Stages of Evidence Based Practice in Physiotherapy

Abstract

Each physiotherapist carries the ethical duty to practice in a holistic manner, ensuring that treatment approaches are firmly grounded in the most up-to-date evidence. Consequently, the primary objective of this chapter is to provide a comprehensive exposition of the essential stages that physiotherapists ought to adhere to when addressing patients with deformities. Additionally, it seeks to empower physiotherapists by offering practical insights into formulating precise and pertinent queries during patient interactions. This includes effective strategies for sourcing and evaluating evidence, which can then be judiciously applied to inform optimal decisions regarding patient care and treatment strategies. Throughout the course of this chapter, I will illustrate these concepts through the lens of a stroke patient scenario, facilitating a more accessible grasp of the material. However, it is crucial to note that the insights and instances presented within this chapter possess applicability that extends to various other neurological conditions within the domain of physiotherapy.

1. Introduction

1.1 Meaning of evidence based practice

Evidence-based practice (EBP) holds a crucial role in the fields of rehabilitation and physiotherapy, progressively gaining significance. EBP is defined as the dedicated use of the most reliable evidence available to guide decisions regarding individual management, involving a fusion of clinical expertise, professional judgment, and systematic research [1]. Sackett et al. [2] further refined the concept, describing it as the fusion of top-tier research evidence, clinical proficiency, and patient preferences. The National Institute of Public Health (NIPH) in 1996 characterized evidence-based as the latest credible facts derived from pertinent, valid research. These encompass the effects of healthcare approaches, potential treatment risks, diagnostic precision, and prognostic foresight [3].

In essence, evidence-based practice in physiotherapy encompasses a methodical process of locating, evaluating, and applying current preeminent evidence to guide clinical actions. Practicing evidence-based physiotherapy involves integrating contemporary research findings with clinical skill and patient values, resulting in the most pertinent and effective care [4]. Despite its evident benefits in physiotherapy and broader healthcare, the adoption of EBP remains inconsistent in terms of quality [5]. Researchers and clinicians have voiced concerns about the compatibility of EBP elements and the scarcity of relevant, substantiated research [6, 7]. Bridging the gap between research and clinical insights can heighten the competence of physiotherapists’ practice [8], guarding against inappropriate healthcare utilization [9].

Given the rising accountability of healthcare professionals, including physiotherapists, this framework gains significance as a guiding principle. Some argue that a moral obligation exists for practitioners to base decisions on research findings [7]. Physiotherapists can enhance patient management outcomes by integrating three distinct forms of evidence into their decision-making process.

1.1.1 Scientific research

Scientific research stems from rigorous hypothesis testing and observation, providing valuable experiential insights. When communicating research evidence to patients, it’s essential to use clear and straightforward language and encourage open-ended questions to ensure patient comprehension. Physiotherapists are responsible for identifying, evaluating, and summarizing research evidence pertinent to patient care.

1.1.2 Clinical expertise

Clinical expertise encompasses both implicit and explicit knowledge gained from experience in diagnosing, intervening, preventing, and predicting outcomes for patients with physical conditions. This knowledge is accumulated over time and contributes to refining patient care.

1.1.3 Patient values

The foundation of decision-making and management lies within the caregivers, patient relatives, and the patients themselves. Patient values can be categorized as values and circumstances. Values include the patient’s beliefs, preferences, expectations, and cultural identity, which significantly influence their life choices and decisions [10].

In the original framework (depicted in Figure 1 above), to summarize, the most reliable evidence often emerges from clinically significant research carried out with robust methodological procedures. Clinical expertise encompasses the amassed knowledge, experience, and clinical skills of the Physiotherapist. Patient values encompass the distinct preferences, concerns, and expectations that each patient brings when engaging in a clinical interaction. The integration of these three elements constitutes the foundation of making evidence-based clinical decisions [11].

Figure 1.

Evidence based medicine (EBM).

2. Aim of evidence based practice

The primary goal is to empower healthcare professionals, including Physiotherapists, to make well-considered choices regarding clinical practice by employing the ‘thoughtful, clear, and prudent utilization of the most current and reliable evidence within the healthcare system’ [11].

