Physical therapists will render evidence based services throughout the continuum of care and improve quality of life for society – APTA Vision 2020
As a student with a background in the arts, I was inclined to shy away from the research aspect of physical therapy. It took effort to get through statistics in undergrad. I learned to respect those that had a passion for research, as I had a fear that statistical analysis would come back to haunt me. It did, multiple times throughout physical therapy school.
The concept of evidence-based medicine, or, more broadly, EBP, marks a shift among health care professionals from a traditional emphasis on actions based on the opinions of authorities to guide clinical practice to an emphasis on data-based, clinically relevant studies and research – Jette et al 2003
Evidence Based Practice (EBP)
The theory of evidence based practice is three-fold. It requires the practitioner to identify the gaps in knowledge, execute a search, and apply the literature to the patient’s problem, while being sensitive to the patient’s values.
The APTA’s 2020 Vision statement regarding the practice of evidence based service is not difficult to comprehend but is important to recognize, especially as future practitioners. Repetition of this type of practice is pivotal in reinforcing the application.
The practice of physical therapy is shifting gears from applying interventions based on beliefs to depending on what the evidence demonstrates. As a student, I’ve shadowed clinicians who do apply EBP, but also frequently fall into reinforcing beliefs that lack foundation in the literature. It is important to recognize the literature as a double-edged sword. It can provide evidence for treatments that work, but can also muddy the waters even more by exposing the gaps in knowledge. In short, the research has a difficult time explaining the question of why. In these situations, I often rely on explanations from either my professors or master clinicians as an attempt to fill these gaps and the best answer at times, despite feeling frustrated enough to say, “I don’t know.” EBP, as stated earlier, is a three-fold beast, but the clinical experience aspect requires definition. My perspective of clinical experience is the integration of anatomy, biomechanics and movement to the literature with human humility.
The information in the literature coupled with what we have learned in school should guide us to think analytically about the source of our patients’ presentation so we can better treat the cause and not just the symptoms. I want to challenge myself, and you, to question common beliefs and not mistake biological plausibility as evidence for causality. Use the literature and the knowledge at your disposal.
In PT school we all learn to use the plum line as one assessment tool to because we are taught that abnormal posture contributes to patients’ complaints. The connection between posture and musculoskeletal dysfunction is an understandable hypothesis but the literature is finding discrepancy within this belief.
In a review that assessed subacromial impingement syndrome (SIS) and its postural component, Dr. Adam Rufa concluded that the importance of static posture in the development and treatment of SIS has not been confirmed by the current literature. Of the nine studies that examined self-selected posture in patients with SIS, none showed a correlation between posture and SIS.
In another study that assessed lumbar lordosis in patients with chronic low back pain Youdas et al states, “We concluded that these patients with CLBP [chronic low back pain] had no more standing lumbar lordosis or pelvic inclination than their counterparts with healthy backs but that their abdominal muscle force was less than that of the control subjects.” The study continued to discourage abdominal strengthening exercises in patients with CLBP based solely on the assessment of their relaxed standing posture.
Using the current literature as a guide for treatment not only increases patient outcomes but also decreases waste. In a survey of physical therapists’ use of interventions with high evidence Mikhail et al reported that 68% of the therapists reported using methods for LBP with strong evidence and 90% used methods with no or poor evidence for LBP. This same study also reported that the most commonly reported interventions used by Canadian physiotherapists included mobilization, ice, and ultrasound. As we know, there have been many articles that evaluate the efficacy of ultrasound for treating pain, musculoskeletal injuries and soft tissue lesions, but its effectiveness remains questionable. Ironically, the September 2014 edition of PT in Motion published the top 10 procedures in total payments to PTs and other providers of physical medicine and rehabilitation services in 2012. Ultrasound made the cut coming in at $29,222,458 in total Medicare payments.
As a student, I want to encourage other students and practitioners to let the literature help guide patient treatments and to use our critical thinking skills to fill in the gaps of knowledge that the literature withholds. If we remember that the strength of our beliefs should be proportionate to the evidence we have to support them, I believe therapists can work together to further enhance the quality of care for our patients. In this way we can avoid wasting our patients’ time and further enhance the patient’s outcomes and experience of physical therapy.
And by practicing this way, physical therapists would not only fulfill the concept placed on practitioners by the APTA’s 2020 statement, but also better the profession of physical therapy.