Clinical Measurement as a Resource for Evidence-Based Practice in Physiotherapy

Abstract

Evidence-based practice (EBP) is the cornerstone of the twenty-first century. It is an approach to healthcare that emphasizes making decisions based on the best available evidence, combined with clinical expertise and patient values. The main goal of every healthcare professional is to have credible and reliable justification for the treatment of an individual patient. Scientific evidence should be used to influence practice in physiotherapy. The need to measure outcomes in physiotherapy practice is undisputed with the growing pressure on physiotherapy to embrace evidence-based practice. An outcome measure gives baseline data before giving any intervention, and initial outcomes may assist in establishing the path of therapy intervention. To evaluate and enhance patient care, uphold professional standards, and “do the right thing,” clinical audit is crucial.

1. Introduction

Evidence-based practice (EBP) is the cornerstone of twenty-first century. It is an approach to healthcare that emphasizes making decisions based on the best available evidence, combined with clinical expertise and patient values [1]. The goal of every healthcare professional is to have a credible and reliable rationale for treating an individual patient. Physical therapists participate in an assessment process that includes taking a medical history, conducting a systems review, and performing clinical tests and measurements to identify potential and existing problems, as well as to establish diagnosis and prognosis. In more recent times, there has been pressure on physiotherapist from the government and other health insurers to become more accountable for their practices and justify what they do. The need to measure outcomes in physiotherapy is undisputed with the growing pressure on physiotherapy to embrace EBP [2].

Herbert and colleagues provided further guidance for using the principles of EBP in physiotherapy, which is informed by relevant, high-quality clinical research (evidence), coupled with physiotherapist practice-generated knowledge and patient preference and perspectives. Integrating research results with the patient’s values, circumstances and preferences, the physical therapist’s practical expertise, and the clinical setting constitutes evidence-based physical therapy practice [3]. Despite the obvious advantages of EBP, its implementation in physical therapy (and other medical disciplines) has been poor and variable in terms of quality [4]. Concerns about the compatibility of aspects of EBP and the lack of clinically relevant research were of concern [2]. Clinical measurement plays a vital role in generating such evidence in order to promote the best possible clinical outcomes and offer patients/colleagues with reliable information (Figure 1).

Figure 1.

Core concept of evidence based practice.

1.1 High quality clinical research

The term clinical research is usually used to mean a comprehensive research of the safety and effectiveness of the most promising advances in patient care that generate knowledge with either experiment or observation conducted in a clinical environment [5].

1.2 Patient values and preference

Values and preferences relate to the belief that patients place on health outcomes. Traditionally, healthcare professionals make decisions about treatment for their patients. Recently, there has been a shift toward patient involvement in making decisions. These concepts see patient values as a central part of quality healthcare practices and highlight the importance of considering aspects that people value in healthcare practices be taken seriously [6, 7, 8, 9].

1.3 Clinical expertise/clinical knowledge

Any knowledge that comes from professional practice and experience, which includes the general basic skills of clinical practice as well as the experience of the individual practitioner [10]. Practice knowledge should always be incorporated into the decision-making process and thus contribute to professional judgments that must be made together with patients. To achieve positive and gratifying outcome, clinical expertise must take into account and harmonize the patient clinical condition and context, pertinent research findings, as well as the patient’s preferences and actions.

1.3.1 Process of clinical decision-making

Clinical decision-making is a continuous and evolving process in which data is collected, interpreted, and evaluated to make an evidence-based action decision [11]. Clinical decision-making brings together information from high-quality clinical research, patient preferences, and information from therapists in a specific context. Practice knowledge alone is not evidence. It only contributes to judgment that has to be made in day-to-day practice. Decision has to interact with research evidence, patient values, and practice knowledge.

Five steps for evidence-based Physiotherapy [12].

1. Ask question Converting the need for information into answerable question (questions related to diagnosis, prognosis or therapy etc.).

