too much evidence?what about how we reason?

Hi people,

I am going to raise a point and many will criticize me probably saying I should know better but for evidence base practice sake, I will raise.
Here is a good topic for the research physio who is more qualitative than quantitative, First of all in recent times, the whole idea of evidence based practice has overwhelmed the profession. everything seems to be constantly researched and critically thought through and I know that is good, for one it makes certain that what we do is right, that we are able to do it in a lesser time and we are alot more sure of anything we do. My question is in the foreseeable future, when most things have been researched and majority of practices have answers to back them up, what happens to the clinical reasoning power of a fantastic physio?Arguably, clinical reasoning involves looking at the evidence however clinical reasoning involves foreward, backward and lateral thinking. forward thinking is in my own opinion aided by what we know, backward and lateral thinking mainly is about what we do not know and try to find answers for. intererstingly backward and lateral thinking is what makes the job exciting. if there are answers to most questions will we stop thinking?have we stopped thinking now? I read a few threads with some physios in the musculoskeletal and orthopedic scene trying some lateral thinking only they were thinking alongside things that have already been thought through.
With each epoch in the physio realm, more concepts will be question, new inventions will be made and the need for more research so one can say the process is not likely to end,but what is the situation now among physios who use evidence and those who do not? who thinks more? who is forced to reason out things more?

A qualitiative research or a survey may help answer this question. Semi structured interview or maybe a questionnaire will do the trick. I reckon a semi structured interview process with some rigorous grounded theory based discourse and content analysis will help us know what impact having the evidence is putting on physios ability to reason and critically look at issues.Do they just wait for the evidence and use it thoroughly without necessarily questioning it once if it is conclusive and unanimous?are they still able to look at conditions and treatment from a practical view anymore? we are thrown in an evidence based practice scene now but no one seems to know or is concerned what effects having too much evidence may be doing to physios generally. I know that with guidelines and the likes, most things can become routine. what is the long term effect of thinking like that?ummmmm....
let me know ur views guys and if anyone is interested in carrying out a study like that..holla at me

And of course the "super clinicians" are exactly that and are not spending time getting huge grants to make Evidence Based Practice (EBP) statements. Is therefore EBP by its nature simply a dilution at the far ends of excellence and a drifting back to the middle of the bell curve. Seems all so Western!

Too much evidence? yeah. Available to all or a large community of physios? No. That is why there is and will always be hope for that talented physio to reason and practice. Maybe not in major clinics where things are written in black and white but in small suberban clinics and centers.This is the kind of practice that may bring the next wave of evidence.
I don't believe EBP is at a peak or will reach a peak soon. Nobody can guess the effect of our interaction with other professions.

The mask of evidence based medicine.

As a frontline clinician, musculoskeletal specialist and educator for 20 years I,m becoming inceasingly concerned with the focus on evidence based medicine without discussion on the practical implications. As most of my working life has been in private practise there is no clearer feedback on patient satisfaction with the care they recieve - or not as the case my be! If we are really serious can we state with confidence that perhaps 20% of what we do is validated (for many different reasons). Is the practicle implication of waiting for evidence to withdraw treatment or simply use common sense to assess the response to intervention? It seems a very simple argument to me but we either are helping a patient achieve their obective or we're not. If we're not then maybe we,re doing the wrong thing, maybe someone else can help or maybe there is nothing else to be done. However not to "try " largely depends on whether the motivation is to reduce waiting lists, save budgets, reduce insurance payouts, or disguise clinical inadequacy to manage the situation. These issues need some serious discussion before we submerge in analysis at the expense of improving patients wellbeing (by mutual assessment) which is our "raison d'etre". We will, struggle without patients and they may well struggle without our relevant expertese.

David

I think it is vital this topic is debated as it is critical to the expansion of our profession. The concept of EBP should be understood by all clinicians. EBP is not, for example, simply reading an article on the effect of mobilisations on LBP and either applying or not applying this intervention based on the outcomes of the study. Any treatment must apply three critical components to be effective EBP:
1. Available research
2. Clinical expertise and experience
3. Patient preferences

Experienced clinicians know what works for their patients. Studies have many characteristics that will mean their applicability to your practice is reduceed. Randomised controlled trials by definition remove a significant amount of clinical reasonoing by applying an intervention to an entire population of people with LBP for example. Rarely do we apply a single intervention on a given occasion of service, as is the case for most studies.

