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Picture

The Dangers of Evidence-Based Practice

11/25/2013

6 Comments

 
Let's start by saying that we fully advocate for the further development of research to better guide our decision-making as physical therapists. This is without a doubt a touchy subject. Throughout schooling, we are taught to have our care as evidence-based as possible and we should be wary to perform any interventions or tests that are not supported by the literature. There lies an issue in this mindset, however: the quality and lack of research.

An obvious component we are trained to look for is how the study was performed. There are many different items to consider when appraising the research, such as type of study, blinding, controls, etc. Something that is often overlooked is the skill of the practitioner. There are hundreds of schools and many different methods of evaluating/treating patients. The gap between an OCS therapist and FAAOMPT therapist is significant. There lie differences in the skills of Fellows from different Fellowships due to variations in treatment styles again. Basically, what we're saying is that you should be careful to disregard treatment styles due to "evidence." If you know you are getting changes that are effective, you owe it to keep treating your patients the best way possible.
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The next issue is the lack of research on exam measures and intervention techniques that we use in the clinic. We have had our mentors and fellow clinicians comment on where the evidence is for some of our treatment styles. A perfect example is Instrument Assisted Soft Tissue Mobilization (IASTM). While there is some initial research out there currently, there is hardly enough evidence to prove that IASTM is a high-quality, proven treatment. That being said, the results can be impressive. The key comes back to test and re-test your patients after a treatment. This applies to more than just IASTM. With your corrective exercises, joint mobs/manips, etc., assess your patient first (pain, ROM, strength, symptoms, SFMA) and re-check afterwards. Going back to IASTM, we have had particular success improving ROM without neural provocation using IASTM. Utilizing the neural tension test as our base and then follow-up, we have seen gains in ROM by as much as 45 degrees after simply a few minutes of IASTM. Basically, if you can prove that a treatment works by doing this, why stop it? Of course, we can't forget about incorporating these changes into our care and reinforcing them to lock in the changes, but the lesson is we shouldn't limit ourselves by what the literature is (or isn't) saying at the time.
6 Comments
Eric link
11/25/2013 02:22:50 am

Hi guys. First, I like what you are doing here - keep up the great work. I like your message of this post - don't just do things only if there's an RCT or meta-analysis that says to do so. With that being said, from my understanding of EBP, I think you are getting a concept mixed up. Evidence Based Practice is different from Evidence Informed Practice. You're talkin' Evidence Informed Practice in this post - where you only care about the research. EBP, I think developed by Sackett an MD, has 3 pillars: current literature, clinical expertise, and patient values. All 3 are part of being an evidence based practitioner. My point is EBP isn't just reading the research - it's about integrating all three pillars in giving the best care to the patient. So, in the end, we're saying the same thing - just because there isn't literature on it doesnt' mean it's not effective. Good clinicians drive good research. Keep up the good work fellas and best of luck to you!

Reply
Chris link
11/25/2013 10:46:41 am

Thank you for your comment Eric. That is exactly what we were trying to say. We found ourselves dismissing things such as Expert Opinion simply because they were not RCTs or Systematic Reviews. So little research has fully been performed in comparison to everything that is out there. Thank you for the clarification!

Reply
Richard, SPT
11/25/2013 10:41:37 am

Great thoughts, I appreciate the clarification from Eric, and even as a student I understand the power of EBP. I would like to add though that one great benefit of evidence from current literature is the inclusion of long term outcomes. For instance corticosteroids have great immediate outcomes, and those outcomes may continue for months, but eventually, as I hope we are all aware, many patients will plateau in their recovery while other PT treatments may have encouraged better longer term outcomes. In this case clinical experience would have led the clinician astray had they not referred to the literature.

I don't know much about IASTM yet, but using this example, what would the authors on this site say about the long term functional outcomes after discharge for patients having received incorporation of this treatment?

Reply
Chris link
11/25/2013 10:53:40 am

Excellent point Richard. If there is evidence out there for long term benefits on a topic, we definitely like to consider the findings. Just because a treatment only has "intermediate effects" I'm not sure we should dismiss them. Instead, we should use those changes to our advantage! With steroid injections, potentially we could use the new pain-free time frame to do things we normally wouldn't be able to do. I actually don't like when my patients have steroid injections and steroid tapers, because I prefer my patients being able to identify when they have pain. Not only does it help diagnosis, but they become aware of when they are doing something wrong! With IASTM, it is essential to incorporate the gains and then take advantage of those changes. For example, if you improve ROM at a joint that previously had decreased motion, we need patient to either perform an exercise to lock in those changes and/or strengthen muscles in those new ranges to help maintain. Basically, interventions that show only short-term or intermediate effects may still have use by facilitating other treatment techniques. Of course we must be aware of any research that this combination is not any different than another treatment alone, but we must also remember to thoroughly analyze the study to see any potential faults! Thank you again for the comment Richard.

