covers outcomes research, epidemiology, qualitative design, single-system design, case reports, survey research, and the data analysis techniques used with these research approaches Each chapter is supported with a wide variety of contemporary and classic references, for those readers who require more details on a particular topic Unique contributions from an interdisciplinary team representing physical therapy and athletic training, speech language pathology, and occupational therapy A new chapter on Synthesizing Bodies of Evidence provides ways and reasons to synthesize the literature More social science and educational research techniques and tools to reflect the variety of ways that different authors conceptualize function across the studies cited in this edition Increased emphasis on randomized controlled trials and evidence-based practice Expanded glossary with more than 150 new words Valuable additions added to the chapter on locating the literature
Call Number: Stacks; WB320 D668r 2005ISBN: 0721600298Publication Date: 2004-08-20
The Sports Rehabilitation Therapists' Guidebook by
The Sports Rehabilitation Therapists' Guidebook is a well-equipped, comprehensive, practical, evidence-based guide that seeks to assist both students and graduate sport practitioners. The book is designed to be a quick-reference book during assessment and treatment planning, giving instant access to figures and case scenarios. It introduces evidence-based practice in all principal areas of sport rehabilitation such as anatomy, musculoskeletal assessment, pitch-side care, injury treatment modalities and exercise rehabilitation principles and related areas, and is designed to be more flexible than the usual single-focus books. It is written by a team of expert contributors offering a systematic perspective on core concepts. The book can be used as a guide in each stage of the sport rehabilitation process and it is an asset for sport clinical practitioners such as sport rehabilitators, sport therapists, personal trainers, strength and conditioning coaches, as well as for students on these and related courses in their daily practice on core clinical placements such as a clinic/sporting environment, pitch side and university.
ISBN: 1003171141Publication Date: 2021-06-30
Therapeutic Electrophysical Agents: Evidence Behind Practice by
The third edition of Therapeutic Electrophysical Agents: Evidence Behind Practice--revised and expanded, with new chapters and ancillary resources and tools on thePoint--is designed to give you the expertise with electrophysical agents you will need in your clinical practice. As with previous editions, the foundation of this book rests solidly and uniquely on evidence from experimental and clinical human trials. The goal of this textbook is to offer all the necessary knowledge, skills, and tools you need to master the practice of therapeutic electrophysical agents. The online resources include new unit conversion and dosimetric calculators, which allows students and practitioners to learn about prescribing treatment and what measurements to think about when dosing, without having to work through all the equations. Also included are new practice questions to help prepare for the Physical Therapy certification exam. These questions are similar to the ones students are likely to face on their board exams and will help build proficiency and competence. Information about the author :Alain-Yvan Belanger, BSc, MSc, PhD, PT is a retired professor from the Department of Rehabilitation, Physiotherapy program, Faculty of Medicine, Laval University, Quebec City, Canada. Dr. Belanger holds a bachelor's degree in physiotherapy from the University of Montreal, a master's of science degree in kinesiology from Simon Fraser University, and a doctoral degree in neurosciences from McMaster University. He has extensive experience as a teacher, researcher, consultant, and author in the field of human neuromuscular physiology and therapeutic electrophysical agents. Dr. Belanger has held the positions of Scientific Editor of the journal Physiotherapy Canada and President of the Canadian Physiotherapy Association. He has also served as Associate Editor of several journals. He is the sole author of the first, second, and third editions of Therapeutic Electrophysical Agents: Evidence Behind Practice. An avid golf and poker player, Alain still dreams of playing a sub 80's round of golf and winning the next World Series of Poker Seniors Championship! To contact Alain Belanger go to alainyvanbelanger.com.
Call Number: Stacks; WB39 B426t 2015ISBN: 9781451182743Publication Date: 2014-01-18
- Dijkers M, Murphy SL, Krellman J. (2012) Evidence-Based Practice for Rehabilitation Professionals: Concepts and Controversies This article describes evidence-based practice (EBP) in the health professions and sciences in general and in the rehabilitation disciplines specifically. It discusses the following: what counts as evidence and how that has changed over the last 4 decades, trends in the short history of evidence-based medicine and EBP, the fallacious nature of most criticisms of EBP, (perceived) shortcomings of clinical research and the resulting evidence in rehabilitation, resources available to clinicians who want their practice to be evidence-based, and the barriers these clinicians face in keeping up with the evidence and applying it in practice. Lastly, it describes how the development of a new art and science, knowledge translation, may play a role in truly making EBP feasible in rehabilitation services.