Clinicians must keep abreast with current clinical research, or risk being left behind.
However, it is only part of the process to practice EBP.

http://pkuebm.bjmu.cn/files/EBM%20wh...20is%20not.pdf

Thankyou Mattsutt for being so succinct. Having practised physiotherapy for a long long time I have seen many buzz words come and go and entire treatment approaches (eg Brunnstrom, Bobath, Sahrmann, McKenzie) go from being right out in the forefront (as is EBP now) to quietly taking their place (or fading away) among the many other facets of treatment. At the moment, EBP is so in my face I find it to be like the proverbial elephant in the living room. Whichever aspect you look at it from is a little different, but you certainly can't ignore it. However, I find it stifling because it considers only those aspects of treatment that are rational, left brain oriented, reproducible, etc. In other words, it doesn't leave the living room and there isn't much room with the elephant there for anything else! Having taken a BSc in Mathematics and statistics etc before studying physiotherapy, I take a rather cynical view of some of the studies out there. In neuro terms I think of it as "splinter skills". I'm looking for courses that take a more open and expansive view of the whole person, not things that narrow my thinking and remove aspects of treatment that haven't been "proved" by research.
I believe the future is that of transformational healing, integrating the emotional/psychological aspects of healing with the physical - at present the EBP camp gives this no credibility but I am willing to bet that will be one of the next "renaissances", along with the explosion of multidisciplinary clinics, wellness centres, "alternatives" such as visceral manip, process acupuncture, craniosacral etc, for it has such profound and lasting effects.
However, it certainly isn't measurable, reproducible or standardised.

Things are not as simple as they seem,

For example drug companies significantly sway the medical community towards what is commonly described as 'over prescription'.

Much evidence is buried in dozens of research studies that are often overlooked or placed at the bottom of the hierarchy of evidence available.

Indeed, clinical reasoning, clinical scholars, and clinical application of treatment methods is significantly important in physiotherapy treatment. There is likely many patients that could benefit from intensive physiotherapy and never get the treatment they deserve.

I agree that EBP is much needed to substanciate our profession (yes in the USA we need to prove ourselves and everything about our profession to be considered equals in the medical world), however, many studies have a very small group number and are often a single subject study. It's like telling the physiotherapy community: "I tried this and it worked", which may or may not work for your client. Isn't this quite similar as having a conversation with a fellow collegue?
Just a thought!:D

Quote:

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Originally Posted by mattsutt

I think it is vital this topic is debated as it is critical to the expansion of our profession. The concept of EBP should be understood by all clinicians. EBP is not, for example, simply reading an article on the effect of mobilisations on LBP and either applying or not applying this intervention based on the outcomes of the study. Any treatment must apply three critical components to be effective EBP:
1. Available research
2. Clinical expertise and experience
3. Patient preferences

Experienced clinicians know what works for their patients. Studies have many characteristics that will mean their applicability to your practice is reduceed. Randomised controlled trials by definition remove a significant amount of clinical reasonoing by applying an intervention to an entire population of people with LBP for example. Rarely do we apply a single intervention on a given occasion of service, as is the case for most studies.

Clinicians must keep abreast with current clinical research, or risk being left behind.
However, it is only part of the process to practice EBP.

http://pkuebm.bjmu.cn/files/EBM%20wh...20is%20not.pdf

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good point...EBP is moving away from "experimentation"...

it just integrates the ideal practice shown by available evidence, and our own clinical expertise and experience (our own reasoning) for the best care of our patients.

hi friends
in this era of evidence based practise,we should be careful about the authencity of the researches published.since there is an increase urge to make more publications people may put up fake researches.what i am mean is a person with good statistical knowledge and reading related articles can come up with a research result-"cooked up study".
i personally know physios who does so and even got such a study published in an indexed journal.

it depends on the clinician if he will integrate the researches to his practice.

who will check the authenticity of a research is another thing...maybe it's the role of PT associations as to what research they can approve to protect the interest of the patients.

cooked up studies are a problem since the start of the literature, it all ends up to -you treating your patient.

I think that Evidenced-Based Practice has been misconstrued by many of the previous posters here. Below is a quote from David Sackett, who many consider to be one of hte biggest proponents of EBP.

"Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research."

Using EBP does not mean only employing interventions that have been subjected to the scientific rigor of a randomized, double-blinded, placebo controlled trial. It means using those interventions when that type of evidence exists. It also means using those interventions that are appliccable to a given scenario that exhibit the best available evidence. In the abscence of any applciable quality evidence, it means relying on your clinical experience and expertise.

