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What is Evidence Based Practice?

One of the most important things for any healthcare or fitness professional to understand is that it is our professional duty to our clients to be sure we are staying current and following the evidence as our professions continue to grow. That is what many people believe is evidence-based practice.

I believe this is one of the most important qualities you need to master to truly become an expert in our fields.

We should always be learning and staying on top of the latest research, while keeping an open mind and growth mindset.

Continuing to follow outdated concepts that have been proven to be ineffective or disadvantageous is a disservice to our clients and ultimately our professions.

However, it is very common for students and new graduates to take this concept too far. This is not a criticism, just a statement that without clinical experience it is often difficult to follow evidence based practice as best as possible.

Paralysis by a Lack of Evidence

Here’s one thing that I wish people understood: a lack of evidence does not mean a lack of efficacy.

Research is hard. We’re humans. It’s difficult to have quality randomized control trials with adequate methodology to determine exactly what to do at all times. It’s the expert people that I know that grasp this concept the best.

It’s more common for the inexperienced to have what I call “paralysis by a lack of evidence.” They often state that without clear evidence we should not be performing certain interventions.

This couldn’t be further from the truth in my mind.

What is Evidence Based Practice?

Evidence based practice is defined by Sackett et al as the integration of the current best research evidence with clinical expertise and patient values.

This is super important to grasp. It’s not just the research, it’s also clinical experience and patient values. My friend Phil Page did an excellent job breaking this down in a recent presentation for my Inner Circle Online Mentorship program. Here’s a quick clip from that presentation where Phil defines evidence-based practice, which I thought was brilliant:

I also really liked the iceberg image, representing that EBP isn’t just the best available evidence, but that experience and patient values also lie under the surface.

How to Follow Evidence Based Practice

In order to follow evidence based practice as best as we can, we need to understand that EBP is a combination of these three things. No one piece of this is stronger than another.

When I am trying to determine if an intervention I would like to do is appropriate based on evidence-based practice, I’ll consider what I call the Evidence-Based Practice Light System.

  • Red Light = Stop.  If there is strong evidence by quality randomized controlled trials suggesting a safety concern or lack of efficacy, then you should find an alternative approach that may be more advantageous.
  • Yellow Light = Proceed, but with caution.  When there is conflicting information, or 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 comfortably use this approach with evidence-based justification.

We also recently discussed how we do this in a podcast episode on Using Physical Therapy Interventions with No Evidence of Efficacy

If you want to learn more about evidence based practice, you can watch this full presentation and many many more in my Inner Circle Online Mentorship program.

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 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 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.

 

What is Evidence-Based Practice?

I have felt many times on social media that some people have forgotten the three components to evidence-based practice:

  1. Best available evidence
  2. Clinicians experience, knowledge, and skills
  3. The patient’s wants and needs

As you can see, “best available evidence” is only one component of evidence-based practice.

Far too many times, especially in the physical therapy world, we are forcing “evidence-based physical therapy” on our patients based solely on best available evidence, 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 serious 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.

evidence based practice light system mike reinold

  • Red Light = Stop.  If there is strong evidence by quality randomized controlled trials suggesting a safety concern or lack of efficacy, then you should find an alternative approach that may be more advantageous.
  • Yellow Light = Proceed, but with caution.  When there is conflicting information, or 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, the APTA’s evidence based practice 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.  I often see issues with groupings of people based on things like “shoulder pain” or “patellofemoral pain.”  How do you define those?  They are so broad there is no doubt that trying to assess efficacy of an intervention is going to be challenging.  Or how about the flip side of that?  The study that looks at “massage” for a certain pathology.  How do you define “massage?”  Would I do it different than you?

So a large amount of time we are going to have a lack of evidence, or conflicting 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.

That’s key.  Sound theoretical principles and your experience.

If you do not have enough experience yourself, I am OK with you relying on the experience of an expert clinician.  Just realize that the number of social media followers does not make you an expert, experience does.  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.

 

 

 

Evidence Based Practice Light System – Photo by Kathera

Using Science to Enhance Exercise

Inner Circle Premium Content

The latest webinar recording for Inner Circle members is now available below.

Integrated Science and Evidence to Enhance Exercises

I use the serratus anterior as a model for discussion but the information is easily applicable to any muscle.  The below webinar will help you understand:

  • What we often miss when performing simple and traditional exercises only
  • How to critically assess how and why we do exercises
  • What to consider when selecting and enhancing exercises
  • How to take your exercise programming to the next level
  • How to make faster gains and better outcomes
  • Why you need to integrate baseline strength and functional stability training

To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.