Evidence-Based Practice and the Journal of Manual Manipulative Therapy

Evidence-based practice (EBP) is clearly the current predominant paradigm in health care with many medical programs and schools for other health professionals implementing and having implemented courses or even whole curricula based on EBP. This is a far cry from my own undergraduate physical therapy training where everything I learned seemed based on a basic science rationale and on the clinical experience and opinions of authorities in the field. It was not until my first graduate degree that I was introduced--still in a somewhat haphazard manner--to research studies upon which I could base at least some decisions related to diagnosis, prognosis, potential harm, and intervention. This lack of research-based knowledge may, of course, have had something to do with a general dearth of research studies available in rehabilitation sciences at that time. It is no wonder that I initially thought that undergraduate courses on statistics and research methodology were little more than curriculum fillers.

However, the situation has most definitely changed. Now there is a true cornucopia of research relevant to rehabilitation sciences available to the interested clinician. Every year the amount of studies seems to double. Applying sound research evidence to determine and then apply the most effective and efficient method of diagnosis, prognosis, prevention of harm, and intervention in the management of our patients is an obvious necessity, not only to secure the best possible outcomes but also to ensure optimal allocation of limited health care, societal, and personal resources. The relevant question is this: How can a busy clinician keep up with all this new evidence that is continuously being produced?

EBP has been defined as the process of integrating the best research evidence available with both clinical expertise and patients’ values1. As such, EBP represents a paradigm shift away from the traditional paradigm predominant in medicine and other health professions up until about a decade ago, the paradigm in which I and likely many of you were educated and which was based mainly on the authority-based knowledge and basic science rationale mentioned above. In the new EBP paradigm, intuition, unsystematic clinical experience, and pathophysiologic rationale no longer constitute sufficient grounds for clinical decision-making. Instead, this paradigm stresses the examination of evidence from clinical research based on a formal set of rules to help clinicians effectively interpret the results of that research2.

From the definition of EBP used above, it is clear that we do not need to discard all we once held dear in terms of authority-based and experience-based knowledge. Patient and clinician experience with, and preference for, a specific diagnostic, prognostic, or therapeutic intervention remains an essential part of EBP. Nor should what we consider evidence be limited to data derived from methodologically rigorous research, such as cohort studies, randomized controlled trials, systematic reviews, and meta-analyses. Guyatt et al2 suggested defining evidence as any empirical observation about the apparent relation between events. Therefore, clinician experience and basic science research are still considered sources of evidence within the EBP paradigm, albeit ones that are located lower in the hierarchy of possible evidence in this new paradigm2,3. The patient still ultimately provides an informed consent after a comprehensive education on potential harm or benefit from a diagnostic, prognostic, or therapeutic intervention. And, of course, professional responsibility and clinician expertise determine whether we apply a specific intervention even after obtaining that consent.

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