Most importantly, employing EBP does not mean throwing all of your clinical reasoning skills out the window. EBP, when used as Sackett proposes allows Physical/physiotherapists to provide interventions that result in a better outcome in a shorter period of time for many of our patients. Sadly, many in our profession do not feel this way. They would rather rely on their past experience to drive their chosen interventions rather than use current evidence to do so.

I see a lot of therapists who ignore the evidence supporting use of spinal manipulation in the acute phase of local LBP, instead choosing to use interventions without documented efficacy. Likewise, many PTs don't use manipulation of the thoracic spine to address cervical pain. There are many other examples.

As a profession, we need to make sure we're using the available evidence, when it exists, rather than relying solely on past experience and the bias of our previous training ( McKenzie, Cyriax, Maitland, Kaltenborn, Osteopathic approach, etc.) Many of us are getting on the EBP bandwagon, but far too many of us dismiss EBP out of hand because it challenges us to treat patients in ways other than we were trained, i.e. manipulate rather than usemuscle energy techniques, etc.

I agree with the practical application of best available evidence.

However, I think much research remains to be completed that will examine the effects of previous therapies that still appear to be effective/non-effective.

For example, we know that just the way we think or perceive an event, or interact with a patient can significantly effect their stress/relaxation response, and subsequently the placebo, nocebo effects can far outweight the effects of treatment.

This is what happens in gr 5 chiropractic manipulations. Person has back pain, hey lets Crack that back, what happens the patient feels better, why does that happen, possibly because of release of Endorphins which is a measurable result due to treatment, but could also be theoretically improved vertebral alignment leading to improved efficiency of peripheral nerve pathways.

Definitely apply the best available evidence, but lets also reason as to why it works, what is occurring physiologically as well. If we don't have the evidence let us continue to question, refine, and discover what works. There is no limitation of creativity, at least I don't think so. But if the profession has to shift markedly to adapt to the demands upon evidence of proof of effectiveness then so beit, let's adapt.

EBP in now way limits, or suggests that we limit our pursuit of the reason "why" behind our interventions.

Also, there is a fair amount of evidence that now suggest that the success of gr. 5 mobilizations comes from a neurophysiological response. I think that the wholevertebral alignemnt theory is about dead in the water.

Good discussion so far.

Case in Point:

Pat Davies described what is now popularly known as Pusher Syndrome that occurs in right sided brain stroke.

Although her reasoning and evidence was incomplete regarding the 'whole picture' in these patients, this important case highlights the need for us to be able to both clinically reason, and ultimately justify the need for research in physiotherapy specific areas.

Pusher syndrome can now be significantly effected by physiotherapy treatment, shortening the symptoms from 6 months without therapy, to as little as a few weeks.

Evidence by researchers in Europe is painting a bigger picture regarding this topic, and if anyone gets to see the research studies you can really see the ingenuity in designing these studies (eg. light rods in a dark room, tilt chair etc.).

Reasoning should be used as the basis to enhance the research that we do.

Regards

I think so far this is a beautiful discussion. I would like to point out where EBP can also lead to. Everyone who is working within community and or elderly care has come accross falls tests and 2 in particular, Tinetti and Berg. These tests are generally known to the physios working in the NHS and since falls has become a big item to safe money, well if people don't fall, it has become a big item and everywhere we find questionairies and tests. And it is said Evidence Based Practice when used p.e. Tinetti. What exactly is evidence based in Tinetti? Simple if I do the test on patient A or another physio does the test on patient A the chance we will have the same results is p.e. 95% and is therefor reliable. But in fact Tinetti has (at least not 2 years ago) not proven to do what it is designed for, to predict the chance of falling! The other problem which arises is that a screening test is used to look if an individual is improving (Tinetti as Berg is only a screening tool) which as much as I am concerned is not acceptable. The physiotherapist who is using this tool is tempted only to use this Evidence Based tool and not look any further(because he/she is in the clear). With evidence based we could end up in a dead end street if we are not careful like having a cook book and we will never try new spices, new veggies and so on just because they are not in the cookbook (or old recipes neither).
And a last point since we have no clue what is really going on in the mind of people we will always be unable to understand fully why a treatment does work for A but not for B with the same symptoms (what do we really know about pain?)

neurospast -
Your statements actually make a significant point for EBP.

