THE PHYSICAL
THERAPIST AS
CRITICAL INQUIRER
Lecture by Dr. Nayab
Critical inquiry
Critical inquiry is the process of applying the principles of scientific methods to
read and interpret professional literature; participate in, plan, and conduct research;
evaluate outcomes data; and assess new concepts and technologies.
In 1921, P.T. Review, the first physical therapy journal, began publication. The aims
of the journal were to provide a means by which physicians and reconstruction aides
could more easily keep up with each others’ work and to preserve the standards and
advance the science of the profession.
The Foundation for Physical Therapy was established in 1979 as a national,
independent, nonprofit corporation to support the research needs of the physical
therapy profession in three areas:
● Scientific research, to create a solid platform for future clinical research
● Clinical research, to assess the efficacy of physical therapy interventions and to help
define best practice
● Health services research, to assess the effectiveness of physical therapy practice in
the emerging health care delivery models
EVIDENCE-BASED MEDICINE
According to Sackett et al.,9 evidence-based medicine (EBM) (or evidence-based
practice [EBP] as it applies to other health care professionals) is the integration of the
best research evidence with clinical expertise and patient values.
Sackett and colleagues define best research evidence as clinically relevant research
from the basic sciences and patient-centered clinical research that leads to accurate and
precise diagnosis and prognostic markers, as well as therapeutic, rehabilitative, and
preventive regimens that replace traditional methods with more powerful, accurate,
efficacious, and safe practice.
Clinical expertise is the ability to use clinical skills and past experiences to identify
each patient’s unique health state and diagnosis, as well as the risks and benefits of
potential interventions in the context of the patient’s personal values and expectations.
These values are defined as the unique preferences, concerns, and expectations of each
patient that must be integrated into the professional’s decision-making.
The popularity of EBP has emerged from clinicians’ realization of the
following:
● They need new information on a daily basis.
● They lack the time to find and assimilate new information.
● Traditional information resources often are out of date, wrong, and
overwhelming in volume.
● A disparity exists between clinical judgment, which increases with
experience, and “current, relevant” information, which decreases with
experience.
STEPS IN APPLYING EVIDENCE-
BASED MEDICINE
1. Convert the need for information into an answerable question.
2. Track down the best evidence to answer that question.
3. Critically appraise the evidence for validity, impact, and usefulness
in clinical practice.
4. Integrate the critical appraisal with clinical expertise and the
patient’s unique circumstances and values.
5. Evaluate the effectiveness and efficiency of the evidence-gathering
process and seek ways to improve these factors
OUTCOMES RESEARCH
Outcomes research is a term applied to different types of healthcare research.
One kind of outcomes research is conducted by analyzing large administrative
databases (e.g., Medicare) to explore such issues as utilization, costs, morbidity, and
mortality related to certain conditions or interventions.
The results of these studies often are used as a complement to evidence-based
information.
For instance, data on Medicare about all patients admitted to hospitals for surgery as a
result of osteoarthritis of the hip could be analyzed for differences in length of stay,
common secondary conditions that affect discharge disposition, and mortality.
The term outcomes research also is used for studies that focus on the end result of
health care in terms of health status, disability, and survival.
Effectiveness studies address how well routine clinical practices work in everyday
practice, whereas efficacy studies, which are typically conducted as randomized
clinical trials in specialty centers with a discrete sampling of subjects, address whether
clinical practices can work in ideal situations
WHOSE RESPONSIBILITY IS
RESEARCH?
Individual research agendas are more often driven by personal interest and
available funding than by the needs of the profession.
As yet, no widespread efforts have been made to engage faculty members to
collaborate with clinicians in formulating clinical research projects that could answer
both efficacy and effectiveness questions.
At a minimum, most physical therapy students are required to demonstrate the
ability to use research and to critique new information.
The experiences of physical therapy students in critical inquiry, as well as their skill
and interest in it, may vary widely.
This variation in educational experience may be one factor in the varying quality and
quantity of clinical research conducted by physical therapists with patients as
subjects.
ROLES OF THE STAFF PHYSICAL
THERAPIST IN CRITICAL INQUIRY
The following sections explore five remaining aspects of critical
inquiry that do not overlap with the PTs’ other roles: the PT as
(1) a user of research
(2) a publisher of case reports
(3) a collaborator in clinical research studies
(4) an assessor of new concepts and technology
(5) a research subject.
Application and Critique of Research
PTs can use research in two ways.
One approach, evidence-based practice, has been discussed
previously.
Increasingly, PTs’ education gives them the skills to practice
evidence-based physical therapy.
However, only a small percentage of the practice of physical therapy
is supported by evidence; therefore the traditional method,
independent critiquing of the literature, continues to be the primary
means of updating the specific information needed for clinical
practice.
Collaboration in Clinical Research
According to Fitzgerald and Delitto, research must be done on patients in clinical
settings if the physical therapy profession is to document the effectiveness of
interventions accurately and identify prognostic indicators of functional limitations and
disability.
These researchers identified the following factors as crucial for clinicians conducting
clinical research:
● Facility or institutional resources
● Patient management issues
● Availability of target patient populations
● Acquisition and maintenance of support from therapists, physicians, and institutional
review boards (IRBs)
● Research-related injuries or illness
● Ethical considerations involved in determining whether a protocol must be modified or
a project terminated
ETHICAL AND LEGAL ISSUES IN
CRITICAL INQUIRY
In the critical inquiry role, PTs must fulfill their responsibility to society to protect research
subjects and their responsibility to individuals to protect their rights.
The APTA’s Guide for Professional Conduct addresses research through the Code of Ethics
that involves the duty on the PT
to maintain and promote high standards for physical therapy practice, education,
and research.
participating in research shall abide by ethical standards governing protection of
human subjects and dissemination of results.
support research activities that contribute knowledge for improved patient care.
to report unethical acts in the conduct or presentation of research.
specifically address the issues of truthfulness, autonomy , consent and compliance
with laws and regulations.
Using and providing accurate, relevant information are also responsibilities of the
researcher.
