Evidence-Based Practice

My undergraduate physiotherapy training seems like a long time ago. Almost everything I learned back then in the 1980’s was based on a pathophysiologic rationale and on knowledge provided by respected authorities in the field. I was convinced that courses on statistics and methodology were just curriculum fillers, because hardly any research seemed available in the area of physiotherapy. Now there is a plethora of studies relevant to our field available to the interested clinician. It seems as if every year the amount of studies doubles. Applying sound research evidence on the most effective and efficient means of diagnosis, prognosis, and intervention in the management of our patients is an obvious necessity, both from the aspect of securing the best possible outcomes and from the aspect of allocation of limited health care resources. But how does the busy clinician keep up with all this new evidence continuously being produced?

Evidence-based practice (EBP) as introduced in the 1990’s represented a paradigm shift away from the traditional paradigm of physiotherapy education as described above. EBP does not hold authority-based knowledge in the same high regard the traditional paradigm did. It states that intuition, unsystematic clinical experience, and pathophysiologic rationale do not constitute sufficient grounds for clinical decision-making. Instead, it stresses the examination of evidence from clinical research based on a formal set of rules to help clinicians effectively interpret the results of clinical research1.

Does this mean we discard all we once held dear in terms of authority-based and experience-based knowledge? Does it mean that patient or clinician preference for a specific diagnostic or therapeutic intervention is irrelevant? Sackett et al2 defined EBP as the process of integrating the best research evidence available with both clinical expertise and patients’ values. Guyatt et al1 suggested defining evidence as any empirical observation about the apparent relation between events. So, obviously clinician experience and basic science research are still sources of evidence, albeit that they are located low in the hierarchy of possible evidence in the EBP
paradigm1. The patient still ultimately makes the decision after a comprehensive education on potential harm or benefit from a diagnostic or therapeutic intervention. And, of course, professional responsibility and clinician expertise determine whether a clinician applies a specific intervention even after obtaining informed consent from the patient.

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