Evidence Based Physiotherapy
Evidence based health care relates to all the health professions – medicine, nursing and allied health - as well as health policy makers, planners and executives.
Simply defined, evidence-based practice is the melding of individual clinical judgement and expertise with the best available external evidence to generate the kind of practice that is most likely to lead to a positive outcome for a client or patient.
Evidence-based physiotherapy is physiotherapy practice that is characterised by these attributes. Evidence based clinical practice takes into account the context within which care takes place; the preferences of the client; and the clinical judgement of the health professional, as well as the best available evidence.
The Joanna Briggs Institute provides extensive, free-access information about evidence based health care on its website and provides easily accessible evidence databases and tools to appraise, embed, utilise and evaluate evidence in practice to its Members through JBICOnNECT, the Clinical Online Network of Evidence for Care and Therapeutics. There is a specialist physiotherapy node of JBICOnNECT.
Evidence-based physiotherapy is closely aligned to the development of evidence based medicine. The origins of contemporary evidence based medicine can be traced to the work of A.L. Cochrane, Ian Chalmers and David Sackett. Cochrane drew attention to the lack of information about the effects of health care, with particular reference to medicine, and suggested that:
"[It] is surely a great criticism of our profession that we have not organised a critical summary by specialty or subspecialty adapted periodically of all relevant randomised controlled trials"
A.L.Cochrane
He argued that, as resources for health care are limited, they should be used effectively to provide care that has been shown, in valid evaluations, to result in desirable outcomes. He emphasised the importance of randomised controlled trials in providing reliable information on the effectiveness of medical interventions.
Evidence based medicine
Evidence-based medicine focuses on the need for medical practitioners to base their interventions and activities on the most up-to-date evidence or knowledge available. The evidence-based approach acknowledges the difficulties faced by busy practitioners in keeping up to date with an ever-growing literature in health care and emphasises the importance of providing them with condensed information gathered through the systematic review of the international literature on a given topic.
Although there is an international focus on a multidisciplinary approach to reviews and dissemination, until 1996 most activity focused on medicine and even now, evidence-based practice is used as an acronym for evidence-based medicine.
The development of evidence-based medicine
The development of evidence-based medicine has been rapid over the past 15 years, and has been led by Professor Ian Chalmers and Professor David Sackett. Evidence-based medicine (EBM) has been defined by Sackett as:
"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".
Sackett and Rosenberg argue for the need to base medical practice on the best possible evidence; to critically appraise research reports for validity and usefulness; and to incorporate the rapidly growing body of evidence into medical practice. They suggest that EBM is concerned with five linked ideas:
1. That clinical and other health care decisions should be based on the best patient-, population- and laboratory-based evidence.
2. The nature and source of the evidence to be sought depends on the particular clinical question.
3. The identification of the best available evidence requires the application of epidemiological, economic and biostatistical principles plus pathophysiology and personal experience.
4. This identification and appraisal of the evidence must be acted upon; and
5. There should be continuous evaluation of performance.
This evidence-based approach to medicine draws on the activities of numerous specialist groups from across the world, linked together to form the Cochrane Collaboration.
The Cochrane Collaboration
The Cochrane Collaboration has played a leading role in developing and promoting evidence-based health care and continues to be pre-eminent in developing methodology related to the systematic review of evidence of effectiveness. The Cochrane Collaboration focuses on the systematic review of randomised controlled trials for specific medical conditions, client groups or specific health professional interventions. The collaboration links review groups internationally and offers training and support to such groups. Review groups commit to an ongoing process of systematic review in a specific area, and this involves:
• determining the objectives and eligibility criteria for including trials;
• identifying studies that are likely to meet the eligibility criteria;
• tabulating the characteristics and assessing the methodological quality of each study identified;
• excluding studies that do not meet the eligibility criteria;
• compiling the most complete set of data feasible, involving the investigators if possible;
• analysing the results of eligible studies, using a meta-analysis or statistical synthesis of data if appropriate and possible;
• performing sensitivity analyses if appropriate and possible; and
• preparing a structured report of the review that states the aims of the review, describes the materials and methods used and reports the results.
Review groups also engage in a continual process of updating reviews. The Cochrane Collaboration caters for other interests (including non-medical groups) such as certain categories of health service users, groups of health professionals, settings for health care, or classes of intervention.
The Joanna Briggs Institute promotes the involvement of nurses and allied health professionals in Cochrane Reviews and JBI reviews of evidence of effectiveness are often carried out through JBI reviewers registering their reviews with a Cochrane Review Group. JBI staff are members of a number of Cochrane Review Groups and Cochrane Methods Groups.
The Cochrane Library
Reviews conducted by Cochrane Review Groups are published in The Cochrane Library, which is published quarterly basis by John Wiley and Sons, and made available on the Internet and on CD-ROM, The Cochrane Library consists of a regularly updated collection of evidence-based medicine resources, including The Cochrane Database of Systematic Reviews (CDSR).
This contains the full text of evidence based systematic reviews of health care interventions, prepared by The Cochrane Collaboration. The Cochrane reviews are updated in the light of new evidence and there are more than 3000 Cochrane reviews in CDSR, more than half of which already contain key findings and conclusions.
