Evidence Based Practice(EBP) in Physiotherapy
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. 
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.
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).
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.
Despite being the emphsis on EBP in recent years, it is to be noted that in Physiotherapy that almost all the clinical implications derived has conlicting evidences. The studies on core stabilization concept can be quoted here as an example. A recent study by Puntumetakul et al (2013) studied the "Effect of 10-week core stabilization exercise training and detraining on pain-related outcomes in patients with clinical lumbar instability" and concluded that core stabilization exercises provides greater training and retention effects on pain-related outcomes and induced activation of deep abdominal muscles in patients with clinical lumbar instability compared with conventional treatment. .However , a recent review suggests a contrast evidence of Stabilization exercises for patients with low back pain may help to decrease pain and disability.It may not be necessary to prescribe exercises purported to restore motor control of specific muscles. 
Thus the evidence based practice is just not to follow the derived implications from the studies but to critically appraise the evidences.The methodology, studied Population, Randomisation, Statistical analysis, clinical significance and the limitations of the study has to be critically appraised before accepting the conclusion. This demands the students in the health care profession to be confident in practising Evidence Based by the time they graduate. Nina R Olsen et al (2013)  did a a qualitative interpretive description on Evidence based practice in clinical physiotherapy education . They noted Four integrative themes emerged from the analysis:
- Attempt to apply evidence-based practice
- Novices in clinical practice
- Prioritize practice experience over evidence-based practice and
- lack role models in evidence-based practice.
Students tried to search for research evidence and to apply this knowledge during clinical placements; a behaviour that indicated a positive attitude towards evidence-based practice. At the same time, students were novices and required basic background information more than research information. As novices they tended to lean on their clinical instructors, and were more eager to gain practical experience than practicing evidence-based; a behaviour that clinical instructors and visiting teachers often supported. Students noticed a lack of an EBP culture. Both students and clinical instructors perceived a need for role models in evidence-based practice. The authors concluded that Clinical instructors are in a position to influence students during clinical education, and thus, important potential role models in evidence-based practice. Actions from academic and clinical settings are needed to improve competence in evidence-based practice among clinical instructors, and future research is needed to investigate the effect of such efforts on students’ behaviour.
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Recent Related Research (from Pubmed)
- Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS: Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71-2
- Alison Rushton,Mel Calvert,ChrisWright, Nick Freemantle;fckLRPhysiotherapy trials for the 21st century – time to raise the bar?; J R Soc Med 2011: 104: 437–441. DOI 10.1258/jrsm.2011.110109
- Karen Grimmer-Somers;Editorial — Incorporating research evidence into clinical practice decisions; Physiotherapy Research International;Volume 12, Issue 2, pages 55–58, June 2007
- Fowler EG1, Ho TW, Nwigwe AI, Dorey FJ ;The effect of quadriceps femoris muscle strengthening exercises on spasticity in children with cerebral palsy ;Phys Ther. 2001 Jun;81(6):1215-23.
- Diane L Damiano, Luke E Kelly and Christopher L Vaughn;Effects of Quadriceps Femoris Muscle Strengthening on Crouch Gait in Children With Spastic Diplegia; Physical Therapy August 1995 vol. 75 no. 8 658-667
- Waddell G1, Feder G, Lewis M.;Systematic reviews of bed rest and advice to stay active for acute low back pain.;Br J Gen Pract. 1997 Oct;47(423):647-52.
- Greg McIntosh, Hamilton Hall; Low back pain (acute);Clin Evid (Online). 2011; 2011: 1102.
- Carol L Hodgson,Sue Berney,Megan Harrold,Manoj Saxena and Rinaldo Bellomo; Clinical review: Early patient mobilization in the ICU; Crit Care. 2013; 17(1): 207.
- Joseph Adler, PT, DPT and Daniel Malone, PhD, MPT ; Early Mobilization in the Intensive Care Unit: A Systematic Review; Cardiopulm Phys Ther J. Mar 2012; 23(1): 5–13.
- Tatiane Mota da Silva, Lucíola da Cunha Menezes Costa, Alessandra Narciso Garcia, Leonardo Oliveira Pena Costa, What do physical therapists think about evidence-based practice? A systematic review, Manual Therapy, Available online 24 October 2014, ISSN 1356-689X, http://dx.doi.org/10.1016/j.math.2014.10.009.fckLR(http://www.sciencedirect.com/science/article/pii/S1356689X1400191X)
- Fruth, S.J., van Veld, R.D., Despos, C.A., Martin, R.D., Hecker, A. and Sincroft, E.E. (2010) The Influence of a Topic-Specific Research-Based Presentation on Therapists’ Beliefs and Practices Regarding Evidence-Based Practice. Physiotherapy Theory and Practice, 26, 537-557. fckLRhttp://dx.doi.org/10.3109/09593980903585034
- Per Nilsen and Susanne Bernhardsson; Towards evidence-based physiotherapy – research challenges and needs; Journal of Physiotherapy 2013 Vol. 59;143-144
- Puntumetakul R, Areeudomwong P, Emasithi A, Yamauchi J;Effect of 10-week core stabilization exercise training and detraining on pain-related outcomes in patients with clinical lumbar instability; Patient Prefer Adherence. 2013; 7: 1189–1199.
- Brumitt J, Matheson JW, Meira EP; Core stabilization exercise prescription, part 2: a systematic review of motor control and general (global) exercise rehabilitation approaches for patients with low back pain ;Sports Med Arthrosc Rehabil Ther Technol. 2010 May 31;2:13. doi: 10.1186/1758-2555-2-13.
- Nina R Olsen1,Peter Bradley, Kirsten Lomborg, and Monica W Nortvedt:Evidence based practice in clinical physiotherapy education: a qualitative interpretive description;BMC Medical Education 2013, 13:52fckLRhttp://www.biomedcentral.com/1472-6920/13/52