evidence-based rehabilitation and physiotherapy: a ...

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•Scientific straitjacket ? •Reliable and valid response to questions from clinical practice ? Clinical expertise ? •Systematic collection of research data (Cochrane.
• Location of Nijmegen in The Netherlands

• Oldest town of The Netherlands

Marketplace of Nijmegen

EVIDENCE-BASED REHABILITATION AND PHYSIOTHERAPY: A CRITICAL APPRAISAL Prof. Rob A.B. Oostendorp (1942) * physiotherapist (1964) * manual therapist (1972) * professor in Manual Therapy (1989) * professor in Allied Health Sciences (2000)

Points of view

• Evidence-based • •

Medicine (EBM) in rehabilitation and physiotherapy Points of criticism with respect to EBM Finally

Evidence-based Medicine (EBM) in rehabilitation and physiotherapy

• EBM new? • Paradigm shift? • Clinical decisions based on



pathophysiological mechanisms, authoritybased reports, systematic approach of scientific insights and systematic literature reviews Value of the EBM-movement

Points of criticism with respect to EBM

• EBM leads to cookbook medicine • Randomized clinical trials: the best proof ? • Patiënt and EBM ? • Implementation of EBM ? • Evidence of EBM ? • Finally

EBM leads to cookbook medicine

• Loss of professional autonomy ? • Scientific straitjacket ? • Reliable and valid response to questions from clinical practice ? Clinical expertise ? • Systematic collection of research data (Cochrane Library) • Inconsistencies and contradictions !

Inconsistencies and contradictions ! An example: acute low back pain

• Clinical practice guidelines in 12 countries • Favourable prognosis: a view common to all guidelines • Similar information about prognosis of acute low back pain (’90% recover within 6 weeks’) • Lack of supporting evidence ! • Risk of developing chronic low back pain ranges from 2% to 56% • Unable to provide accurate information to patients regarding their prognosis

EBM leads to cookbook medicine

• Loss of professional autonomy ? • Scientific straitjacket ? • Reliable and valid response to questions from clinical practice ? Clinical expertise ? • Systematic collection of research data (Cochrane Library) • Inconsistencies and contradictions ! • Accessibility to clinical practice ? • What means therapeutic freedom ? • Tailoring to the individual patiënt !

Points of criticism with respect to EBM

• EBM leads to cookbook medicine

• Randomized clinical trials (RCT): the best proof?

• Patiënt and EBM • Implementation of EBM • Evidence of EBM • Finally

Randomized clinical trials (RCT): the best proof?

• RCT at the top of therapeutic research designs • Gold standard ? • Significant resistance ! • Medical diagnostic frame (ICD) of reference insufficient for rehabilitation and physiotherapy • Functional diagnostic frame of reference: International • • •

Classification of Functioning, Disabilities and Health (ICF) Accessibilty to clinical practice ? What means therapeutic freedom ? Tailoring to the individual patiënt !

Framework of functioning and disability (ICF, 2001)

Randomized clinical trials (RCT): best proof?

• RCT at the top of therapeutic research designs • Gold standard ? • Significant resistance ! • Medical diagnostic frame of reference insufficient for rehabilitation and physiotherapy • Functional diagnostic frame of reference: International Classification of Functioning, Disabilities and Health (ICF) • Accessibility to clinical practice ? • What means therapeutic freedom ? • Tailoring to the individual patiënt !

Points of criticism with respect to EBM

• EBM leads to cookbook medicine • Randomized clinical trials (RCT): the best proof?

•Patiënt and EBM • Implementation of EBM • Evidence of EBM • Finally

Patiënt and EBM

• Critisism: no room for patients perspective within EBM • In contrast to the description by Sackett et al. • Scientific research freely accessible to patients • Catalyzing factor ? • Emanicipation process of patients • Utopia ?

Points of criticism with respect to EBM

• EBM leads to cookbook medicine • Randomized clinical trials (RCT): the best proof? • Patiënt and EBM

•Implementation of EBM • Evidence of EBM • Finally

Implementation of EBM

• Lack of time and practice logistics • Lack of professional competences • Limited access to high-quality information sources in practice • Inconsistencies and contradictions • Attitude of colleagues and patients • Choice of implementation strategies

Professional Knowledge Development professional employment portfolios

• Preservice experience • Novice professional period • Experienced professional period • Expert professional period

Implementation of EBM: new competences of physician and physiotherapist Ability to: Formulate a search query Systematically search for relevant literature Critically assess results found Make a correct translation transfer to practice

• • • •

Implementation of EBM: effectiveness of search operation in literature

• Information specialists: 72% • Experienced clinicians: 48% • Non-experienced clinicians: 29% • Requirement of training of physician and physiotherapist: Evidence-based Rehabilitation. A Guide to Practice (Law, 2005)

Points of criticism with respect to EBM

• EBM leads to cookbook medicine • Randomized clinical trials (RCT)Z: the best proof? • Patiënt and EBM • Implementation of EBM

•Evidence of EBM • Finally

Evidence of EBM

• Assumption: an up-to-date and critical • •

standpoint to their own daily practice would be better in taking the correct clinical decision for the individual patiënt Clinical decison based on experience and expertise of physicians and physiotherapists Growing evidence that practical action according to EBM is more effective and the outcome for the patiënt will improve

Points of criticism with respect to EBM

• EBM leads to cookbook medicine • Randomized clinical trials (RCT): the best proof? • Patiënt and EBM • Implementation of EBM • Evidence of EBM

•Finally

Finally

• EBM: support of clinical decisions in practice • EBM: no cookbook • EBM: optimum care in addition to clinical expertise and patient values • EBM: no loss of professional autonomy • EBM: subject to criticism • EBM: increase of professional acceptance • EBM: promotion through adequate implementation strategies • EBM: competences to make use of available scientific sources