2. Find information/evidence to answer question Track down the best evidence with which to answer that question.

3. Critically appraise the information/evidence Critically appraising that evidence for its validity and applicability.

4. Integrate appraised evidence with own clinical expertise and patient’s preferences Integrating the critical appraisal with our clinical expertise and with our patient’s unique biology, values, and circumstances.

5. Evaluation Evaluating our effectiveness and efficiency in executing Steps 1–4 and seeking ways to improve them both for next time.

1.3.2 Advantages of evidence-based practice

Engaging with both research and clinical findings can enhance the proficiency of physiotherapists’ clinical practice [1] and help prevent the misuse, overuse, and underuse of healthcare services [13]. In an era of growing accountability of healthcare practitioners, this may provide a useful framework within which to work. Indeed, this has led some to argue that there is a moral obligation to base decision-making on research findings [2]. Overall, Evidence-Based Practice provides a systematic and structured approach to decision-making that benefits both practitioners and the individuals they serve. It combines the best available evidence with clinical expertise and patient preferences, leading to improved outcomes and higher quality care. EBP improves patient/client outcomes, provides higher quality of care, ensures cost effectiveness, encourages professional development and transparency and accountability, reduces variation in practice, integrates research and practice, enhances communication among interdisciplinary teams, and emphasizes the importance of considering patient preferences, values, and needs when making treatment decisions. This helps ensure that interventions align with patients’ goals and promote shared decision-making.

2. Clinical measurement

Measurement is a key element of evidence-based practice that gives clinicians the data they need to make decisions regarding patient care [14]. Questioning one’s own practice is the beginning and end of the evidence-based physiotherapy process. It is vital to constantly consider if the evidence-based procedure being used is yielding the optimum results for the patient. The main goal of every healthcare professional is to have credible and reliable justification for treatment on an individual patient. In recent years, due to the escalating expenses of health care, providers have been under more and more pressure to account for how their services are used. Concurrently, increased competition in the market has made it necessary for practitioners to offer evidence of treatment success to clients, insurance companies, and other funding sources. Given these elements, there is a critical need to precisely identify cost-effective treatments from the standpoint of the patient, their family, the healthcare provider, and society at large [15]. Scientific evidence should be used to influence practice in physiotherapy, and appropriately assessing health outcomes is a key tactic for accomplishing this.

An outcome can be considered as the consequences of care, a substantial change in the health condition of a patient [16], while outcome measures are tools used for measuring changes in patients’ functioning, performance, or participation over time following an intervention [17, 18, 19]. Using outcome measure to monitor patient health status is seen as a crucial component of excellent clinical practice in physiotherapy [20]. There are many practical concerns that must be taken into account when implementing the day-to-day use of OMs, including the use and interpretation of OMs in the clinical setting and the psychometric properties.

2.1 Selecting an outcome measure

Choosing the right outcome measure is one of the most crucial steps in its use in clinical practice. When selecting an outcome measurement tool, the clinician must consider the purpose for which the outcomes will be used and the key health areas to be measured in the context of age, stage and patient status, and the clinical environment [21]. The need to decide which are the most relevant should be based upon sound psychometric properties, which should be quick and easy to complete and score and most importantly be intuitive to interpret (Table 1).

Psychometric	Concern
Validity	Validity is often defined as the extent to which an instrument measures what it purports to measure [22].
	Content validity: is the degree to which the content of the tool adequately reflects the construct of interest [23].
	Construct validity: is the degree to which the scores of a tool are consistent with hypotheses based on the abstract concept [23].
	Criterion Validity: when the measurement of one tool can be used as a substitute measurement, for an established reference standard (gold standard) [23].
	Concurrent validity: establishes the validity of two measurements taken at the same time (perhaps one tool is considered more efficient than the Gold Standard) [23].
Reliability	is the reliability of an outcome measure is the extent to which the outcome measure scores remain consistent over repeated tests of the same patient under identical conditions. (intra class correlation coefficient (ICC)) [24].
	Test-retest reliability: indicates consistency of measures over time, (i.e., with more than one application).
	Intra-rater reliability: indicates agreement of repeated measures obtained by the same person.
	Interrater reliability: indicate agreement between two or more examiners.
Responsiveness	is the ability instruments have to measure small changes that are clinically important, where participants or patients respond to effective therapeutic interventions [25].

