This presentation is the classroom lecture for undergraduate physiotherapy students whom I teach at Kathmandu University School of Medical Sciences in Nepal. This is an introductory lecture. Students carry on with steps of EBP in the years to come during the student life and use it for their presentations and clinical learning placement. Other students too may benefit. I highly encourage other students, especially in some parts of India where EBP is not taught, and is reserved for Master's degree program. I completely disagree with this concept, as EBP is the pillar of a responsible physiotherapy practice. Early it starts, better it is.

1. Evidence Based Practice (EBP)
in Physiotherapy
What is it?
What it is not?
Why EBP?
How to do?
Saurab Sharma, MPT
Lecturer, Department of Physiotherapy
Kathmandu University School of Medical Sciences

2. Objective of the session
To explain:
• What is Evidence Based Practice (EBP)?
• What EBP is NOT?
• How to be an Evidence based practitioner?
2

3. 1. What is Evidence based Practice?
3

4. Brainstorming?
Q. How do you decide what
physiotherapy treatment will you
give for a patient with LBP????
4

5. Brain-storming
What do you do when you don’t know
the meaning of a word?
5

6. How to choose which treatment
works?
1. Because we have read about them in books
2. Because we’ve used these before & they have
worked based on our clinical experience
3. Because the research prove that these treatments
work
4. What patients tell you works the best?
6

7. How to choose which treatment
works?
7
All of These
Which are the components of EBP

8. Evidence Based Practice (EBP)
What is it?

9. EBP- components

10. EBP
• EBP promotes the collection, interpretation &
application of valid evidence in clinical
decision making.
• The evidence could be:
 Patient-reported
 Clinician-observed
 Research-derived
10

11. EBP: History
• 1970s at McMaster University, Canada
• So, it is called Evidence Based Medicine (EBM)
• Spread to other disciplines
• Started in Physiotherapy in 1990’s
• Started in Nepal in 2010 at KUSMS
Hoffmann T et al. Evidence based practice across the health professionals. 2010

12. What is “evidence”?
Can be defined as:
“The available facts, circumstances
etc, supporting or otherwise, a belief,
proposition etc or
indication whether or not a thing is true or
valid”
(Thompson D, Concise Oxford Dictionary of Current English, 9th Edition)
12

13. What is EBM?
“ The conscientious, explicit and judicious
use of current best evidence in making
decisions about the care of individual
patients.”
• Conscientious= based on principles
• Explicit= open/ clear/ unambiguous
• Judicious= sensible/ thoughtful/ fair
(Sackett DL., Rosenberg WMC., Gray JAM, Haynes RB, Richardson WS. 1996.
Evidence based medicine: what it is and what it isn’t. BMJ 312”71 – 2.) 13

14. 2. What is EBP is NOT?
14

15. What it is NOT?
• Asking seniors/ teachers for clinical doubts
• Reading outdated books
• Using google for finding the answers
• Solely depending on EVIDENCE for clinical
practice (without considering clinical experience
or patient’s preferences or expectations)
15

16. 3. Why Evidence based practice (EBP)?
16

17. Why do we need EBP?
• Clinical decision-making
• Clinical practice is often 10 years behind research
• Traditional sources of information ie books are no
longer adequate or up-to-date
17

18. Why do we need EBP?
• Improved quality and efficiency of healthcare
management
• Keeps up to date- Life Long Learning
18

19. Why research in Physiotherapy?
• Physiotherapy is SCIENTIFIC approach of patient
treatment
• To justify our action/ treatment
19

20. Why research in Physiotherapy?
• To move from Hit and trial method of treatment to
Evidence based approach
• To standardize the treatment
20

21. Why research in Physiotherapy?
• To deliver the best quality services to the patients
• Easier and safer Clinical Decision Making
• To understand other health care professional’s
research activities (eg. Evidence Based Medicine)
and communicate with them.
21

22. Who would want evidence?
• Consumers – best outcomes - EBP
• Clinicians – best clinical practices, ethical
responsibility- EBP
• Management- Evidence Based management
• Policy making- Evidence Based policy
• Funding bodies – accountability and cost
22
Hoffmann T. Evidence based practice across the health professionals. 2010

23. Usage of PEDro (2010-11)
• One search every 19 seconds
• Maximum utilization- USA (13%), Australia (12%),
Brazil (8%), UK (6%), Spain (6%), Germany (5%)
• Highest usage- Peru (255 times/physiotherapist)
• INDIA – ranks 99 (1.3 times/PT)
23Campos et al. 2013; Physiotherapy

