How do we practice physical therapy? Do we rely more on clinical experience than on clinical research? For those who overlook clinical research as a tool to improve practice, you are comfortable with the reality that you are a creature of intuition when it comes to the care of your patients.

Ignoring clinical research

It is easy to be critical of a lack of research awareness. The thought of personal preference acting as the sole driving force behind treatment planning would be disturbing from any clinical scientist’s point of view. But, before being accused of malpractice, it might be a good idea for all of us to understand why clinical research is often ignored when treatment decisions are made.

It is frustrating to search the literature for the “correct” way to treat patients and not find an answer. Clinical research often produces contradictory findings regarding the effectiveness of care; contradictions which are not always easy to resolve. Then there is the literature showing that a treatment made no difference in the outcome compared to a sham intervention.

The results of research do not make sense when we believe, in our hearts and through our experience, that our treatment really does help some people. Research looses utility when studies on the efficacy of physical therapy produce negative results and alternative methods of care are not available to put into practice.

The rhetoric surrounding the political movement to achieve an evidence-based practice would have you believe that the literature contains truths which are necessary for you to make the “right” clinical decisions. The literature, however, will not guide you to the truth.

What is the best way to treat a patient with anterior curiae ligament insufficiency, neck pain, or shoulder instability? Research has addressed all of these topics and more, but we ultimately must make inferences about the results of published work when we attempt to apply research findings to the patient sitting in front of us.

Research Methodology Discrepancies

Try developing a physical therapy treatment program based on the scientific literature and it will not take long to discover a lengthy list of discrepancies. The literature has addressed patients with acute symptoms, but your patient has chronic symptoms. The literature described a daily intervention given over several weeks, but your payer allows for only one session of physical therapy. The literature described the success of a rehabilitation program for elite athletes, but your patient is a weekend athlete. The literature described an inpatient treatment program, but you must provide treatment on an outpatient basis.

The problems that we encounter when we attempt to use clinical research to make treatment decisions are real. Some studies used to develop practice guidelines are not “grounded” in the realities of clinical practice. What is the “correct” way to treat a patient with acute low back pain? It depends largely on the inferences that you are willing to make when translating clinical science to clinical practice. There is no absolute truth.

How many (and what type) of discrepancies between the patients described in the literature and the patient sitting in front of you can you accept before you disregard clinical research altogether? It has been said that “. . . the long road between scientific work and the care of a patient is a road of uncertain interpretations, many of which are subjective in nature.

Even the “experts” are divided when attempting to select the best treatment approach. The RAND group, for example, evaluated the risks and benefits of cervical spine manipulative therapy by assessing the clinical opinion ratings of 4 chiropractors, a primary care physician, a neurosurgeon, an orthopaedic surgeon, and 2 neurologists. Each panelist reviewed the same literature packet provided by RAND and then rated over 1400 clinical scenarios. They agreed only 40% of the time.

Evidence-based practice & interpretation

Evidence-based practice is undermined by inference because any number of people who read the same peer-reviewed literature could all arrive at a different interpretation of the best method of treatment. What begins as a search for the correct treatment (by reviewing all the relevant controlled trials) can end as a subjective interpretation of disparate results.

In other words, we may be “forced” to rely on our experience as a guide for treatment, because too much inference was required to apply clinical research to our everyday practice.

The current focus on outcome assessment in our profession does not address evidence-based practice. The “treatments” are not usually considered in outcomes research. When outcomes are assessed, we typically get only a glimpse of the output (patient performance) without knowing the input (treatment). There is no proof for practice in descriptive studies that do not evaluate treatments.

The problem of translating research findings to clinical practice does not go away when quantitative procedures are used to review the literature. In order to combine studies for a meta-analysis, studies must be similar enough to justify blending data from different investigations. Someone must make a judgment about the extent of similarity between studies before doing a meta-analysis. This judgment will determine if a study of patients who received treatment “A” can be combined with studies of patients who received treatments “A+B.”

The rationale that is used to justify combining studies for a meta-analysis, therefore, could limit the usefulness this approach as a tool for clinical decision-making by contaminating the treatment-outcome relationship. It is doubtful if we will ever achieve an “evidence based” practice. Evidence means “proof’ or “confirmation” and inferences neither prove nor confirm a treatment decision. We use inference to make a judgment about the best treatment approach because the literature did not exactly fit our patient or our practice environment.

It also means that your judgment could be different from my judgment (or the insurance company’s judgment) about the content and frequency of care. When we use inference to interpret clinical research for the purpose of making treatment decisions, we are not developing an evidence based practice. It is suggested that we need to abandon the quest for absolute truth and look, instead, at clinical research as way to develop a reasoned philosophy about patient care.

If we realize that there will be different interpretations of the scientific literature, the validation of our practice will not rest on some unattainable absolute truth, but on the soundness of a scholarly argument that presents different possibilities for treatment. How sound is your argument for doing what you do? It is conceivable that even with a preponderance of negative findings in the literature involving a treatment approach that you use, you might justify continuing that particular aspect of care. As long as inference is required to translate research to clinical practice, there will be no proof that any treatment plan is absolutely the best choice or the most appropriate for the patient.

Why should we go through the trouble of trying to use peer-reviewed clinical research as a tool to develop our practice or to make clinical decisions? Because it will challenge us to do better; because contradictions in the literature will lead to a dialogue that will help us improve the efficacy of our practice; and because it will help us develop the skills to use inference in the diagnosis of dysfunction.

An understanding of the literature and a perspective based on clinical experience are equally necessary to practice physical therapy effectively. Without clinical expertise as a guide to the application of clinical research, we will suffer from either the dogma of personal preference when making clinical decisions or the paucity of published findings that are tied to our clinical reality.

(Adapted from Richard Di Fabio J Orthop Sports Phys Ther.Volume 29.Number 11. November 1999)

Enjoy the clinical challenge

David

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