Table 1.

Psychometric properties of outcome measures.

2.2 Types of outcome measures used in clinical practice

Generic: These are questionnaires designed to evaluate perceived change in the wide domain of general health and well-being across various medical conditions, populations, or interventions, for example, SF-12 and Sickness impact profile (SIP) [26].

Dimension-Specific: focuses on how the patient perceives aspects like pain, locus of control, anxiety, or coping pain rating scale and the Borg scale of perceived exertion (limited to a single dimension of health) [27].

Condition-specific outcome measurement tools are questionnaires that have been devised for specific diseases. Eg Arthritis impact mea-surement scale (AIMS), and Western Ontario Rotator Cuff Index (WORC) [28].

Region-Specific: These are questionnaires that have been devised for specific regions of the body, for instance, lower limb task questionnaire, Neck disability index (NDI), and Disabilities of the arm shoulder and hand (DASH) [28, 29].

Patient-Specific: rely on the experiences of each patient rather than on predetermined queries.

These center on the functional limitations status of the specific determined at the time of questioning. Questions and answers are specific to individual patients, for example, Patient specific functional scale (PSFS) [30].

3. Barriers toward evidence-based practice among physiotherapist

Evidence-based practice barriers can be thought of as modifiable elements that prevent the implementation of EBP, and understanding them could help to improve the environmental and organizational context as well as education [31]. In a recent systematic review by Matteo Paci and colleagues that investigated the barriers to evidence-based physiotherapy. The review included 29 studies reporting the opinions of nearly 10,000 physiotherapists. Lack of time was the most frequently encountered barrier and was reported by 53% of physiotherapists. This was followed by language (36%), lack of access (34%), and lack of statistical skills (31%). Herbert et al. [32] report that even in most evidence-based practice settings, implementing an evidence-based approach to clinical decision-making and practice faces significant practical challenges. Many studies have identified several barriers to evidence-based practice in physiotherapy and other health professionals. In a cross-sectional survey conducted in Columbia, 56% of the respondents indicated that the most common barrier was lack of research skills as being the most important barrier to using EBP. The next two highest rated barriers that were rated as significant barriers were lack of understanding of statistical analysis and inability to apply findings to individual patients having unique characteristics [33]. Hannah C, [34], conducted a survey among the members of the Malaysian Physiotherapy Association and other practicing therapists in Malaysia to identify the knowledge, attitude, and barriers toward the implementation of EBP among physiotherapists. Time constraints, limited access to databases, and lack of generalizability of studies result are the three major barriers to implementing EBP [34]. Another survey carried out in Pakistan identified lack of availability of resources to access information as the biggest barrier followed by lack of time and lack of support among physiotherapists [35]. In a well-conducted study carried out in New South Wale, United Kingdom, 60% of survey participants reported that perceived impacts on the therapeutic alliance is a barrier to applying evidence, followed by skills and environmental context and resources [36]. These reported barriers are similar to those reported from other similar studies conducted by other healthcare disciplines such as nursing [37, 38, 39, 40, 41], internal medicine [42], emergency medicine [43], and dentistry (Table 2) [44].