The Cochrane Library also includes:
• The Database of Abstracts of Reviews of Effects:
• The Cochrane Central Register of Controlled Trials (CENTRAL
• Cochrane Database of Methodology Reviews
• NHS Economic Evaluation Database
• Health Technology Assessment reports available within The Cochrane Library.
The Cochrane Library supports free text searching of all its content, as well as keyword searching and the sophisticated software allows users to edit and save search strategies, download records and print easily.
Evidence based Physiotherapy
Basing practice on the best available evidence has become a highly valued aspiration for physiotherapists. The evidence-based practice movement is able to afford considerable assistance to physiotherapists to improve research utilisation in practice. It recognises that it is unrealistic to expect busy health professionals to have the time to stay abreast of all the latest research. Hence, one of its key strategies is the development of condensed information that summarises the results of a systematic review of evidence on a topic that includes the meta analysis or meta synthesis of research results. This involves a trained researcher or a team of researchers gathering all the available research papers on a given question and systematically reviewing it for reliability and validity; that is, assessing its quality. Systematic reviews can provide the raw materials for establishing clinical guidelines and assist in identifying gaps in existing research, often discovering that there has been no research (or none of sufficient quality) on a given question.
Evidence based physiotherapy is now almost institutionalised in most industrialised countries and many of these countries have established centres for evidence based health care and evidence based physiotherapy. (For example, there are centres for evidence based physiotherapy in the United Kingdom and Australia and the Centre for Allied Health Evidence, a Collaborating Centre of the Joanna Briggs Institute, includes a Physiotherapy unit).
The Joanna Briggs Institute is an interdisciplinary, not-for-profit, international research and development agency linked to an international collaboration of autonomous specialty, country or state based collaborating centres – The Joanna Briggs Collaboration. There are 26 collaborating centres incorporating the disciplines of nursing, medicine, midwifery, physiotherapy, rural health, multi-professional practice, nutrition and dietetics, podiatry, occupational therapy, complementary therapies, aged care and medical radiation. Since its establishment, the Joanna Briggs Institute has sought to impact on health improvement internationally through advancing evidence-based practice in health care.
The role of the Joanna Briggs Institute is too improve the feasibility, appropriateness, meaningfulness and effectiveness of health care practices and health care outcomes by facilitating international collaboration between collaborating centres, groups, expert researchers and clinicians through:
Developing methods to appraise and synthesise evidence and conducting systematic reviews and analyses of the research literature (evidence translation);
Globally disseminating information in diverse formats to inform health systems, health professionals and consumers (evidence transfer);
Facilitating the effective implementation of evidence and the evaluation of its impact on health care practice (evidence utilisation)
Contributing to clinical cost effective health care through the promotion of evidence based health care practice (evidence utilisation).
Resources:
Websites:
Australian Physiotherapy Association
Canadian Physiotherapy Association (CPA)
Centre for Allied Health Evidence (CAHE)
Centre for Evidence Based Physiotherapy/ PEDro - Physiotherapy Evidence Database
Centre for Evidence Based Physiotherapy, Netherlands
Journals:
Australian Journal of Physiotherapy
Journal of Physical Therapy Science
New Zealand Journal of Physiotherapy
Effective Health Care Bulletin
Evidence Based Health Care and Public Health
International Journal of Evidence-Based Healthcare
Books:
Herbert, R., Jamtvedt, G., Mead, J. and Hagen, K.B. (2005) Practical Evidence-Based Physiotherapy. Butterworth Heinemann
Kitchin, S. and Bazin, S. (2002) Electrotherapy : evidence-based practice. Edinburgh : Churchill Livingstone, 2002.
Everett, T., Donaghy, M. and Feaver, S. [Eds] (2003) Interventions for Mental Health : An Evidence-Based Approach for Physiotherapists and Occupational Therapists. Butterworth Heinemann
Hough, A. (2001) Physiotherapy in Respiratory Care: An evidence-based approach to respiratory and cardiac management. Nelson Thornes
Dawes M.(2005) Evidence-Based Practice: A Primer for Health Care Professionals. 2nd ed. Edinburgh: Churchill Livingstone.
Gelhbach, S. H. (2006) Interpreting the medical literature. 5th ed. New York : McGraw-Hill, Medical Pub. Division.
Geyman, J. P. and Deyo, R. A.(2000) eds. Evidence-based clinical practice: concepts and approaches. Boston: Butterworth-Heinemann.
Greenhalgh, T. (2001) How to read a paper: the basics of evidence based medicine. 2nd ed. London: BMJ.
McKibbon, A. Eady, A., and Marks, S. (1999)PDQ: evidence-based principles and practice. Hamilton, Ont.: B.C. Decker, Inc., 1999.
Mayer, D. (2005) Essential Evidence-Based Medicine. Cambridge University Press.
Pearson, A., Field, J. and Jordan, Z. (2007) Evidence-based Clinical Practice in Nursing and Healthcare: Assimilating Research, Experience and Expertise. Blackwell, Oxford.
Riegelman, R. K. Studying a study and testing a test: how to read the medical evidence. 5th ed. Philadelphia, Lippincott Williams & Wilkins.
Sackett, David L, [et al].(2005) Clinical Epidemiology How to Do Clinical Practice Research. 3rd ed. Boston: Lippincott, Williams & Wilkins.
Straus, Sharon E.[et al].(2005) Evidence Based Medicine. 3rd ed. New York: Churchill Livingstone.