Evidence Based Practice

Has evidence based practice taken over our clinical reasoning?

How often do we see a new par­a­digm break through the world of exer­cise and rehab with mar­ket­ing and sen­sa­tion­al­ized hype? They some­times break into our gyms, clin­ics and hos­pi­tals with lit­tle evi­dence of sound research. We are taught to insist upon a clear clin­i­cal rea­son­ing that is fol­lowed up with research to objec­tive­ly test the par­a­digm. But should we imple­ment these par­a­digms or treat­ment with­in our pro­fes­sion before we read the research? I will go out on a limb. To hell with Evi­dence based prac­tice’. Sound harsh? Sound dangerous?

To hell with evi­dence based practice

Con­sid­er mir­ror ther­a­py, which was ini­tial­ly a cre­ative clin­i­cal­ly rea­soned treat­ment and now has a body of grow­ing evi­dence for periph­er­al nerve injury and stroke. There may have been many skep­tics of the prac­tice before there was any research to sup­port its use. Was it uneth­i­cal to use prism glass­es or a mir­ror box before there was research to sup­port it?

What about all the peo­ple who were helped by the prac­tise before it became evi­dence based’? Would you deny them the treat­ment if you had the chance to treat them? I think it’s time to jump off the pedestal. If exer­cise pro­fes­sion­als did not clin­i­cal­ly rea­son new ideas that are out­side the box’ would there ever be new ideas and modal­i­ties to help peo­ple? Let’s remem­ber, the ideas for research don’t come from research. They come from cre­ative and inno­v­a­tive ther­a­pists and exer­cise pro­fes­sion­als who step out­side of the box in a clin­i­cal envi­ron­ment. Once pop­u­lar­i­ty is gained, sci­en­tists con­duct research.Are we oth­er­wise at risk of stand­ing still as a pro­fes­sion and only using the same treat­ments which are evi­dence based? We could end up with a pro­fes­sion that become a self lick­ing lol­ly­pop, not allow­ing any­thing new into the par­ty! What’s more, I don’t think exer­cise pro­fes­sion­als were unsafe or uneth­i­cal before the advent of evi­dence based practice’?

If we only use evi­dence based meth­ods, are we being uneth­i­cal by refus­ing treat­ments that are known to be effec­tive sim­ply because they have not been researched? If there is con­flict­ing research for a par­a­digm or treat­ment does this mean that we must not use a treat­ment tech­nique since the evi­dence is con­fus­ing? How purist should we be about the use of Evi­dence based prac­tice’? Only use treat­ment tech­niques or meth­ods that have been approved by the Cochrane review?

Inter­est­ing­ly, I wish you to explore your con­science. Is every spe­cif­ic man­u­al treat­ment you use for the foot or ankle joint researched? Is every exer­cise you pre­scribe such as a dead­lift researched for every con­di­tion that presents to you? I won­der how evi­dence-based’ our prac­tice is if we scru­ti­nize it? So why do we hear such chap­ter & verse’ with­in the med­ical and exer­cise pro­fes­sion about being evi­dence-based’?

How can we main­tain a bal­anced perspective

I was involved in a jour­nal club today that had been orga­nized by a col­league after attend­ing a run­ning re-edu­ca­tion’ course recent­ly. She had found the course con­tent to be out­dat­ed since fore­foot, mid foot, pros­thet­ic run­ning re-edu­ca­tion has been researched for near­ly 10 years. The assess­ments used in the course seemed plucked out of the air, lack­ing any real rea­son­ing or evi­dence. It seemed not to fit with any par­tic­u­lar rea­son­ing or ratio­nale. Yet it was alleged­ly backed up with research’.

The course seemed to base its beliefs on a research jour­nal, which we lat­er cri­tiqued in our depart­ment jour­nal club. The jour­nal in ques­tion was a meta-analy­sis of how injuries are affect­ed by dif­fer­ent kinds of exer­cis­es. For those of you that are not well versed with research, that sim­ply means that the authors gath­ered as many research papers that they could, to pro­vide a sum­ma­ry of the evi­dence. This in itself is open to vari­a­tion as two authors could read and inter­pret the same research paper in dif­fer­ent ways. The Cochrane Library works on a sim­i­lar prin­ci­ple yet is very strict on which arti­cles it allows to be used in its collaborations. 

The qual­i­ty of the research is scru­ti­nized to ensure only high qual­i­ty jour­nals are used to inform the Cochrane sum­ma­ry. Unfor­tu­nate­ly, the Cochrane reviews on top­ics of rehab, exer­cise and mus­cu­loskele­tal med­i­cine don’t even get that far. This is because the research with­in mus­cu­loskele­tal med­i­cine and exer­cise often use poor meth­ods or are untrust­wor­thy with biased sta­tis­tics. The Cochrane Library can not trust their find­ings. The risk and the dan­ger as far as evi­dence based-prac­tice’ is con­cerned may be that exer­cise and med­ical pro­fes­sion­als are incor­rect­ly edu­cat­ed by research. So we must be care­ful how much faith we put in many of the jour­nals or best prac­tice path­ways’ that we use to under­pin our work. If the jour­nals have not made it into a Cochrane review, we must be care­ful of how attached we become to our own beliefs.

So how can we main­tain a bal­anced perspective?

The par­tic­u­lar meta-analy­sis that was used to under­pin the run­ning re-edu­ca­tion course made many con­clu­sions and it is very easy to be drawn into believ­ing absolute­ly every con­clu­sion made by a research paper with­out under­stand­ing, or apply­ing the find­ings with­out rea­son­ing. An exam­ple of this can be seen in the con­clu­sions drawn from the evi­dence sur­round­ing stretching/​flexibility train­ing. Most evi­dence on stretch­ing is involved with pre-exer­cise stretch­ing. There is very lit­tle evi­dence as to the effect of a long term stretch­ing pro­grams on strength, pow­er, injury, mus­cle length etc. The meta-analy­sis in ques­tion insin­u­ates that stretch­ing of all kinds is not effec­tive for run­ning and injuries.

Is this short sight­ed? What about sep­a­rate flex­i­bil­i­ty train­ing ses­sions? Can they help and if so how? What evi­dence exists for long term flex­i­bil­i­ty train­ing for injury and the per­for­mance of running?

Is it clin­i­cal­ly effec­tive In the form of yoga, fas­cial stretch­ing, sta­t­ic or dynam­ic stretch­ing? What if the evi­dence hasn’t cap­tured such results?

Anoth­er dan­ger of adher­ing to best prac­tice’ path­ways and evi­dence-based guide­lines is that it risks reduc­ing a very com­plex process into an over-sim­pli­fied recipe’. For those phys­io­ther­a­pists who like to oper­ate in recipes’, there is a risk that an assess­ment can look for the signs, symp­toms and objec­tive tests to con­firm that our recipe is cor­rect, rather than assess­ing each knee as being dif­fer­ent and in need of dif­fer­ent man­age­ment from the last client.

Should we ever allow Evi­dence-based prac­tice’ to stand in the way of sound clin­i­cal reasoning

On a per­son­al note, I am always skep­ti­cal of lis­ten­ing to peo­ple that sell their beliefs by dis­cred­it­ing oth­er approach­es, and speak with­out detail or evi­dence. We have to con­sid­er the evi­dence by assess­ing its qual­i­ty and the clin­i­cal rea­son­ing we use when pre­scrib­ing exer­cise or giv­ing treatment.

To end on a philo­soph­i­cal note, I won­der whether we should ever allow Evi­dence-based prac­tice’ to stand in the way of sound clin­i­cal reasoning?