Evidence Based Practice(EBP) in Physiotherapy

Original Editor - Sheik Abdul Khadir

Top Contributors - Sheik Abdul Khadir, Scott Buxton, Redisha Jakibanjar, WikiSysop and Vidya Acharya  

 Introduction 

Evidence based practice (EBP) is 'the integration of best research evidence with clinical expertise and patient values.  Evidence Based Practice (EBP) describes about  the steps involved and the problems with EBP. Physical therapy being the widely recognised health care profession has to upgrade its method of practice to remain alive in the era of scientific research.As the number of physiotherapy trials and systematic reviews increase, we could hope that we are developing a robust evidence base to inform patient care.

Anecdote to Evidence

Anecdote and word of mouth have lost credibility and are replaced by scientific scrutiny and the rigour of evidence from carefully controlled and sufficiently powerful trials. The evidence-based practice (EBP) movement has gained ground steadily in physiotherapy over the past decade.Influential researchers and clinicians have argued that physiotherapists have a moral and professional obligation to move away from assessment and treatment methods based on anecdotal testimonies or opinion. 

Paradigmal Shift

The EBP or the scientific research has brought quite a few paradigmal shifts in the field of physiotherapy and its practice. Some of them to mention includes:

1. Strengthening Exercise in Cerebral palsy : A widely used physical therapy intervention for children with cerebral palsy (CP) has been based on the Bobath neurodevelopmental treatment (NDT) approach.This approach focused on consideration of abnormal tone and postures during treatment and interventions were not based on scientific research. The use of strengthening exercises was strongly discouraged by proponents of the approach because they believed that excessive effort would increase co-contraction, spasticity, and associated reactions. The rationale for the NDT approach was based on a reflex-based or hierarchical view of motor control. It was felt that the patient's primary problem in producing a voluntary movement was antagonist restraint, not agonist muscle weakness. Emphasis was placed on interventions to prevent abnormal postures and excessive muscle co-contraction. Clinicians following this treatment approach avoided exercises with maximum efforts in people with the spastic form of CP.

Shift :  Investigators have demonstrated the benefits of strengthening exercises in individuals with CP. Improvements in muscle performance have been demonstrated for people with CP using isometric exercise,isotonic exercise,isokinetic exercise and a combination of isotonic exercise and weight machines.The finding refutes the premise that the performance of exercises with maximum efforts will result in a large, or detrimental, increase in spasticity. Damiano et al  suggests resistance exercise is an effective treatment strategy and as such should be considered as one component in the habilitation of children with cerebral palsy.

2. Bed rest for Back ache : Bed rest is a traditional treatment for back pain, yet only in recent years has the therapeutic benefit of this been questioned. The most common management of back pain and sciatica is to prescribe analgesics and advise rest, and to treat acute attacks with bed rest. This recommendation is based on orthopaedic teaching, but there are increasing doubts and dissatisfaction with this kind of management.

Shift:   Two key trials by Gilbert et al  and Deyo et al first showed that longer periods of bed rest have no advantage compared with shorter periods. The 1994 clinical guidelines recommend that bed rest should be for short periods of 2-4 days, and they still advise activity limitation. More recently, even short periods of rest have come under question.Bed rest does not improve symptoms any more effectively than other treatments, but does produce a number of adverse effects including joint stiffness, muscle wasting, loss of bone mineral density, pressure sores, and venous thromboembolism.

3. Early Mobilisation in Intensive Care setting : Attempts at full active mobilization are often reserved until after the acute phase of the illness has resolved. In particular, it is recognized that rehabilitation may not commence until after ICU discharge, as the patients are viewed as too sick to participate whilst receiving mechanical ventilation. These traditional practices are not based on high-quality evidence and are simply derived from expert opinion.

Shift :  Joseph Adler and Daniel Malone (2012) conducted a systematic review on the effect of early mobilisation and concluded literature supports early mobilization and physical therapy as a safe and effective intervention that can have a significant impact on functional outcomes such as muscle strength, functional mobility, quality of life and patient symptoms. 

Barriers

A recent systematic review analysed "What do physical therapists think about evidence-based practice?"  and concluded that the barriers most frequently reported were:

• lack of time,
• inability to understand statistics
• lack of support from employer
• lack of resources
• lack of interest and
• lack of generalisation of results.

Although the majority of physiotherapists have a positive opinion about EBP, they consider that they need toimprove their knowledge, skills and behaviour towards EBP. 

Limited research in some areas of physiotherapy also constitutes an obstacle to practising evidence-based physiotherapy (Fruth et al 2010).

Facilitators 

Some authors express the influences on EBP in physiotherapy as facilitators rather than barriers. For example, Bridges et al (2007) identified several personal characteristics that may facilitate EBP:

• self-directed learning,
• a postgraduate degree, 
• a belief that research (particularly in a digested format such as clinical guidelines) can be used in everyday clinical decision-making without interfering with productivity and an efficient patient flow, and
• nonconformity, ie, not being afraid to diverge from traditional or common practice if newer research reveals more effective methods. Salbach et al (2011) identified online access to research summaries and systematic reviews as a potentially important facilitator because this can save time to search and critically evaluate research articles.
  

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