The document discusses evidence-based practice (EBP) in physical therapy. It defines EBP as integrating the best research evidence, clinical expertise, and patient values and describes the 5 steps of EBP as formulating a question, finding evidence, appraising evidence, implementing evidence, and evaluating outcomes. The document also explores barriers to EBP, such as lack of time and understanding of statistics, and facilitators, like access to online research summaries.

1. Dr. Namrata Bavalekar
M.P.Th

2.  Introduction
 What is EBP?
 Steps
 What do I need to know?
 The Problem with EBP
 Barriers
 Facilitators

3.  The physical therapy profession recognizes
the use of evidence-based practice (EBP) as
central to providing high-quality care and
decreasing unwarranted variation in
practice.
 Evidence-Based Practice (EBP) describes the
steps involved and the problems with EBP.

4.  Physical therapy, being the widely
recognized health care profession has to
upgrade its method of practice to remain
alive in the era of scientific research.
 As the number of physiotherapy trials and
systematic reviews increase, we could
hope that we are developing a robust
evidence base to inform patient care.

5.  Evidence-based physiotherapy practice
(EBPP) is "open and thoughtful clinical
decision making" about the physical
therapy management of a patient/ client
that integrates the "best available
evidence with clinical judgement".

6.  Evidence based practice (EBP) is 'the
integration of best research evidence
with clinical expertise and patient
values' which when applied by
practitioners will ultimately lead to
improved patient outcome.

7. In the original model there are three
fundamental components of evidence based
practice.
Individual
Clinical
Expertise
Best
External
Evidence
Patient
Values &
Expectation
EBP

8.  best evidence which is usually found in
clinically relevant research that has been
conducted using sound methodology
 clinical expertise refers to the clinician's
cumulated education, experience and
clinical skills
 patient values which are the unique
preferences, concerns and expectations
each patient brings to a clinical
encounter.

9.  Evidence-based practice encompasses more
than just applying the best available
evidence, but many of the concerns and
barriers to using EBP revolve around finding
and applying research.
 National PT-organisations are committed to
help physical therapist develop, synthesize
and use evidence.

10.  The physical therapist knowledge and skills
are a key part of the evidence based process.
 This personal scope of practice consists of
activities undertaken by an individual
physical therapist that are situated within a
physical therapist's unique body of
knowledge.
 Using clinical decision-making and judgment
is key.

11.  The patient's wants and needs are a key part
of the evidence-based process.
 As described in guiding principles to achieve
the Vision under patient/client values and
goals will be central to all efforts in which
the physical therapy profession will engage.
 Incorporating a patient's cultural
considerations, needs, and values is a
necessary skill to provide best practice
services.

12. 1. Formulate an answerable question
2. Find the best available evidence
3. Appraise the evidence
4. Implement the evidence
5. Evaluate the outcome

13.  One of the fundamental skills required for
EBP is the asking of well-built clinical
questions.
 By formulating an answerable question you
are able to focus your efforts specifically on
what matters.
 These questions are usually triggered by
patient encounters which generate questions
about the diagnosis, therapy, prognosis or
aetiology.

14.  The second step is to find the relevant
evidence.
 This step involves identifying search terms
which will be found in your carefully
constructed question from step one;
selecting resources in which to perform your
search such as PubMed and Cochrane Library;
and formulating an effective search strategy
using a combination of MESH terms and
limitations of the results.

15.  It is important to be skilled in critical
appraisal so that you can further filter out
studies that may seem interesting but are
weak.
 Use a simple critical appraisal method that
will answer these questions: What question
did the study address? Were the methods
valid? What are the results? How do the
results apply to your practice?

16.  Individual clinical decisions can then be
made by combining the best available
evidence with your clinical expertise and
your patients values.
 These clinical decisions should then be
implemented into your practice which can
then be justified as evidence based.

17.  The final step in the process is to evaluate
the effectiveness and efficacy of your
decision in direct relation to your patient.
 Was the application of the new information
effective? Should this new information
continue to be applied to practice?
 How could any of the 5 processes involved in
the clinical decision making process be
improved the next time a question is asked?