24. Why EBP in Students?
• To gain updated knowledge
• To identify the most accurate diagnostic tests and
the most effective interventions
• To build strong clinical reasoning based on the
best available evidence
• To defend the answer in viva or exams.
24

25. 25
1st 30%
2nd 29%
3rd 17%
4th 11%
Intern 11%
EBP utilization in Nepal
Subedi K, Maharjan J, Sharma S; 2015- under review
Year of Study

26. 26
Yes – 98 %
No – 2 %
Do You Use Internet As Learning
Source?
Subedi K, Maharjan J, Sharma S; 2015- under review

27. 27
No. of students
61%
31%
45%
32%
9%
How Did You learn about
E-learning?
Subedi K, Maharjan J, Sharma S; 2015- under review

28. WHICH ALL E-LEARNING SITES ARE
YOU AWARE OF?
28
94%
83%
52%
59%
33%
41%
14%
28%
42%
10%
9%
5%
EBP utilization by students in
Nepal
Subedi K, Maharjan J, Sharma S; 2015- under review

29. 29
91%
30%
6%
74%
5%
Awareness of social sites as
E-learning source
Subedi K, Maharjan J, Sharma S; 2015- under review

30. 30
5%
11%
33%
40%
10%
How often you use E-learning for
regular learning?
Subedi K, Maharjan J, Sharma S; 2015- under review

31. 31
24%
65%
10%
0%
1%
Does internet help in your
E-learning?
Subedi K, Maharjan J, Sharma S; 2015- under review

32. 32
83%
33%
41%
52%
10%
8%
What Are Your Barriers to
E-learning?
Subedi K, Maharjan J, Sharma S; 2015- under review

33. 3. How to do EBP?
33

34. 5 steps to EBP
1. Convert a clinical problem into answerable
clinical question
2. Find the best evidence (literature search)
3. Critically appraise evidence for validity, impact
and applicability
4. Apply results to clinical practice
5. Evaluate the effectiveness and efficacy 34
(Hoffmann T. Evidence based practice across the health professionals. 2010)

35. Step 1. Convert a clinical problem
into a searchable question
• Patient or population (P)
• Intervention (I)
• Comparison (C)
• Outcome (O)
= PICO
35

36. How to ask a clinical question?
• Patient or population (P)- adult, children,
pregnant women, elderly?
• Intervention (I)- Cryotherapy
• Comparison (C)- Ice vs Ultrasound
• Outcome (O)- Pain, functional ability, muscle
strength, range of motion etc.
36

37. Step 2 –Search for the best evidence
• Recent evidences
• Internet – try to find articles which have
already been through an appraisal process
eg. Cochrane, PEDro
• Some databases: PubMed/ Medline,
Scopus, Embase, CINAHL, proquest
37

38. Step 3 – Critically appraise the
evidence
• Level of Evidence - SACKETT, NHMRC, Oxford,
GRADE
• Quality scoring- PEDro scale
• Adopt standard guidelines or checklists-
PRISMA, CONSORT, STROBE checklists
(http://equator-network.org)
38

39. Step 3 – Critically appraise the
evidence
• Validity- is the evidence trustworthy?
• Impact-
– Look at the results
– Clinical importance of study
– Significant effect on the outcome
• Applicability- are the results clinically important?
39

40. Hierarchy of Evidence
40
Experimental
studies
Meta-analysis &
Systematic reviews
Randomised Controlled Trials
(RCT)
Observational
Studies
Cohort
Case-control
Cross-sectional
Case-series
Case-report
Expert opinion

41. Step 4 : Apply the Results to Clinical
practice
Use the results of your literature search
• to frame your treatment protocols;
• to generate future research questions and
• to determine the cost-effectiveness of treatments
41

42. Step 5 : Evaluate
• Evaluate the effectiveness and efficacy with which
steps 1-4 were carried out
• Think about ways to improve
• Evaluate the efficacy of the intervention on
outcomes
42

43. Steps in EBP
43
5 A’s

44. What is optimal evidence?
 Best available
 Current/latest
 Valid and reliable
 Relevant
 Applicable
 Cost-effective
44

45. Summary
1. What is EBP?
2. What it isn’t?
3. Why EBP?
4. How to do EBP?
45

46. Thank You!!!!
46
saurabsharma1@gmail.com
Kathmandu University
School of Medical Sciences