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Research Reports: Nancy M Salbach, Susan B Jaglal, Nicol Korner-Bitensky, Susan Rappolt, and Dave Davis Practitioner and Organizational Barriers to Evidence-based Practice of Physical Therapists for People With Stroke PHYS THER 2007; 87: 1284-1303 [Abstract] [Full text] [PDF]

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More than one way

Nancy M Salbach   (21 December 2007)

Reaction from a clinician

David J. Smyntek   (2 November 2007)

More than one way 21 December 2007
Nancy M Salbach, Physical Therapist Researcher and Lecturer Department of Physical Therapy, University of Toronto Send rapid response to journal: Re: More than one way nancy.salbach{at}utoronto.ca Nancy M Salbach	The first rapid response posted for our article published October 2007 in Physical Therapy raised a number of important issues related to implementing evidence-based practice (EBP), including: the need for evidence-based teaching; the lack of strong, quality evidence to guide stroke management; and the limited applicability of research findings due to exclusion of individuals with complex presentations after stroke. There are clearly multiple ways in which we can make progress towards facilitating EBP and each avenue deserves attention from the relevant stakeholders. By moving forward and developing solutions together, not by placing blame on any one sector or individual, we will get closer to our goal of providing effective and efficient physical therapy services that acknowledge client values and preferences.
Reaction from a clinician 2 November 2007
David J. Smyntek, physical therapist Forum Hillside Hospital Send rapid response to journal: Re: Reaction from a clinician davesmyntek{at}yahoo.com David J. Smyntek	I was very much attracted to the title of this article. Somehow I was expecting a simple solution, something to help clinicians overcome the “barriers.” How naïve of me! Nevertheless, I found the article interesting and somewhat provocative, especially the invited commentary (http://www.ptjournal.org/cgi/content/full/87/10/1304) and the author response (http://www.ptjournal.org/cgi/content/full/87/10/1305). I got the impression that there was a negative judgment being made about clinicians and their presumed lack of implementing/instituting so- called "evidence-based practice." The word "blame" came to mind. As a clinician, I felt defensive for several reasons. I wonder about what might be called "evidence-based teaching." I am pretty sure that poorly supported interventions for stroke--such as neurodevelopmental treatment, or NDT (antiquated, outdated, misleading, and based on an obsolete understanding of the CNS and learning and recovery from brain injury) and electrical stimulation--are still taught with little regard to the dearth of high-quality supporting evidence. I wonder to what extent recent graduates--within the past 2 to 10 years--are informed about the quality and quantity of evidence for the interventions that they are taught to use for patients with stroke. Unrelated to stroke but related to evidence-based practice, there was a recent PTJ article indicating that limited/poor evidence for use of ultrasound in musculoskeletal problems doesn’t prevent many orthopaedic certified specialists (who presumably are familiar with some of the relevant literature) from using it. My point is that knowledgeable clinicians do, at least in some cases, apparently disregard the evidence in clinical practice. The question is: Why? Could it be that their clinical experience conflicts with the evidence? Or, is it more likely that the evidence is far from persuasive or compelling or might be irrelevant to the individual patient being treated? I believe this is the case for many clinicians with regard to stroke and its treatment. I wonder whether current physical therapist students are given an honest, thorough awareness of the current evidence supporting a given treatment or intervention. How much teaching is based on outdated but apparently thoroughly ingrained tradition? Is information available to answer that question? Also, do academic programs rely on clinical education (clinical instructors?) excessively, a situation that might perpetuate treatment methods poorly supported by evidence? Perhaps clinical instructors contribute considerably to the deficiencies in evidence-based practice. Another issue is the quality and quantity of the available evidence. These factors comprise what I consider to be the strength or persuasive/influential value of the evidence. I skimmed the Clinical Practice Guidelines for Adult Stroke.[1] There were 39 tables of evidence with 107 fairly specific “recommendations.” In the "overall quality" category, I found that only 16 (15%) of 107 recommendations had evidence that was considered “good,” 45 (42%) had “fair” evidence, and 46 (43%) had “poor” evidence. For 12 tables of evidence that fairly directly address physical therapy-related issues, 4% had evidence categorized as “good,” 54% had evidence categorized as “fair,” and 42% had evidence categorized as “poor.” Those numbers and percentages might be considered misleading and might benefit from further interpretation and analysis. Nevertheless, I am not impressed with “fair” or “poor” evidence. My final comment refers to statements made in Duncan’s invited commentary and in Salbach’s author response. Duncan refers to a survey suggestion “that research products are not clinically relevant and generalizable to routine care.” She made 3 extremely appropriate recommendations. In summary, they addressed inclusion/exclusion criteria, clinical feasibility of interventions, and clinically relevant outcomes. My (admittedly limited) experience with the available literature has very often been disappointment with how the evidence treats those items, especially with respect to frequently seen patients. For example, clinicians often treat patients with aphasia and cognitive disorders, common exclusion criteria. Salbach mentions the “incredibly complex” issue about innovations and feasibility and clinical relevance. The most striking point she made was about “the weight of the evidence” needed to change practice. She gave a great example referring to a review of body-weight- supported treadmill training and indicated that a 2003 Cochrane systematic review found it “no more effective than other interventions in improving walking speed and independence.” Hasn’t there been a kind of push to jump on the bandwagon of body-weight-support? Might some clinicians wonder if they have short-changed their patients because of absence of the needed equipment and personnel, etc? What does the evidence support? Salbach also refers to the unavoidable problem of applying results from some “averaged” heterogenous group to an individual. It is no simple matter to do that. Clinicians may be underappreciated in being appropriately selective when trying to apply the evidence to a given individual. I wonder what I have conveyed in this not-very-rapid response. I might boil it down to respect--respect for the strengths and weaknesses of the evidence and respect for the clinicians, who simply want to help their patients in the most effective way. To the researchers, I suggest trying to provide clinicians with practical, palatable, understandable, relevant, persuasive, evidence. Until that happens to a greater extent, I will rely on principle-based treatment. I will use the well- established principles of specificity of training, the overload principle, and the principle of repetition as fundamental to learning. I believe the evidence supporting those principles is fairly solid. Reference 1 Gresham GE, Duncan PW, Stason WB. Post-Stroke Rehabilitation. Clinical Practice Guideline No 16. Rockville, Md: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1995. AHCPR Publication No 95-0660.