How to Best Integrate Evidence Based Practice

Over the last couple of decades, our professions have made great strides towards moving towards evidence-based practice.  As our understanding of the body and principles behind our professions expand, it is imperative we seek out evidence behind our exercises and manual therapy techniques so that we provide the best services as fast and safe as possible.

However, I am seeing a mild trend too far along the curve towards evidence-based practice that I am not sure is good or bad.  I feel like I have heard so many people lately arguing against a technique just because it has lack of evidence suggesting efficacy.

We have created this “paralysis-by-evidence” situation where some people think you can’t do anything unless it has strong evidence suggesting it is effective.  This approach is challenging and ultimately unrealistic.

Far too many times, especially in the physical therapy world, we are forcing “evidence-based physical therapy” on our patients instead of providing them with the service they originally came to see you for, which is to simple to “feel better.”   I am not talking about a situation with a pharmaceutical effect and potential adverse reactions, I am talking more about some of our exercises and manual therapy techniques that will at best make people feel better and at worse do nothing.

Now before you begin your criticisms, please continue to read the rest of this article.  You should at all times base your practice on evidence.  However, what do you do when there is lack of evidence?

 

The Evidence-Based Practice Light System

When I teach students and young clinicians how to begin integrating evidence based practice, I always begin discussing what I call the evidence-based practice light system.  Using this system, it becomes clear very quickly what techniques you should absolutely perform and not perform.

  • Red Light.  Stop.  If there is strong evidence by quality randomized controlled trials suggesting a lack of efficacy, then you should find an alternative approach that may be more advantageous.

    evidence based practice light system

    Evidence Based Practice Light System – Photo by Kathera

  • Yellow Light.  Proceed, but with caution.  When there aren’t enough quality studies examining the effect you are assessing, then you must proceed with caution.  In this scenario, perhaps there are some low quality studies (like a case study or publication without strong methodology) that show efficacy, or maybe even some conflicting results in the literature without an overwhelming trend towards efficacy or lack of efficacy.
  • Green Light.  Go.  If there is strong evidence by quality randomized controlled trials suggesting efficacy, then you can comfortable use this approach with evidence-based justification.

There are many great resources to search the available evidence on a technique in question, including published clinical practice guidelines (such as this one on low back pain in JOSPT), the APTA’s open source Hooked on Evidence website, and performing your own literature review on PubMed.

 

How to Integrate Evidence Based Practice

Unfortunately, where do you think the majority of our techniques, assessments, exercises and other approaches fall into the evidence-based light system?

Yellow.

It is very hard to create a well controlled study assessing everything we do, so a large amount of time we are going to have a lack of evidence suggesting an effect or lack of effect. In this scenario, you have to make the judgment yourself based on sound theoretical principles and experience.  If you do not have enough experience yourself, I am OK with you relying on the experience of an expert clinician.  However, you should never be comfortable doing anything just because someone else told you that it was effective in THEIR experience.  You should continue to carefully scrutinize the technique in your hands based on YOUR experience.

As new research is conducted and evidence becomes available, you will need to continually refine your techniques based on our current understanding of the evidence.

Base the foundation of what you do on green light principles.  But in the meantime, don’t feel that everything needs to fall within the green light designation.   Consider including techniques that fall within the yellow light designation if based on sound theoretical principles and your experience has shown positive outcomes.

 

 

 

 

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  • http://SethOberst.com Seth Oberst, DPT, CSCS

    Excellent post Mike as you bring up some great points. Try as we might as a profession, if we wait for an RCT for every intervention we implement we will be waiting a long time. Given that evidenced-based practice is comprised of patient experience, clinical experience, AND best evidence we need to integrate all 3 for best use of our skills. I also think it’s important to never undermine what you see and feel with the patient and try to integrate the clinical “gut feeling” with best practice. Thanks for the post!

    • http://www.mikereinold.com Mike Reinold

      I like that Seth, putting all 3 together!

  • http://Website(optional) Kenny Venere

    Hi Mike,

    I really like how you highlighted the need for a sound theoretical basis when using “Yellow Light” interventions. I feel that critical thinking, scientific reasoning, and deep models are something should drive all our interventions and decision making in physical therapy. Does this always happen? Maybe not as much as it should, but posts like yours help.

    I think Jules Rothstein’s “When Thoughtfulness Dies” (http://ptjournal.apta.org/content/76/4/342.full.pdf+html) and Jason Silvernail’s EBP, Deep Models, and Scientific Reasoning (http://www.evidenceinmotion.com/about/blog/2008/05/ebp-deep-models/) are excellent adjuncts to your post, and must reads for every clinician and student.

    Thanks for sharing.

    • http://www.mikereinold.com Mike Reinold

      Kenny I agree!

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  • jacellingson

    Great article and comments! I have especially noticed this trend in recent students that I have had. This focus on strong EBP interventions through RCTs has resulted in them being fairly closed minded with very few “tools” in their “toolbox”.

    • http://www.mikereinold.com Mike Reinold

      I agree!

  • http://Website(optional) Ghulam rasool khan

    Really nice to read your article on EBP.

    • http://www.mikereinold.com Mike Reinold

      thanks!

  • http://www.healinghandsms.com/ Chiropractor in Gulfport MS

    I think that a lot of the decisions we make have to be balanced morally. We don’t want to do risky things with our patients, but we don’t want to withhold beneficial treatments either. Our patients trust us to make proper decisions and recommendations for them.