Domain	Barrier	Facilitator
Competence/skills	Lack of knowledge, education, routine, and experience; Diagnosis focused on International classification of function domain: body functions	Sufficient knowledge and education; Measurement instruments are already used in daily routine
Attitude	Resistance to change; No conviction of additional value on the plan of care; Being overloaded with information	Readiness to change; Positive attitude toward the use of measurement instruments; Conviction of contribution to quality of physical therapy care
Practice	Takes too much time; Absence of practice policy	Patient computer system; Presence of practice policy
Colleagues	Lack of discussions, meetings, and feedback from colleagues; No adherence to the agreements made	Regular meetings and feedback from colleagues; Innovative teamwork and cooperative colleagues
Patient	Different expectations and preferences: needs no measurement instruments, wants only therapy, and puts pressure on therapist	Patient wants objectives to evaluate outcome of therapy
Measurement instrument	Poor availability; Difficult choice; Feasibility: extensive, difficult interpretation, and unclear instructions	Good availability

Table 2.

Stevens, J. G. A., identifies some physical therapist barriers to and facilitators of the use of measurement instruments.

4. Audit of clinical practice in physiotherapy

Audit of treatment is an accepted technique for assessing the effectiveness and efficiency of a practice as well as the accuracy of record keeping that should be based upon high-quality clinical research. A clinical audit is an approach of quality improvement that strives to enhance patient care and outcomes by a systematic evaluation of treatment based on specific criteria. Changes will be undertaken as appropriate, and additional monitoring will be employed to validate healthcare improvements [45].

4.1 Why audit the clinical practice?

Clinical auditing is a valuable tool for assessing and enhancing patient care, maintaining professional standards, and promoting ethical practices. Healthcare professionals can use this approach to identify and track areas of risk in their services. Additionally, auditing fosters a culture of quality improvement within the healthcare industry, increases job satisfaction, and improves healthcare quality and efficiency. Completion of the audit cycle establishes the effectiveness of the audit in improving the care of patients [46]. The practice audit can be carried out by the individual clinician; however, it is better to have someone else collect the data methodically and without bias. The patient’s physiotherapy record is the primary source of data that the auditor examines to check if the practice recorded tallies with set evidence-based criteria. If there was a discrepancy between the practice and the criteria, an action plan should be implemented against the established discrepancies. Repeating the audit cycle is mandatory to ensure adherence is greater.

The cyclical process of clinical audit can be outlined in five stages.

• Planning for audit

• Setting standards/criteria

• Measuring performance

• Making improvement

• Sustaining Improvement

Stage 1. Planning for audit: The success of an audit project’s outcome depends on proper planning and preparation. In this stage stakeholder engagement, choosing the audit topic and planning the delivery of audit fieldwork are crucial for the success of the audit [45].

Stage 2. Selection of standards and criteria: Following the selection of the audit topic, the next critical step is to analyze the available evidence to define the standards and audit criteria against which the audit will be conducted. Evidence-based standards are preferred [47].

Stage 3. Measuring performance: This stage involves collection of data, analysis of data, drawing conclusions, and presenting results. It is essential that the data collected during a clinical audit is accurate and relevant to the audit being conducted. The audit team should specify and approve the data source. Deciding which source to use depends on various factors, including accessibility, accuracy, and completeness [48].

Stage 4. Making improvement: Changes should be put into effect in this stage, and to ensure that necessary changes are made, all effective audit programs must include a program of change activities and post-identification of the audit results to ensure that the required changes take place [49].

Stage 5. Sustaining improvements is also crucial: This stage involves monitoring the quality improvement plan, performance indicators, dissemination and celebrating success, and reauditing. The audit cycle is a continuous process that involves two data collections and a comparison of that data after the change has been implemented after the first data collection to determine whether the desired improvements have been achieved (Figure 2) [50].

Figure 2.

Cycle of clinical audit.

5. Conclusion

Measurement is a fundamental component of evidence-based physical therapy that provides most of the essential information clinicians need to make decisions in patient management. Effort to enhance the utilization of outcome measure in physiotherapy practice through the use of best available research evidence have resulted in the wide spread use of the term “evidence-based practice.” Physiotherapists should be better equipped to integrate data from high-quality research with patient preferences and professional expertise.