Evidence-based physiotherapy practice - editorial

Physiotherapy has become increasingly research-based both nationally and internationally over the past 30 years. Universities and colleges, where physiotherapists are trained, are usually active research institutions. Research means that an activity or treatment is subject to scrutiny and that methods are re-evaluated and often changed. This is a challenge that we must embrace, and we should be prepared to change our way of working if research indicates so.

One debate in physiotherapy emphasises the lack of evidence and questioning of randomised controlled trials and that the profession uses methods that are not evidence-based. Randomised controlled trials form the basis for comparisons of different treatment approaches. However, in recent years other research designs have also been included in reviews, such as clinically controlled studies, observational studies and qualitative studies. Although randomised controlled trials may have weaknesses, especially in comparisons where the underlying cause of the disorder is not known, such as in non-specific spinal disorders, this design is considered to have the greatest evidentiary value. Even in physiotherapy, randomised trials have been of great importance globally. The PEDro database, Physiotherapy Evidence Database from Neuroscience Research Australia (NeuRA), contains over 46 000 randomised studies, systematic reviews and clinical guidelines in physiotherapy [1]. PEDro, which is free online, conduct a quality review as a guide for research and clinical guidelines. Physiotherapy is thus relatively well elucidated in research, although there are many areas where more studies are needed. It should also be emphasised that we are not inferior in terms of evidence than other clinically-focussed specialties. In fact, if you didn’t know you can subscribe to PEDro and click on ‘Evidence in your inbox’ and select from 15 areas of physiotherapy practice.

Evidence is the best available proof that a treatment method is effective. Evidence should be based on a systematic review of multiple studies, which are then combined to provide a measure of evidence: high, medium or low. Clinical guidelines, which may be international, national or local, should underpin an evidence review. For example, an international group of experts in low back pain performed a systematic review of international literature on low back pain published in the Lancet [2–4]. This review is the basis for evidence-based programmes for low back pain in primary care and provides guidelines for physiotherapists to create local programmes.

Several countries have models for evidence-based practice which physiotherapists are required to adhere to in their clinical practice. These models are focussed on professional expertise, i.e. the professional physiotherapist’s practice, which must be based on the best available knowledge generated through research and proven experience. The models also show that the patient’s context, experiences and beliefs are heavily weighted. Thus, the patient’s role in treatment is significant and should be person-centred. An evidence-based approach is thus not only based on the results of scientific studies, but also includes the patient’s context, experiences and beliefs and our professional practice.

Questions often raised are what we have evidence for and whether there are areas where evidence is lacking. The evidence is relatively good for treatment studies, but the specific assessment methods we use are scarcely investigated. It is therefore gratifying that PEDro has launched a new database, DiTA, Diagnostic Test Accuracy [5], which specifically evaluates the diagnostic tests used by physiotherapists.

Should we discard existing methods that are unexplored within research but have been used for a long time in physiotherapy practice based on proven experience? The answer is that they should be subjected to critical review as a basis for continued use. It is a challenge for researchers in physiotherapy to address the gaps that exist, and an even bigger challenge is to make clinicians read research studies. Yet the biggest challenge of all is to change clinical practice. All these steps are challenges for our profession.

Gunnevi Sundelin
Umea University, Umeå, Sweden
[email protected]