You state the Tinetti is an EBP tool, but then go on to state that has not been proven to have any predictive value for falls. As an EBP you realize that this tool has faults, i.e. no validity for the ability to predict falls, and are more than likely using other examination tools to help ascertain whether the patient you are examining is at a high risk for a future fall. This is the way an evidence-based practitioner works - they are familiar with the measurement properties of the tests they use, and use other additional test when appropriate. When there is a lack of evidence to support any test, they use their clinical reasoning to determine the apporiate way to predict, in this case, the liklihood that a patient will experience a fall.

jesspt,
You should have read on and you would have understood what I am trying to say. Tinetti was a real example of how things can go wrong and we are just at the beginning of evidence based. I used as well pain as an example which we still have no clue of and already with a simple test as Tinetti we as a community go wrong well that does promise a lot of good wouldn't you say? i try to prevent to go into how it should be I look at how it is. Humans cannot be put into research and if someone can massage the results on anti depressants which is far easier to research than whatever we do what do you expect of our so called evidence based? Why do we still use Bobath as far as I know it is not the best method to treat CVA (according to multiple researches), why don't we use accupuncture for headaches (about the only well researched on acupuncture and bogus acupuncture is not possible otherwise japanese acupuncture would be bogus and acupressure aswell) And we are depending on mathematicians to provide us with the statistics, we have no clue, and I would think that a mathematician will have his problems with more than 3 variables. Most likely to happen within our settings (patient, practisioner, time of day [homonal influences], time of year [hormonal influences] just to name a few) And we do not know what we measure. Yes I fully agree with you; use common sence!

Evolve or devolve:

We don't just sit back on our asses waiting for answers to be presented. Progressive rehabilitation research is all about seeking out and piecing together recent advances in rehabilitation, muscular biochemistry/endocrinology, muscular physiology to form a substantiated logic that supports a hypothesis. Then you apply it, either in real life or a clinical setting. It is not about making assumptions from one research paper. Anyone can recite research findings.

Analyzing research data, examining the effectiveness of a study, and applying its results to real world training situations is an entirely different matter.

Research studies are continuing to show that what we thought or perceived work (Ultrasound, massage, acupuncture, electrotherapies, etc.) may not work in specific settings or cases. Lack of evidence does not mean they do not work, but perhaps we need to utilize our CLINICAL Knowledge, examine specific physiological variables or outcome measures, and apply a hypothesis to determine in which setting/situation each modality is important. If we can specifically cite research to back this up, it will only add to the clinical reasoning/justification that is available unto us.

Wake up people, chiropractic is not going to survive forever considering the onslaught it has been taking from the medical/scientific community in the past few decades.

Physiotherapy must adapt to ensure it's survival. Maybe this way professors at college will stop blurting to students that 'oh we don't know how it works, but we think it does', or 'it just works'.

The need for evidence is important, but let us also bridge the gap between clinical reasoning and clinical research, let's use the hypothesis as the basis to conduct good, no High quality research that can make sure we stay a strong profession for years to come.

I would like to use Canucks imput because I think he has a good point here. What I have added is in capital letters

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Originally Posted by Canuck Physio

Evolve or devolve:

We don't just sit back on our asses waiting for answers to be presented.
BEFORE EVEIDENCE BASED PRACTICE NO ONE EITHER SAT ON THEIR BACKS.

Progressive rehabilitation research is all about seeking out and piecing together recent advances in rehabilitation, muscular biochemistry/endocrinology, muscular physiology to form a substantiated logic that supports a hypothesis.
THIS ALL WAS ALSO DONE BEFORE EVIDENCE BASED PRACTICE.

Then you apply it, either in real life or a clinical setting. It is not about making assumptions from one research paper. Anyone can recite research findings.
ASWELL DONE PRIOR TO EVIDENCE BASED PRACTICE, AT LEAST THE ENVIRONEMT I GREW UP IN.

Analyzing research data, examining the effectiveness of a study, and applying its results to real world training situations is an entirely different matter.
EVEN WITHIN MATHEMATICS NOT EVERYTHING CAN BE PROVEN, E.G DEFINITION OF A POINT, A STRAIGHT LINE, A FLAT SURFACE CANNOT BE PROVEN BUT IS EXPECTED TO BE TRUE.

