Lecture 01

Evidence Based Practice(EBP) in Physiotherapy

What is EBP?

Evidence based practice (EBP) is 'the integration of best research evidence

with clinical expertise and patient values' [1] which when applied by
practitioners will ultimately lead to improved patient outcome.

In the original model there are three fundamental components of evidence based
practice.

 best evidence which is usually found in clinically relevant research that has
been conducted using sound methodology
 clinical expertise refers to the clinician's cumulated education, experience and
clinical skills
 patient values which are the unique preferences, concerns and expectations
each patient brings to a clinical encounter.
It is the integration of these three components that defines a clinical decision
evidence-based. This integration can be effectively acheived by carrying out the
five following steps of evidence based practice.
The 5 Steps
1. Formulate an answerable question

One of the fundamental skills required for EBP is the asking of well-built clinical
questions. By formulating an answerable question you are able to focus your
efforts specifically on what matters. These questions are usually triggered by
patient encounters which generate questions about the diagnosis, therapy,
prognosis or aetiology.

2. Find the best available evidence

The second step is to find the relevant evidence. This step involves identifying
search terms which will be found in your carefully constructed question from step
one; selecting resources in which to perform your search such as PubMed and
Cochrane Library; and formulating an effective search strategy using a
combination of MESH terms and limitations of the results.

3. Appraise the evidence

It is important to be skilled in critical appraisal so that you can further filter out
studies that may seem interesting but are weak. Use a simple critical appraisal
method that will answer these questions: What question did the study address?
Were the methods valid? What are the results? How do the results apply to your
practice?

4. Implement the evidence

Individual clinical decisions can then be made by combining the best available
evidence with your clinical expertise and your patients values. These clinical
decisions should then be implemented into your practice which can then be
justified as evidence based.

5. Evaluate the outcome

The final step in the process is to evaluate the effectiveness and efficacy of your
decision in direct relation to your patient. Was the application of the new
information effective? Should this new information continue to be applied to
practice? How could any of the 5 processes involved in the clinical decision
making process be improved the next time a question is asked?
These steps may be more memorable if remembered as [2]:

1. Ask
2. Acquire
3. Appraise
4. Apply
5. Audit
In 2010 Melnyk et al [3] proposed adding 2 other steps to the process:

Resources
 Evidence-Based Practice: An Interprofessional Tutorial from University of
Minnosota Library
 Evidence based practice education resources from WCPT
 This short overview article by World Confederation of Physical Therapy
(WCPT) addresses the issue of EBP.
 EBP Tools from CEBM
 EBM Toolkit from University of Alberta
 Cleland JA, Noteboom JT, Whitman JM, Allison SC (2008) A primer on
selected aspects of evidence-based practice relating to questions of treatment,
part 1: asking questions, finding evidence, and determining validity, J Orthop
Sports Phys Ther. 2008 Aug;38(8):476-84
 Noteboom JT, Allison SC, Cleland JA, Whitman JM (2008) A primer on
selected aspects of evidence-based practice to questions of treatment, part 2:
interpreting results, application to clinical practice, and self-evaluation, J
Orthop Sports Phys Ther. 2008 Aug;38(8):485-501
A series of eight articles on Getting Research Findings into Practice
published in the British Medical Journal (BMJ):

1. Making better use of research findings. Andy Haines and Anna Donald.
BMJ. 1998 Jul 4; 317(7150): 72–75.
2. When to act on the evidence. Trevor Sheldon, Gordon Guyatt and Andy
Haines. BMJ. 1998 Jul 11; 317(7151): 139–142
3. Finding information on clinical effectiveness. Julie Glanville, Margaret
Haines, and Ione Auston. BMJ. 1998 Jul 18; 317(7152): 200–203.
4. Barriers and bridges to evidence based clinical practice. Brian Haynes and
Andy Haines. BMJ. 1998 Jul 25; 317(7153): 273–276.
5. Using research findings in clinical practice. Sharon Straus and Dave
Sackett. BMJ. 1998 Aug 1; 317(7154): 339–342.
6. Decision analysis and the implementation of research findings. R J Lilford,
S G Pauker, D A Braunholtz, and Jiri Chard.BMJ. 1998 Aug 8; 317(7155):
405–409
7. Closing the gap between research and practice: an overview of systematic
reviews of interventions to promote the implementation of research
 findings. Lisa A Bero, Roberto Grilli, Jeremy M Grimshaw, Emma Harvey,
Andrew D Oxman, and Mary Ann Thomson. BMJ. 1998 Aug 15; 317(7156):
465–468.
8. Implementing research findings in developing countries. Paul Garner,
Rajendra Kale, Rumona Dickson, Tony Dans, and Rodrigo Salinas. BMJ.
1998 Aug 22; 317(7157): 531–535.
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