- Ebenbichler G. Kerschan-Schindl K. Brockow T. Resch KL. (2008) The future of physical & rehabilitation medicine as a medical specialty in the era of evidence-based medicine The professional perspective of medical specialties will increasingly depend on the evidence supporting the effectiveness of their therapeutic measures, particularly in the field of physical and rehabilitation medicine (PRM; also known as physical medicine and rehabilitation), because PRM makes use of many management and treatment approaches for which evidence of effectiveness is inherently difficult to develop.
- Grimmer-Somers K. (2007) Incorporating research evidence into clinical practice decisions Physiotherapy journals have a responsibility to encourage reporting on opportunities to improve clinical practice, as there is increasing international expectation that research evidence will be used to inform allied healthcare decisions. The words ‘evidence-based practice’ should now be familiar to most therapists and managers, and they are increasingly familiar to patients. Most allied health practices would consider themselves to be ‘evidence-based’, usually because they run a journal club, audit treatment notes, become accredited or treat some patients using clinical guidelines or pathways. Academic allied health journals around the world publish research articles purporting to add to the body of evidence which informs clinical practice. Journals are placing an increasing emphasis on bringing research closer to clinical practice in terms of user-friendly titles for papers, insisting on better quality reporting, providing key point sections in papers which explain the findings in clinical terms, and providing clinical commentaries to put the research evidence into a clinical context.
- Grol R. Grimshaw J. (2003) From best evidence to best practice: effective implementation of change in patients' care Major difficulties arise when introducing evidence and clinical guidelines into routine daily practice. Data show that many patients do not receive appropriate care, or receive unnecessary or harmful care. Many approaches claim to offer solutions to this problem; which ones are as yet the most effective and efficient is unclear. We aim to provide an overview of present knowledge about initiatives to changing medical practice. Substantial evidence suggests that to change behavior is possible, but this change generally requires comprehensive approaches at different levels (doctor, team practice, hospital, wider environment), tailored to specific settings and target groups. Plans for change should be based on characteristics of the evidence or guideline itself and barriers and facilitators to change. In general, evidence shows that none of the approaches for transferring evidence to practice is superior to all changes in all situations.
- Johnson C. (2008) Evidence-based practice in 5 simple steps Evidence-based practice (EBP) is a life-long learning technique that may help healthcare practitioners continue to improve practice methods and approaches to patient care.1 Sackett et al originally described the fundamental principles and the 5 steps of EBP that are described in this editorial.2 These steps are similar to the basic underlying principles of the continuous quality improvement (CQI) cycle.3 The CQI cycle typically begins with an identified need and a desire for improvement. The next steps include a search for the most appropriate information/solution, evaluation to make sure that the information/solution is appropriate, application of the appropriate information/solution to the situation, monitoring the effects of implementation practices to make sure that an improvement has been made, then incorporating this information into regular practice.3 Most people are familiar with the concept of CQI and may subconsciously apply these steps during daily activities. However, consciously applying these steps in clinical practice may help us achieve even better patient care.
- Kalef L, Reid G, MacDonald C. (2013) Evidence-based practice: A quality indicator analysis of peer-tutoring in adapted physical education The purpose of the research was to conduct a quality indicator analysis of studies investigating peer-tutoring for students with a disability in adapted physical education. An electronic search was conducted among English journals published from 1960 to November 2012. Databases included ERIC, PsycINFO, and SPORTDiscus. Fifteen research studies employing group-experimental (Gersten et al., 2005) or single-subject designs (Horner et al., 2005) met inclusion criteria. Each study was assessed for the presence and clarity of quality indicators. Group designs met an average of 62.5% essential and 69% desirable indicators. An average of 80% of indicators was present for single-subject designs. Results suggest claims of peer-tutoring being an evidence-based practice are premature. Recommendations for clarifying and applying the quality indicators are offered.
- Scurlock-Evans L, Upton P, Upton D. (2014) Evidence-Based Practice in physiotherapy: a systematic review of barriers, enablers and interventions Despite clear benefits of the Evidence-Based Practice (EBP) approach to ensuring quality and consistency of care, its uptake within physiotherapy has been inconsistent. The objectives were to synthesise the findings of research into EBP barriers, facilitators and interventions in physiotherapy and identify methods of enhancing adoption and implementation. Literature concerning physiotherapists’ practice between 2000 and 2012 was systematically searched, and reference lists were searched to identify additional studies. Thirty-two studies, focusing either on physiotherapists’ EBP knowledge, attitudes or implementation, or EBP interventions in physiotherapy were included. Synthesis was organised around the themes of EBP barriers/enablers, attitudes, knowledge/skills, use and interventions. Many physiotherapists hold positive attitudes towards EBP. However, this does not necessarily translate into consistent, high-quality EBP. Many barriers to EBP implementation are apparent, including: lack of time and skills, and misperceptions of EBP. Furthermore, narrative synthesis may be subject to greater confirmation bias. There is no “one-size fits all” approach to enhancing EBP implementation; assessing organisational culture prior to designing interventions is crucial. Although some interventions appear promising, further research is required to explore the most effective methods of supporting physiotherapists’ adoption of EBP.