3. The stages of evidence-based practice (EBP)

In their work [12], a set of six stages outlining evidence-based practice was delineated. Physiotherapists are advised to adhere to these stages in order to provide optimal care for their patients (Figure 2).

Figure 2.

Stages of EBP.

3.1 How to formulate a clear and answerable clinical question

The time allocated for assessment and diagnosis in a clinic is often limited for a Physiotherapist. As a result, efficiently searching for the most suitable available evidence requires mastering the skill of formulating well-structured questions within a short timeframe. Questions posed by a Physiotherapist to their patients can be categorized into these groups [11]:

1. Etiology: How can I identify potential causes of a problem? For instance, what leads to limited shoulder range of motion among stroke survivors?

2. Assessment/Diagnosis: What crucial information should I collect? How can I obtain that information and correctly interpret the results? For example, what’s the optimal method for evaluating balance in stroke patients?

3. Treatment: Which intervention or procedure will be most beneficial for my patient? For instance, what are the outcomes of applying the Proprioception Neuromuscular Facilitation concept in post-stroke patients compared to other physiotherapy approaches?

4. Prognosis: What’s the recovery pattern over time and what potential complications might arise? As an illustration, if my patient had a stroke two months ago, when can they expect to regain independent walking ability?

5. Prevention: How can I avert emerging problems and enhance my patient’s well-being? As an example, what’s the most effective approach to prevent shoulder pain in post-stroke patients?

6. Differential diagnosis: When symptoms point to various potential diagnoses, how do I determine the most probable one? For example, in a young man with knee swelling, stiffness, pain, crepitus, quadriceps atrophy on examination, pain on palpation, and resistance during extension, what’s the likely underlying cause?

3.1.1 PICO framework

The PICO framework holds great importance in shaping a precise question. This framework identifies and outlines the crucial components of a well-organized question. It’s important to remember that a focused question should address a single issue at a time (Figure 3 and Table 1).

Figure 3.

PICO framework.

		Example
Patient population or relevant issue	What is the specific disease or condition under consideration?	A 60-year-old woman dealing with shoulder pain post-stroke
Intervention	What particular treatment, modality, or procedure is being focused on?	Transcutaneous Electrical Nerve Stimulation (TENS)
Comparison	What is the alternative to the current treatment being administered? For instance, placebo or medication.	Non-steroidal anti-inflammatory drugs
Outcome	What are the goals in terms of measurement, enhancement, or impact?	Reduction in the level of experienced pain

Table 1.

Using the PICO framework to develop a clear question.

An example of clinical question from the above table could be ‘Is TENS better than non-steroidal anti-inflammatory drugs at reducing the intensity of post stroke shoulder pain?’

3.2 Searching and finding the best evidence

Once you have carefully formulated a precise clinical question addressing the disease or condition presented by your patient, your next step involves sourcing the most reliable evidence to address this query. A range of resources exists to aid your quest for answers. These encompass personal experience, logical reasoning, and intuition, inquiring with a fellow practitioner, referring to textbooks, accessing pertinent scientific papers from your personal collection, utilizing bibliographic databases such as Medline or Embase, and consulting literature that’s clinically assessed or grounded in evidence, along with established healthcare guidelines.

However, a caveat exists when relying on personal experience and subjective opinions. Such an approach might not yield the most efficient, effective, and economically viable treatment pathways. Conversely, seeking advice from a seasoned colleague can be an expedient approach, especially when grappling with unique or infrequent scenarios. It’s worth noting that textbooks, while informative, often become outdated even before their publication, necessitating a cautious approach when consulting them.

The specific type of evidence you seek hinges on your question’s scope. Navigating the different types of research available will direct you toward attaining the utmost level of evidence relevant to your specific clinical inquiry. By discerning the nature of your question, you can methodically select the research avenue that aligns with your inquiry, leading you to the most robust evidence available to inform your clinical decisions effectively and accurately.