18.  Before we begin the hunt for evidence
that relates to our clinical questions, we
need to spend some time making the
questions specific. Structuring and
refining the question makes it easier to
find an answer.
 One way to do this is to break the
problem into parts.

19.  The first part identifies the patient or the
problem. This involves identifying those
characteristics of the patient or problem
that are most likely to influence the
effects of the intervention.
 If you specify the patient or problem in a
very detailed way, you will probably not
get an answer.

20.  The second and third parts concern the
interventions.
 Here we specify the intervention that we
are interested in and what we want to
compare the effect of that intervention
with. We may want to compare the effect
of an intervention with no intervention,
or with another active intervention.

21.  The fourth part of the question specifies
what outcomes we are interested in.
 E.g, when considering whether to refer an
injured worker to a work hardening
programme, it may be important to
determine whether the patient is
interested primarily in reductions in pain,
or reductions in disability, or returning to
work, or some other outcome.

22.  you may be interested in your patient’s
attitudes to his condition.
 In a similar scenario in your own practice
you recently heard a patient expressing
concern about whether his complaint
might become chronic, or whether he
might have a serious illness.

23.  You become interested in knowing more
about the concerns of patients with acute
low back pain.
 Consequently your two-part question is:
‘What are the principal concerns of adults
with acute low back pain?’

24.  The question may be about the expected
amount of the outcome or about the
probability of the outcome.
 When you discuss different management
strategies with your patient, he asks you
whether he is likely to recover within the
next 6 weeks, because he has some
important things planned at that time.

25.  So your first question about prognosis is a
broad question about the prognosis in the
heterogeneous population of people with
acute low back pain.
 The question is: ‘In patients with acute
low back pain, what is the probability of
being pain-free within 6 weeks?’

26.  Even the best diagnostic tests
occasionally misclassify patients.
 Misclassification and misdiagnosis are an
unavoidable part of professional practice.
It is useful to know the probability of
misclassification so that we can know how
much certainty to attach to diagnoses
based on a test’s findings.

27.  Our patient’s general practitioner has told
him that he does not have sciatica.
 You first interpret this to mean there
were no neurological deficits, but after
the patient describes radiating pain
corresponding with the L5 dermatome you
are not sure.

28.  You are aware that general practitioners
often do not examine patients with low
back pain very thoroughly, so you start
thinking about doing further clinical
examinations, perhaps using Lase`gue’s
test, amongst others, to find out whether
there is nerve root compromise.
 So you ask: ‘In adults with acute low back
pain, how accurate is Lase`gue’s test as a
test for nerve root compromise?’

29.  The evidence based “quality mark” has been
misappropriated by vested interests.
 The volume of evidence, especially clinical
guidelines, has become unmanageable.
 Statistically significant benefits may be
marginal in clinical practice.

30.  Inflexible rules and technology driven
prompts may produce care that is
management driven rather than patient
centred.
 Evidence based guidelines often map poorly
to complex multi-morbidity.

31. A recent systematic review analysed "What do
physical therapists think about evidence-based
practice?" and concluded that the barriers most
frequently reported were:
 lack of time,
 inability to understand statistics
 lack of support from employer
 lack of resources
 lack of interest and
 lack of generalisation of results.

32. Some authors express the influences on EBP
in physiotherapy as facilitators rather than
barriers. For example, Bridges et al (2007)
identified several personal characteristics
that may facilitate EBP:
 self-directed learning,
 a postgraduate degree,

33.  a belief that research (particularly in a
digested format such as clinical guidelines)
can be used in everyday clinical decision-
making without interfering with productivity
and an efficient patient flow, and

34.  nonconformity, i.e, not being afraid to
diverge from traditional or common practice
if newer research reveals more effective
methods.
 Salbach et al (2011) identified online access
to research summaries and systematic
reviews as a potentially important facilitator
because this can save time to search and
critically evaluate research articles.

35. Summary
Introduction
What is
EBP?
Steps
Need to
know
Problem
with EBP
Barriers
Facilitators

36.  Physiopedia website.
 Practical Evidence-Based Physiotherapy by
Rob Herbert