Using Evidence Based Practice

If you’re like me, you’re more than a little frustrated when you hear “evidence-based practice” or “evidence-informed practice.”  Shouldn’t everyone just use what the research says works? Why would you spend time doing something that isn’t supported? Because just like everything else, it’s not that simple. 

Evidence-based practice (EBP) is the intersection of the best available evidence, clinical expertise, and patient beliefs or expectations. 

This is often described as a 3-legged stool (here is a great piece on that if you want to read more) which seems like a very stable base to rest our decisions on…but what if the weight isn’t distributed equally or the legs aren’t the same size? How do we know where to place the weight to stay balanced??

Is this: 

The same as this: 

The short answer is YES. Both are EBP.   The point is that EBP is predicated on giving consideration to all 3 legs of the stool during clinical decision making- EBP doesn’t tell you what to do, rather it provides a framework for gathering data and making an informed decision. And that’s why it’s hard.  

The first example is pretty straight forward, right? Imagine you have a patient with knee pain who would benefit from quad strengthening:  

• There is plenty of evidence that says quad strengthening is appropriate for knee pain. 
• Your clinical expertise (or clinical experience if you don’t consider yourself an expert yet) allows you to recall several cases of patients with knee pain who benefitted from quad strengthening.  
• The patient is an avid exerciser and recognizes that when her quads were stronger, her knee felt better.

Perfect, easy clinical decision making. Strengthen the quads! 

Now imagine you have a patient who brings a script that says “Ultrasound for lateral epicondylitis.” How does the process change when:

• There are mounds of evidence that ultrasound (US) is little more than placebo (or at the very least that it doesn’t do what we were taught it does).
• Your clinical expertise tells you that those 7-10 minutes would be better spent doing something else in the clinic.
• The patient believes US works because his tennis partner had lateral epicondylitis 20 years ago and that’s what he says his PT did. 

To ultrasound or not to ultrasound?  The evidence says no.  Your clinical knowledge says no.  Your patient says yes. 

Here’s what I would do:

1. Educate the patient about how much we have learned about the effects of US in the past 20 years.
2. Educate the patient about alternative uses of that time (ie. building rotator cuff and scapular stabilizer strength). 
3. Ask the patient how they want to proceed after my education is complete.
4. Cross my fingers and hope they say “Thanks for all the great education, let’s skip it and strengthen my rotator cuff!”
5. Do the US anyway if that’s what they chose because their expectations are part of my clinical decision making process.

Is my way the right way? It is for me.  This is what I’m comfortable with.  That doesn’t mean this is the right way for you.

If you read that and felt outraged because I would apply a treatment that: (1) has only placebo evidence for support and (2) think it is a waste of time, just because of patient expectations, I get it. I really do. 

You can refuse to apply ultrasound (or cupping, or dry needling, or kinesio tape, or massage, or manual therapy, or Graston, or…do I need to keep going?) and let the patient decide if they want to keep working with you or if they want to find a clinician who will US them.  What I’ve found to be quite effective is to make a deal with the patient. Something along the lines of “let’s try US the first week and exercise the second week. We’ll monitor how you feel with each and make a decision from there.” How many times do you think US has made someone feel better than exercise? I honestly can’t recall a time I’ve had to do US more than once or twice.

At the end of the day, you have to practice in a way that you are comfortable and only you can make that decision. Essentially, you are the key to balancing your stool. Sometimes you’ll put the weight in the wrong place and fall, but most of the time you’ll be able to make small adjustments to keep evidence, expertise and expectations balanced while you deliver the best care to your patient.