Evidenced Based Practice May Be Killing an Important Part of Our Profession

EBP Going Too Far?
I may have just ruffled some feathers, but hear me out.  Evidence Based Practice (EBP) is incredibly important.  Without EBP, we lose the respect of our colleagues in various fields and do a disservice to our patients.  It is vitally important for the profession of Physical Therapy that we stress EBP.

Here’s the caveat.  What do you do when you don’t have evidence pointing you towards a specific intervention?  During the past 10 years, there has been a push towards Clinical Prediction Rules (CPRs).  I think that has been a fantastic way of going about things.  We moved away from treating diagnoses based on an anatomical diagnosis as we understood that back pain was not a homogenous group.  Shoulder pain was not a homogenous group.  And even when we tried to break down shoulder pain into a diagnosis like impingement, we have started to understand that one patient’s impingement may not be the same as another patient’s.

We need evidence based practice and if clinicians are not following it, then we are in trouble as a profession!

So why do I say some have taken it too far?  What would you do with a 17 year-old with non-specific low back pain.  It is painful when he runs and the pain has been present for 3 months.  Our best research would likely lead us towards Julie Fritz’s treatment based classification.²  Unfortunately, as we start to look at the classification, our patient (like many others)⁴ may not fit into any of the classifications.  Additionally, the patient is younger than the inclusion criteria in the study which the classification is based.  So what do we do here?  How do we follow EBP if there’s no Randomized Controlled Trials (RCT) or Clinical Prediction Rules (CPR) to treat this patient?

Evidence Informed Practice

Evidence Informed Practice (EIP) is quite similar to EBP.  We use the evidence to guide us, but also recognize that there may not always be evidence for your specific intervention.  When there is evidence, you MUST use it.  In the presence of a lack of literature, consider borrowing from a similar condition.  For example, regional interdependence has helped in stenosis for the back and anterior knee pain. ^1,3,5  Could we use regional interdependence for our 17 year-old runner?  Could we justify from a biomechanical standpoint that poor hip extension range of motion may be resulting in excessive compensatory pelvic anterior tilt or rotation and increasing the stress on the lower lumbar spine?  Certainly!

If we do this, we need to have a rationale and check our work.  A simple test, treat, retest philosophy will do the trick here.  If you’re making a change in the patient, move forward!  If you’re not, change course!

With every treatment, we need to exercise Evidence Informed Practice where we take the available literature and make clinic decisions on how it applies to our specific patient.   What is the patient’s pain state?  What’s his/her personality?  What do his/her movement patterns look like?  These are issues that are difficult to quantify and make meaningful in an RCT and therefore we may never be able to identify a specific paper for every patient.

References

1. Backstrom KM, Whitman JM, Flynn TW. Lumbar spinal stenosis-diagnosis and management of the aging spine.  Man Ther.  2011;16(4):308-317.
2. Fritz JM, Cleland JA, Child JD. Subgrouping patients with low back pain: Evolution of a classification approach to physical therapy.  J Orthop Sports Phys Ther.  2007;37(5):290-302.  
3. Powers C. The influence of abnormal hip mechanics on knee injury:  A biomechanical perspective.  J Orthop Sports Phys Ther.  2010;40(2):42-51.  
4. Stanton TR, Fritz JM, Hancock J, et al. Evaluation of a treatment-based classification algorithm for low back pain: A cross-sectional study.  Phys Ther.  2011;91(4):1-14.  
5. Whitman JM, Flynn TW, Childs JD, et al. A comparison be­tween two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial. Spine. 2006;31:2541-2549.