PHYST-776; No.
of Pages 2
ARTICLE IN PRESS
Physiotherapy xxx (2014) xxx–xxx
Letter to the Editor
Evidence-based practice in physiotherapy: time to
involve the patient?
Dear Editor
Scurlock-Evans et al. wrote an extensive article on
strategies to implement evidence-based practice (EBP) in
physiotherapy practice [1]. They defined EBP as a process
whereby clinicians integrate best research evidence with clin-
ical expertise and client preferences, producing the most
appropriate and effective service. They based this definition
on the landmark publication of Sackett et al. [2] and the more
obscure publication by Bello [3]. Despite the uptake of Sac-
kett’s et al.’s definition for EBP, we believe that the role of
the patient should be emphasized even further.
The role of the patient within the healthcare system has
changed profoundly over the last years. Some even speak of
a patient revolution to establish a healthcare system where
clinicians and patients work in partnership [4]. The defini-
tion of EBP has also evolved to align more closely with
‘shared decision-making’, ‘patient-centred’ and ‘patient-led’
approaches to health care. In 2005, the Sicily statement con-
cluded that EBP requires that decisions about health care are
based on the best available, current, valid and relevant evi-
dence, made by those receiving care, informed by the tacit and
explicit knowledge of those providing care, within the context
of available resources [5]. This mindset—that patients should
make decisions about health care—is admittedly a dramatic
evolution in healthcare philosophy and will have substantial
implications on how we should implement and disseminate
scientific knowledge about physiotherapy practice. However,
this mindset is vital considering that the definition for health
is also changing, from ‘complete mental physical and social
well-being’ towards ‘the ability to self-manage and adapt’
[6]; successful self-management may, in fact, be made more
difficult for patients when providers assume the majority of
clinical decision-making responsibility.
In the article by Scurlock-Evans et al. the individual
receiving care is mentioned twice [1]. One of these occa-
sions (p. 10) is particularly interesting as it suggests that
http://dx.doi.org/10.1016/j.physio.2014.08.001
0031-9406/© 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Hoogeboom TJ, et al. Evidence-based practice in physiotherapy: time to involve the patient?. Dear
Editor. Physiotherapy (2014), http://dx.doi.org/10.1016/j.physio.2014.08.001
physiotherapists are concerned about where the patient fits
into the process of EBP. In light of the changing understand-
ing of what constitutes EBP, we believe this concern to be
particularly well-founded. The interventions identified by the
authors to improve adoption of EBP were primarily aimed
at improving the physiotherapist’s ability to find and inter-
pret new scientific evidence; generally with mixed results
[1]. However, the usefulness of such evidence for inform-
ing individual clinical interactions was not assessed. Given
that the methodologies employed in many research studies
use group-level evidence (e.g., comparing mean differences
in outcomes between intervention and control groups), this is
not purely an academic issue [7]. Physiotherapists’ interpreta-
tion and understanding of research information may actually
be tangential to the more relevant problem: the nature of the
evidence is really inadequate for effective EBP. Therefore,
a new perspective on dissemination and implementation of
scientific knowledge may be critical to furthering EBP.
One of the major challenges for EBP is that patients are not
readily provided with information that could allow them to
actively participate in the care process. For example, it takes
time and effort for individuals to gain access to their med-
ical records, as their records are typically scattered around
the healthcare landscape. Even when an individual does
manage to access their medical records, the data are often
fragmented, incomplete and oriented to describing healthcare
processes rather than summarising relevant measures, such
as functional outcomes [8]. Therefore, instead of developing
guidelines or training physiotherapists to perform systematic
literature searches, we believe that researchers should strive
to provide patients and practitioners with real-life, indivi-
dualised and easily interpretable scientific data. Such efforts
might, for example, aim to describe normative trajectories
of recovery for a particular diagnosis or treatment—also
known as estimated treatment response—to support decision-
making regarding an individual’s health [9].
