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Continuing to follow outdated concepts that have been proven to be ineffective or disadvantageous is a disservice to our clients and ultimately our professions.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

How to Stay Current with Evidence

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

How to Stay Current with Evidence

In this month’s Inner Circle webinar, I discuss how you can set up a system to stay on top of all the latest news, articles, and research.    This is essentially the system I use to:

  • Keep an eye on new news, articles, and journal articles
  • Get custom emails when journal articles I am interested in get publish
  • Utilize things like Tweetdeck, Pinterest, and Youtube
  • Organize all of this in Evernote
  • Access everything from any computer, phone, or tablet with internet

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

Using the QUADAS Tool to Assess the Quality of Research

Have you been feeling lately that the quality of research reports are not always the same across journals?  Or that some articles you read do not appear to have the best methodology?  With all the emphasis on evidence based medicine, it is more valuable now than ever to assure that research reports are of superior quality to assure that we are conveying accurate information to our colleagues.  Harrison Vaughan

Today’s guest post is written by Harrison Vaughan, PT, DPT.  Harrison is a physical  therapy practicing in South Hill, VA at In Touch Therapy.  His professional interests include clinical diagnostic tests and treatment consisting of orthopedic manual therapy, predominantly spinal manipulation.

Using the QUADAS Tool to Assess the Quality of Diagnostic Accuracy Research Studies

The research community has fortunately developed a tool to critique studies and aid in clinician’s decisions to choose the correct physical examination tests, called QUADAS.  QUADAS stands for:

  • Q – Quality
  • A – Assessment of
  • D – Diagnostic
  • A – Accuracy
  • S – Studies

Many of you may have never heard of it and from speaking with others, this appears to be the norm.

What is QUADAS?

QUADAS is an evidence based tool to be used for the quality assessment of diagnostic accuracy studies.  It consists of 14 items phrased as questions, each of which should be scored a “yes”, “no” or “unclear” that examine bias in the study.

How do clinicians determine which study is most appropriate based on QUADAS score?

Past studies have shown a score of 7 of 14 or greater of “yes’s” to be of high-quality and scores below 7 to be of low-quality.  However, some authors have recommend articles with 10 or higher “yes’s” as cut-off for a high-quality diagnostic accuracy study.

How do I use this tool in my clinical assessment?

Below is an example of comparing two studies using the QUADAS score to clinically diagnose SLAP lesion.  These studies were mentioned in a previous post on the clinical examination of SLAP lesions.

O’Brien’s test: Sensitivity: 100, Specificity: 99, LR+: NA, LR-:NA, QUADAS Score: 3

Biceps Load Test II: Sensitivity: 90, Specificity: 97, LR+: 26.38, LR-: .11, QUADAS Score (0-14): 10

clinical examination of SLAP lesions

From the data above, it appears from first glance that the O’Brien’s test is superior showing great statistical numbers compared to the latter test (even though both show promising figures). However, if you look at the QUADAS score, you can see the significant differences between the two showing O’Brien’s test has much more bias. The Biceps Load Test II is on the lower end of a high quality score (10/14) but much greater study that O’Brien’s (3/14). I am not specifically picking on O’Brien but this makes a good example of similar diagnostic values but very different QUADAS score. In other words, if you obtained a (+) O’Brien’s test, you shouldn’t be so optimistic of a positive SLAP lesion due to poor study design.

I recommend the book Orthopedic Physical Examination Tests-An Evidence Based Approach by Cook & Hegedus to obtain recent QUADAS scores (as well as sensitivity, specificity, etc) for most, if not all clinical diagnostic tests; both new and old. It will surprise you that most of the “classic” special tests that many have been using for years have poor diagnostic value.

Download the QUADAS tool.

It may be difficult for many to change their evaluation regimen, but I do hope this data changes your outlook on the best special test to choose and strengthen your examination.  I hope this information adds to your realm of knowledge and help you become more objective in clinical diagnostics.  Have you used the QUADAS tool before?  What popular study do you know of that everyone references but has a very low QUADAS score?  Thanks Harrison, great post.

Penny Whiting, Anne WS Rutjes, Johannes B Reitsma, Patrick MM Bossuyt, Jos Kleijnen (2003). The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews BMC Medical Research Methodology, 3 (1) DOI: 10.1186/1471-2288-3-25