Reply
matt
12/10/2013 01:38:02 am

Jules Rothstein had an editors note that responded to someone making the exact argument of this post over ten years ago. I've included a link to it below. His words truly speak for themselves and embody what I have learned in school to be evidence based practice. My favorite paragraph

"Proponents of evidence-based practice are not saying that practitioners can use treatments only when there is evidence or that they must seek dogmatic adherence to practices because of data. We are saying that clinicians have a moral responsibility to know about the evidence relating to their interventions and techniques and to consider this evidence in patient management. The ethical and moral issues arise not over whether there is evidence for all that we do, but whether we are aware of evidence relating to our actions and whether we choose to base our approaches on our own personal biases when sufficient data exist to suggest we should use a different approach."


http://ptjournal.apta.org/content/80/1/112.long

Reply
Brian
12/11/2013 01:21:50 pm

Matt,

Thanks for sharing. I think that paragraph sums up what this post was all about and what we all should strive for when speaking about EBP. Our interventions certainly do not have to all be "EBP" but we should have a clinical rationale for why we are choosing our interventions while respecting the evidence out there. Great comment!

Reply



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  • Home
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  • Special Tests
    • Cervical Spine >
      • Alar Ligament Test
      • Bakody's Sign
      • Cervical Distraction Test
      • Cervical Rotation Lateral Flexion Test
      • Craniocervical Flexion Test (CCFT)
      • Deep Neck Flexor Endurance Test
      • Posterior-Anterior Segmental Mobility
      • Segmental Mobility
      • Sharp-Purser Test
      • Spurling's Maneuver
      • Transverse Ligament Test
      • ULNT - Median
      • ULNT - Radial
      • ULNT - Ulnar
      • Vertebral Artery Test
    • Thoracic Spine >
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      • Passive Neck Flexion Test
      • Thoracic Compression Test
      • Thoracic Distraction Test
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    • Lumbar Spine/Sacroiliac Joint >
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      • Alternate Gillet Test
      • Crossed Straight Leg Raise Test
      • Extensor Endurance Test
      • FABER Test
      • Fortin's Sign
      • Gaenslen Test
      • Gillet Test
      • Gower's Sign
      • Lumbar Quadrant Test
      • POSH Test
      • Posteroanterior Mobility
      • Prone Knee Bend Test
      • Prone Instability Test
      • Resisted Abduction Test
      • Sacral Clearing Test
      • Seated Forward Flexion Test
      • SIJ Compression/Distraction Test
      • Slump Test
      • Sphinx Test
      • Spine Rotators & Multifidus Test
      • Squish Test
      • Standing Forward Flexion Test
      • Straight Leg Raise Test
      • Supine to Long Sit Test
    • Shoulder >
      • Active Compression Test
      • Anterior Apprehension
      • Biceps Load Test II
      • Drop Arm Sign
      • External Rotation Lag Sign
      • Hawkins-Kennedy Impingement Sign
      • Horizontal Adduction Test
      • Internal Rotation Lag Sign
      • Jobe Test
      • Ludington's Test
      • Neer Test
      • Painful Arc Sign
      • Pronated Load Test
      • Resisted Supination External Rotation Test
      • Speed's Test
      • Posterior Apprehension
      • Sulcus Sign
      • Thoracic Outlet Tests >
        • Adson's Test
        • Costoclavicular Brace
        • Hyperabduction Test
        • Roos (EAST)
      • Yergason's Test
    • Elbow >
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      • Chair Sign
      • Cozen's Test
      • Elbow Extension Test
      • Medial Epicondylalgia Test
      • Mill's Test
      • Moving Valgus Stress Test
      • Push-up Sign
      • Ulnar Nerve Compression Test
      • Valgus Stress Test
      • Varus Stress Test
    • Wrist/Hand >
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      • Carpal Compression Test
      • Finkelstein Test
      • Phalen's Test
      • Reverse Phalen's Test
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      • Dial Test
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      • Long-Axis Femoral Distraction Test
      • Noble Compression Test
      • Percussion Test
      • Sign of the Buttock
      • Trendelenburg Test
    • Knee >
      • Anterior Drawer Test
      • Dial Test (Tibial Rotation Test)
      • Joint Line Tenderness
      • Lachman Test
      • McMurray Test
      • Noble Compression Test
      • Pivot-Shift Test
      • Posterior Drawer Test
      • Posterior Sag Sign
      • Quad Active Test
      • Thessaly Test
      • Valgus Stress Test
      • Varus Stress Test
    • Foot/Ankle >
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      • Calf Squeeze Test
      • External Rotation Test
      • Fracture Screening Tests
      • Impingement Sign
      • Navicular Drop Test
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      • Talar Tilt
      • Tarsal Tunnel Syndrome Test
      • Test for Interdigital Neuroma
      • Windlass Test