It is our opinion that patients are already interested in data
regarding their health and performance (see, for instance, the
—‘quantified self’ movement and to a lesser extreme, self-
monitoring in people with chronic diseases [10]), and we
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2 Letter to the Editor / Physiotherapy xxx (2014) xxx–xxx
believe the thought leadership of physiotherapists, in part-
nership with researchers, can further encourage this interest,
both for patients (who may be empowered with knowledge of
their performance in therapy) and for society at large. Physio-
therapists could and should drive future efforts at clinical data
collection, as they (in conjunction with patients) understand
which data are likely to be the most meaningful. Thera-
pists should devote resources to collecting and understanding
what these data say about performance of the profession
[11], and perhaps even more importantly, what the outcomes
tell patients about their prognosis and trajectory of recovery.
By making relevant, practice-based projections on expected
treatment outcomes accessible and interpretable for patients
and physiotherapists, it will allow them to make evidence-
based decisions on therapy initiation, therapy titration and
therapy cessation, and therefore establish true EBP.
Conflict of interest: None declared.
References
[1] Scurlock-Evans L, Upton P, Upton D. Evidence-based practice in phys-
iotherapy: a systematic review of barriers, enablers and interventions.
Physiotherapy 2014;100:208–19.
[2] Sackett D, Straus S, Richardson W, Rosenberg W, Haynes R. Evidence-
based medicine how to practice and teach. 2nd ed. Edinburgh: Churchill
Livingstone Inc.; 2000.
[3] Bello A. Utilizing research findings in physiotherapy: a call for gap
bridging. Niger Postgrad Med J 2011;18:54–8.
[4] Richards T, Montori VM, Godlee F, Lapsley P, Paul D. Let the patient
revolution begin. BMJ (Clin Res Ed) 2013;346:f2614.
[5] Dawes M, Summerskill W, Glasziou P, Cartabellotta A, Martin J,
Hopayian K, et al. Sicily statement on evidence-based practice. BMC
Med Educ 2005;5:1.
Available online at www.sciencedirect.com
ScienceDirect
Please cite this article in press as: Hoogeboom TJ, et al. Evidence-based practice in physiotherapy: time to involve the patient?. Dear
Editor. Physiotherapy (2014), http://dx.doi.org/10.1016/j.physio.2014.08.001
[6] Huber M, Knottnerus JA, Green L, van der Horst H, Jadad AR,
Kromhout D, et al. How should we define health? BMJ (Clin Res Ed)
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[7] Tuttle N. Is it reasonable to use an individual patient’s progress after
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[8] Meijerink R, van Blerck-Woerdman A, Bosma H, Groot W, Mack-
enbach J, Sint M, et al. In: Patient information: patient focused
information services; 2014. http://rvz.net/en/view/patient-information
[9] Van Buuren S, Hulzebos EHJ, Valkenet K, Lindeman E, van
Meeteren NLU. Reference chart of inspiratory muscle strength: a new
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[10] Peterson A. Improving type 1 diabetes management with mobile tools:
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[11] Jette AM. 43rd Mary McMillan Lecture, Face into the storm. Phys Ther
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T.J. Hoogeboom a,∗
A.J. Kittelson b
G. van der Sluis c
N.L.U. van Meeteren a,d
a Department of Epidemiology, Maastricht University,
Maastricht, The Netherlands
b Rehabilitation Science, University of Colorado Denver,
Aurora, CO, USA
c Department of Physiotherapy, Nij Smellinghe, Drachten,
The Netherlands
d Healthy Living, TNO, Leiden, The Netherlands
∗ Correspondence: Department of Epidemiology, Maastricht
University, 132 Universiteitssingel 40, 6200 MD
Maastricht, The 133 Netherlands. Tel.: +31 622321229;
fax: +31 433884128.
E-mail address: thomashoogeboom@gmail.com
(T.J. Hoogeboom)