This document outlines the process of evidence-based practice in physiotherapy. It defines evidence-based practice as integrating the best research evidence, clinical expertise, and patient values and preferences. The document discusses what constitutes high quality clinical research and the importance of patient-centered care. It also enumerates some common barriers to evidence-based practice like lack of time and difficulty generalizing research findings. Finally, the 7 steps of evidence-based practice are presented: assess, ask, acquire, appraise, apply, analyze, and adopt.

1. Prepared by:
Dr. Hazrat Bilal Malakandi, PT
DPT (IPMR, KMU), MSPT (KMU),
CHPE (KMU), CHR (KMU)

2. • To define the evidence based practice
• To describe what do we mean from
– High quality research
– Patient preferences
– Practice knowledge
• To enumerate the barriers towards EBP
• To enlist and describe the steps for practicing EBP

3. • Evidence-based physiotherapy is physiotherapy
informed by relevant, high quality clinical
research

4. • EBP is the integration of the best research
evidence, clinical expertise, and the patient’s
values and circumstances. (Sackett et al 2000).
• 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

7. • The World Confederation for Physical
Therapy (European region) has defined
EBP as
– “a commitment to use the best available
evidence to inform decision-making about the
care of individuals that involves integrating
physiotherapist practitioners and individual
professional judgement with evidence gained
through systematic research.

8. • EBP is Not:
• Focused only on research studies
• How to conduct research , but how to use
research
• Only to be used or understood by
professionals who routinely participate in
research studies
• A discouragement from trying new treatment
• Using Google to find the answers
• Reading outdating books

9. • 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- valid (it has a low risk of bias) and
– is relevant to our questions.

10. • Traditional clinical model:
– Decisions about therapy for the patients is made by
the physiotherapists.
• Contemporary Patient model
– Patients have developed expectations that they will
be given an opportunity to contribute to, and share,
decisions involving their health (Edwards & Elwyn
2001).

11. • 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.

12. • 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

13. • 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.

14. • 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.

15. Why we need evidence for better
clinical decision making?
• Research shows that EBP leads to
– higher quality care,
– improved patient outcomes,
– reduced costs, and
– greater care provider satisfaction than traditional
approaches to care.” (Melnyk, 2010)

16. • 28% better patient outcomes if patients receive
care based on the best and latest evidence from
well-designed studies compared to traditional
practice (Heater 1988)
• Higher level of satisfaction among healthcare
providers who use evidence-based approach in
delivering patient care than those who deliver
care steeped in tradition.” Dawes, M. (1996)

17. Paradigm Shift
• Intervention process in Cerebral palsy:
– Bobath neurodevelopmental treatment (NDT)
approach.
– strengthening exercises was strongly discouraged
– Shift : Investigators have demonstrated the benefits
of strengthening exercises in individuals with CP.
– Damiano et al suggests that resistance exercise is an
effective treatment strategy and as such should be
considered as one component in the rehabilitation of
children with cerebral palsy.

18. • Bed rest for Back ache :
– Bed rest is a traditional treatment for back pain
– Shift: Two key trials by Gilbert et al and Deyo et al
first showed that longer periods of bed rest have no
advantage compared with shorter periods.
– Bed rest does not improve symptoms any more
effectively than other treatments but does produce a
number of adverse effects including
• Joint stiffness
• Muscle wasting
• Loss of bone mineral density
• Pressure sores
• Venous thromboembolism

19. • Early Mobilization in Intensive Care setting
– It is recognized that rehabilitation may not commence
until after ICU discharge,
– These traditional practices are not based on high-
quality evidence
– Shift : Joseph Adler and Daniel Malone (2012)
conducted a systematic review on the effect of early
mobilization and concluded literature supports early
mobilization and physical therapy as a safe and
effective intervention that can have a significant
impact on functional outcomes such as muscle
strength, functional mobility, quality of life and patient
symptoms.

21. • Increasing volume of literature.
• Produced too quickly
• Poor quality.

22. The number of randomized controlled trials (RCTs) within physiotherapy
has increased substantially over the last few years as indicated in the
PEDro data base

23. Barriers …
What evidence say?

24. Barriers
• A systematic review in 2014 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
– lack of generalization of results

25. • Another study published in 2017 reported that
The most common barriers to implementing
evidence by physical therapists were
– lack of time,
– limited access to evidence sources and a
– perceived lack of generalizability of research findings
to specific patient groups.

26. • Another recent study published in 2018 reported
that the top three barriers towards EBP were
– Insufficient time (66.7%),
– lack of generalizability of the literature findings to their
patient population (49.0%) and the
– inability to apply research findings to individual
patients with unique characteristics (45.1%)
• Other barriers were
– Most articles are vague and time consuming
– Searching for relevant , uptodate and reliable article is
difficult

27. • 7 A
– Assess
– Ask
– Acquire
– Appraise
– Apply
– Analyze
– Advancing and Adopt

28. 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)

29. 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)