Evidence Based Practice

Evidence Based Practice

Has evidence based practice taken over our clinical reasoning?

Evidence Based Practice

Has evidence based practice taken over our clinical reasoning?

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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?

David Barrow


David is a Physiotherapist who has been involved in Professional Sport, battlefield trauma, chronic pain and the NHS. He continues to work clinically alongside his development role in Rehab Guru. David is passionate about Health tech to transform outcomes for patients