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Evidence-based Rehabilitation Medicine and Physiotherapy: A Critical Appraisal

Rob A.B. Oostendorp 1,2 (A,E,F)
Maria W.G. Nijhuis-van der Sanden 2,3 (E)
Yvonne F. Heerkens 1,4 (A,E,F)
Erik H.M. Hendriks 1,5 (A,E,F)
Peter A. Huijbregts 6 (E)

Abstract:
Evidence-based medicine is the current undisputed predominant paradigm within medicine and allied health care. Guidelines for standardized reporting of research findings have facilitated critical evaluation of the relevant research literature. In addition, systematic reviews of the literature made available through computerized databases allow even busy clinicians and researchers rapid access to current best evidence. Despite the potential benefits of Evidence-Based Medicine (EBM) to clinical practice, over the years various points of criticism with respect to EBM have been formulated. This article provides a critical appraisal of the EBM paradigm discussing perceptions of EBM as cookbook medicine, inconsistency and contradiction in research findings, a proposed research pyramid not necessarily emphasizing the randomized controlled trial, a conceptual framework more relevant to the clinical and research needs of rehabilitation medicine and physiotherapy, the role of and impact on patients within the EBM paradigm, implementation of EBM, but also the current lack of evidence for increased efficacy of patient management based on EBM. The research base used in the EBM paradigm to support clinical decision-making is still far from complete. Demonstrating scientific evidence for EBM is a difficult task. Yet the EBM movement is of great importance for rehabilitation and physiotherapy to allow for increased transparency of care. The purpose of promoting this paradigm is optimum quality of care with conservation of professional autonomy.

Keywords: EBM, rehabilitation medicine, physiotherapy, critical appraisal

Introduction

Since the introduction of evidence-based medicine (EBM) in rehabilitation medicine and physiotherapy, clinicians in both fields have – some more willingly perhaps than others-increasingly been using current, research-based information for clinical decision-making in the care of individual patients1. However, the basic concept in EBM that clinical procedures should be based on scientific data is anything but a recent advent. For some 20 years now this concept has gained momentum and credibility, as EBM has evolved into the undisputed predominant international paradigm within medicine and allied health.

With regard to this increasing role of EBM, there is often talk of a paradigm shift. In other words,
EBM is said to have led to the introduction and adoption of a whole set of values, techniques, and convictions in medicine and allied health distinctly different from those present before the introduction of EBM. There is a greater quantity of scientific information and the availability of this information has also increased considerably. Where formerly insights into pathophysiological mechanisms were the most important source for clinical decisionmaking, now a multitude of diagnostic and therapeutic research is available and accessible in the form of systematic reviews of the literature. Whereas previously many publications were written based solely or predominantly on author authority, now authors are required to clearly indicate the path that was followed to reach the results presented. Research should be reported in a transparent manner, such that readers may follow along in the planning, implementation, results, and conclusion stages. The credibility of research depends on a critical assessment of strengths and weaknesses in study design, conduct, analysis, and conclusion. Transparent reporting is needed to allow critical assessment but also to determine if and how results can be included in systematic reviews of the literature. Various checklists have been developed that contain recommendations on the reporting of research with the aim of improving reporting quality.

The CONSORT statement (an acronym for consolidated standards of reporting trials) was developed in 1996 and revised five years later2. Many medical journals have supported this initiative, which has helped to improve the quality of reporting of randomized controlled trials. Similar initiatives have followed for other research areas, e.g., for diagnostic studies in form of the STARD criterion list (standards for reporting of diagnostic accuracy)3,4. Recently guidelines have also been developed for reporting observational studies (STROBE statement)5. The STROBE statement is a checklist of items that should be addressed in articles reporting on cohort, cross-sectional, and case-control studies. The requirements outlined in these checklists make the literature increasingly transparent and contribute to a more systematic approach to the production and dissemination of scientific insights into clinical practice. This is perhaps the greatest value of the EBM paradigm.

However, transparent and standardized reporting of relevant research is only one step when it comes to integrating current research-based evidence into clinical practice. With the ever-increasing multitude of relevant research available, busy clinicians and researchers may find it hard to keep up-to-date. Making large amounts of research more readily available, the Cochrane Collaboration has played an important pioneering role in the field of the systematic collection of research data. The Cochrane Library currently consists of over 2,200 systematic reviews of the literature, of which several hundred are in the area of rehabilitation medicine and physiotherapy. Thus, the Cochrane Library is one of the most useful references with regard to the scientific validation of daily clinical practice in physiotherapy and rehabilitation medicine.

Another such useful reference, but more specific to physiotherapy, is the Physiotherapy Evidence Database (PEDro), which is maintained by the Centre for Evidence Based Physiotherapy of the University of Sydney in Australia and the University of Maastricht in the Netherlands. Randomized trials included in the PEDro database are rated to help physiotherapists quickly assess methodological quality and thereby discriminate between trials. These ratings help therapists to judge the usefulness of the results of trials to inform clinical decision-making.

Recently the BMJ Publishing Group and the Health Information Unit at McMaster University in Canada have teamed up to provide bmjupdates+. The goal for this service is to provide clinicians with the best new evidence concerning important advances in health care, tailored to their interests. For clinicians such as physicians and physiotherapists, aiming to keep up with the most relevant studies and reviews, the 2-step process used for the bmjupdates+ shrinks the number of articles they need to read from on average 100 articles in 10 different journals to only 2-3 per month, a reduction of about 99% in required reading. After consulting databases and initiatives such as bmjupdates+ that allow access to systematic reviews of relevant literature, the physician or physiotherapist then determines based on clinical expertise whether the results can be applied to the individual patient consulting the clinician with a health problem.

Despite the potential benefits of EBM to clinical practice described above, over the years various points of criticism with respect to EBM have been formulated. Therefore, the aim of this article is to provide a critical appraisal of the EBM paradigm.

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