Evidence-based practice is the idea that occupational practices ought to be based on scientific evidence. The movement towards evidence-based practices attempts to encourage and, in some instances,

INTRODUCTION
EBP(evidence based practice)
LECTURE -1

Objective of the lecture
• To Define the evidence based practice
• To describe what do we mean from
– High quality research
– Patient preferences
– Practice knowledge
• To discus additional factors influencing clinical decisions
• To describe the process of clinical decision making
• To describe the importance of EBP for patients,
professionals and funders of physiotherapy services
• To describe the history of evidence-based health care
• To enlist and describe the steps for practicing EBP

Definition
• Evidence-based physiotherapy is physiotherapy
informed by relevant, high quality clinical
research
• Practice was evidence based when it involved
the use of the best available evidence.

• EBP is the integration of the best research
evidence, clinical expertise, and the patient’s
values and circumstances
• Best Research Evidence:
• valid and clinically relevant research with a
focus on patient-centered clinical research
• Clinical Expertise:
• use of clinical skills and experiences
• Patient’s Values and preferences:
• The patient’s unique preferences, concerns,
and expectations in his or her setting

• EBP is Not:
• Focused only on research studies
• Only to be used or understood by
professionals who routinely participate in
research studies
• A discouragement from trying new treatment

WHAT DO WE MEAN BY ‘HIGH
QUALITY CLINICAL RESEARCH’?
• Clinical research
– research on patients, conducted in clinical settings
that generates knowledge with experiment or
observation rather than theory.
• There is an enormous volume of clinical
research, but not all of it is of high quality.
• High quality clinical research is that
– which is carried out in a way that allows us to trust
the results (it has a low risk of bias) and
– is relevant to our questions.

WHAT DO WE MEAN BY ‘PATIENT
PREFERENCES’?
• Traditional clinical model:
– Decisions about therapy for the patients is made by
the physiotherapists.
• In recent years there has been a movement
towards consumer involvement in decision-
making.
• Patients have developed expectations that
they will be given an opportunity to contribute
to, and share, decisions involving their health
(Edwards & Elwyn 2001).

• In contemporary models of clinical decision
making, patients are encouraged to contribute
information
• It requires
– That physiotherapists are able to communicate to
patients the risks and benefits of alternative actions
– communication skills, empathy and flexibility from
physiotherapists.

WHAT DO WE MEAN BY ‘PRACTICE
KNOWLEDGE’?
• Practice knowledge is knowledge arising from
professional practice and experience (Higgs &
Titchen 2001).
• Consciously or subconsciously, physiotherapists
add to their personal knowledge base during
each patient encounter.
• Practice knowledge is created through reflective
processes that enable practitioners to evaluate
their practice and learn from their experience

Cont
• Practice knowledge ‘underpins the practitioner's
rapid and fluent response to a situation’.
• It is what differentiates competent well-educated
new graduates and experienced physiotherapists.
• Practice knowledge is not ‘evidence’ still practice
knowledge should always be brought to the
decision-making process.

WHY IS EVIDENCE-BASED
PHYSIOTHERAPY IMPORTANT?
• Patients may be offered the safest and most
effective interventions
• The expectation is that this will produce the best
possible clinical outcomes
• Practice knowledge might suggest alternative
interventions even if the evidence indicates a
particular intervention is effective.

• There is some evidence that upper extremity
casting for children with cerebral palsy may
increase the quality and range of upper
extremity movement (Law et al 1991).
• However, an experienced physiotherapist might
suggest alternative interventions if his or her
practice knowledge indicates that casting will
cause the child distress, or if the child or the
child’s parents are unlikely to tolerate the
intervention well.

ADDITIONAL FACTORS
• Particular context and the availability of context
interaction (culture, setting and resources).
• We all work within different settings and work
environments and these influence both our way
of posing practice-related questions and the way
we communicate with patients and populations.
• Availability of resources,: expensive effective
intervention, expensive piece of equipment.