Research studies are continuing to show that what we thought or perceived work (Ultrasound, massage, acupuncture, electrotherapies, etc.) may not work in specific settings or cases. Lack of evidence does not mean they do not work, but perhaps we need to utilize our CLINICAL Knowledge, examine specific physiological variables or outcome measures, and apply a hypothesis to determine in which setting/situation each modality is important. If we can specifically cite research to back this up, it will only add to the clinical reasoning/justification that is available unto us.
HOW FAR DO WE WANT TO GO WHEN IS ENOUGH ENOUGH. WHEN CAN WE SAY WE DO NOT KNOW BUT AFTER OUR EXPERIENCE IT DOES WORK?

Wake up people, chiropractic is not going to survive forever considering the onslaught it has been taking from the medical/scientific community in the past few decades. I EXPECT IT SIMPLY TO GO ON, IT MIGHT CHANGE NAMES OR GOING UNDERGROUND AS HAS HAPPENED WITH OTHER MODALITIES. MEDICAL WORLD IS UNABLE TO JUSTIFY ALWAYS WHAT THEY ARE DOING, WE GOT ENTANGLED IN THEIR WAY OF REASONING AS THE ONLY WAY. WHY DO WE ACCEPT A REFERRAL OF LBP OR OA OF THE LOWER BACK ( MAYBE 90% OF PEOPLE OVER 40 HAVE SOME OA OF THE LOWER BACK)

Physiotherapy must adapt to ensure it's survival. Maybe this way professors at college will stop blurting to students that 'oh we don't know how it works, but we think it does', or 'it just works'.
LIKE IN MATHEMATICS WE HAVE ACCEPTED A STRAIGHT LINE IS THE SHORTEST DISTANCES BETWEEN 2 POINTS, IT JUST IS SO.


The need for evidence is important, but let us also bridge the gap between clinical reasoning and clinical research, let's use the hypothesis as the basis to conduct good, no High quality research that can make sure we stay a strong profession for years to come.

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EVIDENCE IS VERY IMPORTANT.
IF THE PATIENT IS BETTER OFF AFTER A TREATMENT WHICH IS BASED LIKELY ON OUR INVOLVEMENT AND WE ACCEPT OUR RESTRICTIONS.

WHAT WE TEND TO FORGET WE ARE DEALING WITH PEOPLE AND THE ELEPHANT IN THE ROOM COULD MAKE US FORGET ABOUT THEM.

Neurospast -
In reference to your previous post:

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You should have read on and you would have understood what I am trying to say. Tinetti was a real example of how things can go wrong and we are just at the beginning of evidence based

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No, I understood what you were getting at, but I think you, as well as some of the other posters on this thread, actually are taking issue with how clinicians misunderstand EBP, rather than EBP itself. The practitioners you mention who are using the Tenetti as a falls predictor are NOT practicing EBP. I am not that familiar with the Tenetti, but from a precursory literature review I performed, it seems like it is only a valid predictor of falls in patients who have parkinson's disease. Those physios who use the test for other patient populations need more education on how to impliment EBP. In fact, most of your arguments seem to indicate that you have seen numerous practitioners misuse the term EBP due to poor understanding of 1) what EBP is, and 2) how to impliment it.

EBP is not blindly following the results of one research article. It is familiarity with a body of evidence that has good external validty to your patient population (or in essence, good clinical utility), and applying that evidence to drive your examination and/or intervention. When there is a lack of evidence, EBP requires the EBP practitioner to fall back onto sound scientific theory to drive ther exam and intervention, or essentially to use clinical reasoning.

EBP is not abandoning clinical reasoning. It is combining clinical reasoning with the appllication of a body of current best evidence.

You state that implimentation of progressive rehabilitation research was already occuring prior to the current push for EBP. I agree that it was happening as well, but not nearly to a large enough extent. For example, passive management of patients with modalities still occurs to a large extent within our profession, despite the large amount of evidence that suggests that this is not only not helpful to achieving a positive outcome, it is in fact detrimental to the patient. How do we change this, without getting our profession to accept the changes that widespread EBP will bring.

In short, our profession needs to better understand what EBP is. From better understanding will come acceptance of its principles.

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In short, our profession needs to better understand what EBP is. From better understanding will come acceptance of its principles.[/QUOTE]

Tell me if I am wrong, is it true that clinical reasoning is a major part of Evidence based practice?
If so I would like to refer to a book "clinical reasoning for manual therapists" edited by Mark Jones and Darren Rivett. A book in which several examples of clinical reasoning are given. I would like to know of the people who are really in favor of EBP, the direction it is taking, do their assessments as the contributors of the book like e.g. james butler and Brian Mulligan. I would like to know out of curiosity.