- Sherrington C, Moseley AM, Herbert RD, Elkins MR, Maher CG (2010) Ten years of evidence to guide physiotherapy interventions: Physiotherapy Evidence Database (PEDro). Clinicians are increasingly using evidence from high-quality clinical research to guide clinical decision making. Recent articles in this journal have examined research evidence to assist in clinical decisions as diverse as the prescription of running shoes, exercise therapy in the treatment of chronic disease and the use of protective equipment to prevent concussion
- Traiano, JJ (2008) What constitutes evidence for best practice? The guiding principles, methods, and common factors that serve as the foundation for the Commission of the Council on Chiropractic Guidelines and Practice Parameters best practices initiative are discussed in the context of the chiropractic practice environment.
- van der Wees PJ. Jamtvedt G. Rebbeck T. de Bie RA. Dekker J. Hendriks EJ. (2008) Multifaceted strategies may increase implementation of physiotherapy clinical guidelines: a systematic review Question: What is the effectiveness of strategies to increase the implementation of physiotherapy clinical guidelines? Design: Systematic review. Participants: Physiotherapists treating any type of patients. Intervention: Single or multiple strategies to increase the implementation of physiotherapy clinical guidelines. Outcome measures: Professional practice, patient health, and cost of care. Results: Five papers reporting three cluster-randomised trials evaluated whether multifaceted strategies based on educational meetings increased the implementation of low back pain guidelines (2 trials) or whiplash guidelines (1 trial). Educational meetings were effective in increasing adherence to the following recommendations of low back pain guidelines: limiting the number of sessions (RD 0.13, 95% CI 0.03 to 0.23), using active intervention (RD 0.13, 95% CI 0.05 to 0.21), giving adequate information (RD 0.05, 95% CI 0.00 to 0.11), increasing activity level (RD 0.16, 95% CI 0.02 to 0.30), changing attitudes/beliefs about pain (RD 0.13, 95% CI 0.01 to 0.24). Educational meetings were effective in increasing adherence to the following recommendations of whiplash guidelines: reassuring the patient (RD 0.40, 95% CI 0.07 to 0.74), advising the patient to act as usual (RD 0.48, 95% CI 0.15 to 0.80), using functional outcome measures (RD 0.62, 95% CI 0.32 to 0.92). There was no evidence that patient health was improved or that the cost of care was reduced. Conclusion: This review shows that multifaceted interventions based on educational meetings to increase implementation of clinical guidelines may improve some outcomes of professional practice but do not improve patient health or reduce cost of care. These findings are comparable with results among other health professions.
- Evidence-Based Healthcare TutorialsAn Evidence Based Medicine / Physical Therapy Tutorial from Duke University and the University of North Carolina
- Evidence-Based Practice: An Interprofessional TutorialA clickable walkthrough of evidence-based practice designed by the University of Minnesota
- Evidence-Based Practice in Applied Health SciencesTutorial consisting of six instructional modules (Introduction to Evidence-Based Practice in Applied Health Sciences, Structure of literature, Research design, Searching the literature, Literature resources, and Evaluating the quality of research) by the University of Illinois Chicago
- Evidence-based Practice TutorialsEight tutorials created by Rutgers University Libraries that provide an overview on evidence-based practice that includes graphics, videos, and mini quizzes, and a practice quiz to test overall knowledge.
- ArticleSearch (Formerly Open Door)APTA's Portal to Evidence Based Practice. Provides access to several databases and health care literature from ProQuest, Joanna Briggs Institute, Cochrane Library and more. Must be an APTA member.
- Agency for Healthcare Research and Quality (AHRQ)Government site providing access to evidence reports, technology assessments, outcomes research, and the National Guidelines Clearinghouse's database of evidence-based clinical practice guidelines.
- Centre for Evidence-Based MedicineOxford University is ranked number one in the world for medical sciences and is home to the Centre for Evidence-Based Medicine (CEBM). As part of the UK’s leading centre for academic primary care, the CEBM is a renowned global centre for evidence-based medicine research and learning.
- National Rehabilitation Information Center (NARIC)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.
- PEDro - Physiotherapy Evidence DatabaseCompiled 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.