“We can't have full knowledge all at once. We must start by believing; then afterwards we may be led on to master the evidence for ourselves.” —Thomas Aquinas
When I was a physical therapist student in the early 1970s, we were required to conduct a research project. I compared forced passive stretching with “contract-relax,” a proprioceptive neuromuscular facilitation technique, for reducing tight hamstrings and used my classmates as experimental participants. In seeking a rationale for the two intervention techniques, I did not go to the literature to determine which technique was more effective—there was none. I went to the library with my 3 × 5 cards and abstracted results from the basic science literature, which discussed theory related to how the Golgi tendon organ and the muscle spindle worked using evidence from experiments in animal models. My purpose in writing the review of the literature was to “guess” how the two receptors worked in the human body when the techniques improved the passive range of motion at the knee. In the classroom, we were introduced to treatment techniques with no thought of evidence to support one technique over another. Instead, we were given a “bag of tricks,” and we were told that experience and master clinicians would help us to identify the most effective intervention to achieve our treatment goal. There was no emphasis on consensus as to the best intervention; the emphasis was on our ability to decide what was right. But, today, if physical therapists could agree on the best intervention rather than relying on their own opinion, a consumer would be guaranteed that the best intervention would be offered regardless of which physical therapist provided care.
Now we almost suffer from the opposite problem I faced when I was completing my master's thesis; we have a plethora of evidence! And yet, during his address to congress on behalf of people with disabilities, the actor Michael J. Fox said that if you ask people what their favorite therapy is, they will tell you it is the one that works (http://ptwa.org/Content/Legal/EBP.htm).
Wouldn't it be wonderful if we all selected the same intervention, and it worked? Physical therapists have to reduce unnecessary variation in practice so that they can determine if what the literature indicates is the “best” is in fact the most effective. Imagine a time when our patient records are collected in a common database and that we are all using the same outcome measures. We will then be able to determine if the intervention is effective, if the intervention works only in certain conditions and what they are, if there is residual disability, and if the “best” needs to be better. Clinical decision making is not removed from the therapist who selects the “best practice.” The decision making is focused instead on making an accurate diagnosis; classifying the impairments into a set and matching the best intervention with the classification is where we should be honing our expertise. How do we get there in the absence of “best practice” guidelines? We search the literature.
How does a clinician choose within the evidence to select an examination tool or an intervention that will help a patient achieve a goal effectively and efficiently? What sources should be trusted? How do we help patients understand why we have selected one intervention instead of their “favorite”?
I would like to write that all that you have to do is read Physical Therapy (www.ptjournal.org). As I am Editor-in-Chief, I know that the editorial board, reviewers, and staff work diligently to provide a venue with immediate clinical relevance. Unfortunately, we do not have all the information that all practitioners need. At this time, there are more than 23,000 biomedical journals. The United States National Library of Medicine at the National Institutes of Health publishes a free database, PubMed (http://ncbi.nlm.nih.gov/pubmed/). Using the Medical Literature Analysis and Retrieval System (MEDLINE), a bibliographic database of life science and biomedical information, PubMed has 21 million citations. Where does one start? You could also use CINAHL (http://ebscohost.com/biomedical-libraries/thecinahl-database), a cumulative index for nursing and allied health literature that provides indexing for more than 3000 journals. MEDLINE and CINAHL can provide access to original research, but what if you want assistance in reviewing the articles? There is PEDro (Physiotherapy Evidence Database), (http://pedro.org.au/) produced by the Centre for Evidence Based Physiotherapy at The George Institute for Global Health in Australia, a free database of over 22,000 randomized trials, systematic reviews, and clinical practice guidelines in physiotherapy. There is also The Centre for Evidence Based Physiotherapy, based in Maastricht, Netherlands (http://cebp.nl), whose mission is to seek, collect, and disseminate available scientific evidence in the physiotherapy domain for physiotherapists, health care workers, patients, and financiers of health care. This Web site has over 2500 white papers, all free. As well, there is Hooked on Evidence, (http://hookedonevidence.org), produced through the American Physical Therapy Association. This database does not restrict itself to randomized controlled trials; it includes clinical trials, cohort studies, case-control studies, case reports, single-subject experimental design, and cross-sectional studies. There are also disease-specific Web sites, such as Stroke Engine (http://strokengine.ca/about.html) developed by the Canadian Stroke Network that provides information on the effectiveness of over 35 interventions used in stroke rehabilitation, including Canadian Best Practice Recommendations for Stroke Care. International best practice guidelines, practical guides, e-learning modules, and pocket guides are also included to assist clinicians. StrokEngineAssess provides information on over 60 assessments related to stroke.
Suppose you want someone else to synthesize the work and provide you with a summary of multiple trials conducted on a particular intervention? The Cochrane Collaboration is an international network of more than 28,000 dedicated people from more than 100 countries. This team helps health care providers, policy makers, and patients and their advocates make well-informed health care decisions by preparing, updating, and promoting the accessibility of the Cochrane Reviews (http://cochrane.org). There are over 5000 so far. In 1997, the Agency for Health Care Policy and Research (AHCPR)—now the Agency for Healthcare Research and Quality (AHRQ)—launched an initiative to promote evidence based practice in everyday care through the Evidence-based Practice Center (EPC) Program (http://ahrq. gov/clinic/epc/). The EPCs develop evidence reports and technology assessments on topics relevant to clinical and other health care organization and delivery issues, specifi cally those that are common, expensive, and/or significant for the Medicare and Medicaid populations. Within the Effective Health Care (EHC) Program, EPCs conduct comparative effectiveness reviews, effectiveness reviews, technical briefs and future research needs reports, focused on patient-centered outcomes.
The amount of available information is daunting. But we have no choice, in my opinion, other than to search for the optimal method to produce the most eff ective outcome. It is not only a professional responsibility; it is a mandate. Third-party payers have access to the same information that we do; if we select an intervention because it is “what everyone else is using,” we may not get reimbursed if there is evidence that the intervention is not effective. I believe that resources such as PTNow (http://apta.org/ptnow/) will provide quick and evidence based answers to clinical questions. This portal will answer a question such as “What is the most effective intervention to treat a grade III ankle sprain?” I believe that you will be able to access an answer to your question from a hand-held device during a treatment sessions.
We do not have access to this type of answer right now. While we await tomorrow's technology, we have to design effective plans of care today. The authors of this textbook have a commitment to helping you find the best evidence to assist you with clinical decision making. They have explored each of these topics in depth to help you make the best possible clinical decisions. They have also placed the evidence in the context of your clinical judgment and your patients. As theologian Thomas Aquinas suggested, you have the belief ... now seek evidence to support or refute that belief.
Rebecca L Craik, PT, PhD, FAPTA
Department of Physical Therapy