THE PROCESS OF CLINICAL
DECISION-MAKING
• At the heart of the practice of evidence-based
physiotherapy is the process of clinical decision-
making.
• Clinical decision-making brings together
information from
– High quality clinical research
– Patients values
– Physiotherapists

cont
• Physiotherapists live with uncertainty because
there is often a lack of reliable, relevant
evidence.
• But decisions still have to be made, and
physiotherapists need to use the best
information that is available to them when
making clinical decisions.
• Our position is simply that we should reserve
the term ‘evidence-based physiotherapy’ for
physiotherapy practice that is based on high
quality clinical research.

cont.
• Clinical decision-making is complex.
• It requires clinical reasoning to analyse,
synthesize, interpret and communicate relevant
information from and to the patient in a dynamic
and interactive way.
• Practice knowledge, evidence and information
from patients are integrated using professional
judgement

HISTORY OF EVIDENCE-BASED HEALTH
CARE
• The term ‘evidence-based medicine’ was first
introduced in 1992 by a team at McMaster
University, Canada, led by Gordon Guyatt
(Evidence-Based Medicine Working Group 1992).
• They produced a series of guides to help those
teaching medicine to introduce the notion of
finding, appraising and using high quality
evidence to improve the effectiveness of the
care given to patients (Oxman et al 1993, Guyatt et al
1994, Jaeschke et al 1994).

cont.
• Growing concern in some countries that the gap
between research and practice was too great.
• In 1991, the Director of Research and Development
for the Department of Health in England noted that
‘strongly held views based on belief rather than
sound information still exert too much influence in
health care’ (Department of Health 1991).
• High quality medical research was not being used
in practice even though evidence showed the
potential to save many lives and prevent disability.

cont.
• For example, by 1980 there were sufficient
studies to demonstrate that prescription of clot-
busting drugs (thrombolytic therapy) for people
who had suffered heart attacks would produce a
significant reduction in mortality.
• But in the 1990s, thrombolytic therapy was still
not recommended as a routine treatment except
in a minority of medical textbooks (Antman
1992).

cont.
• Similarly, despite high quality evidence that
showed bed rest was ineffective in the treatment
of acute back pain, physicians were still advising
patients to take to their beds (Cherkin et al
1995).

cont.
• Another driver was the rapidly increasing volume
of literature.
• New research was being produced too quickly
for doctors to cope with it.
• At the same time, there was a recognition that
much of the published research was of poor
quality.
• Doctors had a daily need for reliable information
about diagnosis, prognosis, therapy and
prevention (Sackett et al 2000).

cont.
• One way of dealing with the growing volume of
literature has been the development of systematic
reviews, or systematically developed summaries of
high quality evidence.
• In 1992 the Cochrane Collaboration was
established.
• The Cochrane Collaboration’s purpose is the
development of high quality systematic reviews,
which are now carried out through 50 Cochrane
Review Groups, supported by 12 Cochrane
Centres around the world.

cont.
• One of the early drivers of evidence-based
physiotherapy was the Department of
Epidemiology at the University of Maastricht in
the Netherlands.
• Since the early 1990s this department has
trained several ‘generations’ of excellent
researchers who have produced an enormous
volume of high quality clinical research relevant
to physiotherapy.

• In 1998 Evidence-based Healthcare: a practical
guide for therapists (Bury & Mead 1998), was
published, providing a basic text to help
therapists understand what evidence-based
practice was and what it meant in relation to
their clinical practice.
• From 1999 PEDro, a database of randomized
trials, has given physiotherapists easy access to
high quality evidence about effects of
intervention.

Guiding Steps to Practice EBP
1. Analyze what we know and what we do not
know, in relation to improving our clinical
practice. Form answerable questions to
address any gaps in our knowledge.
2. Search for and find the best research evidence
to address our questions.
3. Critically appraise the information, based on its
validity, impact or size of effect, and
applicability.
(Straus et al, 2005)

4. Integrate information gathered from the best
research evidence with clinical expertise and the
patient’s values and circumstances
5. Evaluate the effectiveness of any intervention taken
based on steps 1-4, and the effectiveness and
efficiency of the process
(Straus et al, 2005)

EBP Process
(Forming a Question)
• Convert the need for information into a clinically
relevant, answerable question. What exactly is it
that you want to know?
• One method for formulating the question is referred
to as PICO.
• P refers to the patient or population of interest,
• I to the intervention,
• C to the comparison intervention (if one exists),
• O to the outcome.

