On Evidence based medicine

We as therapists and humans in general try to compartmentalize concepts in a manner that drastically oversimplifies physiological, biomechanical and psychosocial processes of human movement. Evidence based practice is NOT shifting from one indoctrination to another whilst abandoning the prior practice patterns and research.. Too often are we, physical therapists, guilty of subscribing to the newest trend in research and abandoning what existed prior. There are too many examples of this: McKenzie based extension exercises for patients with low back pain, everyone with back pain has a weak TrA, every runner needs to start running bare foot and shoes are suddenly the worst thing ever, all patients with tendinopathy need to do eccentrics, patients who fall within a CPR for SMT need to be manipulated and suddenly everyone has a weak diaphragm. Patients improved prior to these studies and body systems are rather complex. That’s not stating that we should not adapt our behaviors and practice patterns, as research continues to develop more effective treatments. As a clinical researcher, DPT educator and PhD student, I fully support the idea of evolving your practice with time and staying current. I do not condone jumping ship, once a new idea presents itself

Science is a constantly evolving process that builds on the work of previous studies and changes gradually; most often due to the development a novel method of visualizing and measuring phenomena. There are few absolutes in life, one that best reflects this particular problem we face is that “The Truth Defies Simplicity”. Evidence based practice is not defined as abstaining from treatments that aren’t supported by the most recent meta-analysis. It is also not giving the same treatment for every person because research supports it. For example, when a patient demonstrates signs of Achilles tendinopathy it doesn’t mean you should automatically use eccentrics 3×15 x 5 times per day per Alfredson. Some patients won’t tolerate it or be appropriate and there are other interventions that can be used to reduce pain and improve function. Blanket statements for treatment decisions such as those can’t possibly be valid and therefore interventions cannot be the same for every patient. If we are to believe that exercise is medicine, which it is, then we must conceptualize it as such and be dose specific.

Movement disorders are multimodal with varying degrees of deficits relative to each person. My mentor from my cardiopulmonary residency at the VA in Madison, WI, Jim Carlson, offered a great quote to me, which my students may be familiar with as a I use it often, “treat what you see in front of you.” This simple quote offers a lot in terms of practice patterns and decision making. Identify what limits a patient’s ability to function and interact with their environment; then address those issues. Identifying dysfunction also coincides with another great quote I remember by CI from my first clinical, Emily Kelley, “focus on function not the diagnosis”. The diagnosis often doesn’t matter as much as we give it credit for and often even correct imaging or diagnostic tests don’t reflect a patient’s ability to move and function. For example a patient may have positive findings on an MRI for a herniated disk but be asymptomatic and a patient with heart failure may have an ejection fraction of 27% but may move better than a patient with an ejection fraction of 45%. Diagnoses are useful as a starting point but can also cause clinicians to be too myopic with decision making. This segways into, another quote from a mentor of mine here at UIC, Aaron Kiel, our residency director, “have a reason for doing what you choose as an intervention”. That quote right there so succinctly defines EBM at its core. Don’t just go through the motions and solely base decision making on the regurgitation of results from a meta-analysis or clinical practice guideline. Though often the patient will improve over time, that’s not EBM, that’s being a technician. That type of practice is wasteful not only to you but to the patient. In a climate where reimbursement and coverage is increasingly becoming more based on outcomes and efficiency, one cannot afford to continue practice in this manner. Evidence is meant to enhance decision making and critical thinking, not replace it. Clinical practice is called such, as a clinician one should be constantly reflecting, refining and appraising their skills over time. It is easy to become complacent with perpetuating the same practice patterns; and within the current landscape of healthcare that is still reimbursable. Being a good clinician, scientist or any skilled worker is difficult and requires all those things mentioned prior. It is up to the individual to decide on how they choose to act and doing the right thing may be more difficult, however the fruits of that labor are much more enjoyable.

Have a Happy Sunday.

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