3.2.1 Levels of evidence

‘Levels of evidence’ refer to frameworks for categorizing research designs. These systems rank research designs based on intervention assessment, evaluating their reliability, validity (protection against bias and error), and truthfulness. Systematic reviews, meta-analyses of randomized controlled trials, and evidence-based clinical practice guidelines hold the highest status on the evidence hierarchy (illustratedas a pyramid in Figure 4), forming a robust foundation for treatment decisions. Conversely, expert opinion is widely considered the least robust evidence category in this hierarchy.

Figure 4.

Level of evidence pyramid.

3.2.2 Observational studies: Understanding research design

Research design encompasses two main approaches: qualitative and quantitative. Both methods, if properly executed, are rigorous and valuable for addressing significant clinical inquiries [13, 14]. Employing both designs within a single study is especially advantageous for extensive trials assessing clinical practices. This comprehensive approach is particularly beneficial for large-scale trials aimed at evaluating clinical practice.

3.2.3 Quantitative design

The quantitative design focuses on robustly examining hypotheses related to predefined variables. Examples of such designs encompass clinical trials, comparative studies, and epidemiological investigations. These studies primarily address queries like “whether” (evaluating whether Physiotherapy treatment yields more benefits than harm) and “how much” (measuring the strength of the correlation between a specific risk factor, like hypertension, and the occurrence of a particular disease or condition, such as stroke) [15].

3.2.4 Qualitative design

Qualitative studies delve into inquiries involving “how,” “what,” and “why” [15]. These studies often employ detailed interviews and focus group interactions to investigate and gain insight into “social, emotional, and experiential phenomena” within healthcare contexts. Examples encompass exploring the significance of the stroke experience for survivors and their families, offering a deeper understanding of these individuals’ perspectives.

4. Critical appraisal

Critical appraisal constitutes a crucial aspect of evidence-based practice (EBP), involving the meticulous and systematic evaluation of research evidence to gauge its credibility, significance, and relevance to clinical application [16]. It’s pivotal to recognize that diverse research designs entail distinct methodological procedures and levels of validity. This distinction underscores the significance of comprehending how findings can be translated into practical use within specific clinical contexts.

5. Implementing evidence-based into clinical practice

Incorporating optimal evidence-based practices into your daily routine as a Physiotherapist is challenging. However, identifying barriers specific to your setting can aid in devising a more efficient strategy, enhancing the likelihood of successful patient management [17].

6. Barriers to evidenced based physiotherapy

Barriers to evidence-based Physiotherapy can impede optimal patient care. The challenges of a busy clinical setting may make accessing current, relevant evidence difficult [18]. Reluctance to alter established practices in light of new evidence can impede progress. Limited familiarity with research resources and a lack of confidence in interpreting findings are common obstacles [19]. Moreover, the absence of conclusive evidence might discourage practitioners, though it should not deter them from engaging in evidence-based processes [20]. Overcoming these barriers through education, enhanced resource accessibility, and fostering adaptability is vital for advancing evidence-based Physiotherapy and ensuring informed, effective patient management (Table 2).

Barriers	Example
Structural	Policies and Financial disincentives
Organizational	Lack of staff skills, poor working environment or lack of equipment/diagnostic tools
Peer group	Local standard of care not standard
Individual	inadequate knowledge, quackery, attitudes or skills
Professional-patient interaction	Problems with information processing, lack of communication skills
Consumers	Wrong information and illiteracy

Table 2.

Barriers to implementing evidence-based practice [21].

7. Conclusion

Embracing evidence-based practice within Physiotherapy necessitates a resolute commitment to furnishing optimal care for patients. Amid the bustling hospital milieu, the initial stride toward effective evidence-based practice in Physiotherapy lies in discerning where to access the most current, fitting, and superior evidence, ideally in a readily accessible format. Equally vital is the determination and self-assuredness to recalibrate practices in light of evidence.

Occasionally, the sought-after answers to inform clinical practice may remain elusive. It’s essential to internalize that the absence of evidence does not imply an absence of impact. The absence of conclusive evidence should not hinder Physiotherapists from participating in the evidence-based process; instead, it should fuel the impetus to galvanize fresh research endeavors in pursuit of the requisite evidence within the domain of Physiotherapy. This resilience underscores the dynamic nature of evidence-based practice as a driver for continuous improvement and growth in the field.