Example
• Use of the PICO method to refine a question regarding the role of exercise for a clinical
problem (Post polio syndrome);
• P - What individual or patient populations do I have in mind?
– (People with post-polio syndrome).
• I - What type of exercises am I considering?
– (Strength training).
• C - How does my intervention compare to the effects of another
intervention? What is that other intervention?
– (Relaxation exercises).
• O - What are the goals of the exercise intervention?
– (Increased daily activity level).
Refined question. "For clients with post-polio syndrome, is strength
training better than relaxation exercises for increasing levels of daily
physical activity?"

Formulate a PICO Question
• 80 years old man referred to physical therapy
after ® hip fracture because of his poor balance,
he is the 5th
person in the last month with the
same problem.
• Using PICO criteria what will be the answerable
question ?

 P ( Situation): 80 years old man with ® hip
fracture due to poor balance
 I (Intervention) Balance training with ROM and
muscle strengthening program.
 C (Comparison) 5 patients with same age had
hip fracture due to same problem
 O (Outcomes) Fall prevention in old age
population to live independent.

An answerable Question
• What will be the affective intervention strategies
for poor balance in old age population ?
• Could hip fracture be prevented with balance
training in the old age population?

Different types of questions
• By far the most common type of clinical question
is about how to treat a disease or condition.
• In EBM, treatments and therapies are called
‘interventions’ and such questions are questions
of INTERVENTION.
• However, not all research questions are about
interventions.

Other types of questions:
• 1. What causes the problem?
– AETIOLOGY AND RISK FACTORS
• 2.What is the frequency of the problem?
– FREQUENCY
• 3. Does this person have the problem?
– DIAGNOSIS
• 4. Who will get the problem?
– PROGNOSIS AND PREDICTION
• (In each case the P I C O method can be used to formulate the question).

Scenario
• Jeff, a smoker of more than 30 years, has come to
see you about something unrelated. You ask him if
he is interested in stopping smoking. He tells you
he has tried to quit smoking unsuccessfully in the
past. A friend of his, however, successfully quit with
accupuncture. Should he try it? Other interventions
you know about are nicotine replacement therapy
and antidepressants.
• Develop a clinical research question using P I C O:

Scenario
• At a routine immunization visit, Lisa, the mother of
a 8-month-old, tells you that her baby suffered a
nasty local reaction after her previous
immunization. Lisa is very concerned that the
same thing may happen again this time. Recently,
a colleague told you that needle length can affect
local reactions to immunization in young children
but can’t remember the precise details.
• Develop a clinical research question using P I C O

Scenario
• George has come in to your surgery to discuss
the possibility of cancer after discectomy. He
says he has heard something about discectomy
causing an increase in cancer chances later in
life. You know that the risk of this is low but want
to give him a more precise answer.

Scenario
• A middle aged patient with chronic lateral
epicondylitis comes to you. During the history
taking process he states that he has had
corticosteroid injection and had used
electrotherapeutic modalities to treat the
condition earlier.
• How would you formulate the question?

Scenario
• A 30 years old patient comes to your clinic with
back pain. You discuss the treatment plan, along
with other interventions you suggest the use of
Diathermy, the patient shows concern about the
use of diathermy stating that he has heard that
diathermy cause cancer!!!
• What would be your question(PICO), In order to
find the answer?

Scenario
• Mabel is a 6-week-old baby at her routine follow-
up. She was born prematurely at 35 weeks. You
want to tell the parents about her chances of
developing hearing problems.
• PICO?

Scenario
• An adult male (Abid) comes to you with acute
lower back pain. He never had such pain and he
thinks of some serious underlying condition.
After objective examination you find nothing
serious. You reassure him but he is still not
convinced.
• Develop a clinical research question using
PICO to help reassure Mr. Abid?

This lecture is prepared from
the following text book.

Evidence-based practice is the idea that occupational practices ought to be based on scientific evidence. The movement towards evidence-based practices attempts to encourage and, in some instances,

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