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Lecture

Robert

Evidence-Based

Physical

Therapy

*

D.

Herberti'2,

Catherine

Sherringtoni'3,

Anne

M

Christopher

Maheri'2

and

Mark

EIkinsL5MoseleyL4,

Abstract

Professional

practice

has

always

been

based

on evidence of one sort or another,

So

what

is

new about

''evidence-based"

practice

and

hew

does

evidence-based

_practice

differ

from

_what

health

_{professionals}

_have

always

done?

The

novelty of evidence-based

_practice

_is

that

it

emphasizes routine, systematic and criti-cal use

of

high

_quality

clinical research

for

setving clinical

_problems.

Antagonists

have

raised a series of objections

to

evidence-based

_practice

including

that

it

is

too

time-consummg,

there

is

not enough evidence, and

the

eviclence

is

not

_good

enough.

We

consider

these

and other objections and conclude

that,

while

there

is

some

truth

in

each, none need

preclude

evidence-based

practice.

Difficulties

_in

_{implementation}

of evidence-based

practice

need

to

be

weighed against

the

bene-fits

of

basing

clinicat

practice

on

_the

least

_biased

_forms

of evidence.

Randomized

triats

and systematic reviews new

provide

us with suthcient evidence

to

make

informed

judgments

about

the

effects of a range of

physical

therapy

interventions.

The

best

evidence confirms

the

value of some current

_physical

therapy

practices

and

the

ineffectiveness

of others.

We

briefiy

summarize

studies which

demonstrate

the

effectiveness of

physical

therapy

interventiens

for

chronic musculoske}etal

pain,

stress urmary incontinence, stroke, respiratory

disease

and

prevention

of

falls

in

the

elderly,

Key

word:

physical

therapy,

evidence-based medicine

This

paper

considers some

theoretical

and

_practical

issues

related

to

implementation

of evidence-based

phys-ical

therapy.

It

begins

with a

brief

overview

of

what

is

implied

by

evidence-based

_practice

and

discusses

_how

this

differs

from

traditienal

clinical

_practice.

It

_then

con-siders some

frequently

raised objections

te

the

evidence-based

_practice

model.

The

paper

conctudes

by

summa-rizing evidence of

the

effectiveness of some

key

physi-cal

therapy

interventions,

Most

of

the

material

in

this

paper

has

been

previously

published

in

English-tanguage

*1)2)3)4)5}

_{pt\tsdiptv:nd<mp7rkza}

Centre

for

Evidence-Based

Physiotherapy,

Scheot

of

Physio-therapy, University ef

Sydney,

Australia

School

of

PhysiotherHpy,

University

of

Sydney,

Australia

Prince

of

Wales

Medical

Research

Institute,

Australia

Rehabilitation

Studies

Unlt,

Department of

Medicine.

University

of

Sydney,

Australia

Department of

Respiratory

Medicine.

Royal

Prince

Alfred

Hospital,

Austraiia

Corresponclence/

Dr.

Reb

Herbert,

School

of Physiotherapy,

University

of

Sydney.

PO

Box

170,

Lidcombe

NSW

1825,Australia

(e-mail/

R.Herbert@ths.usyd.edu.au)

journalsi'3).

What

is

Evidence-Based

Practice?

Sackett

and colleagues coneeive ofevidence-based

prac-tice

as

consisting

of a

five-step

process

that

is

routinely carried

out

in

clinical encounters,

The

_process

_involves

(i},

asking

answerable

clinical

questions,

{ii},

finding

the

best

evidence with which

to

answer

these

_questions,

_(iii),

critically appraising

the

evidence,

(iv),

applying

the

evi-dence

to

clinical

_problems,

and

(v),

evaluating

_the

effects of

the

interventien

on

individuals4}.

These

five

steps allude

to

some of

the

most

important

distinctions

between

evidence-based

practice

and

tradi-tional

models of clinieal

_practice.

First,

evidence-based

practice

begins

with an acknowledgment of uncertainty,

This

contrasts with some

traditional

models of clinical

practice

in

which uncertainty

is

seen as a

failing.

An

attitude of itncertainty

_is

_likely

to

better

equip

health

professionals

to

deal

with rapidly changing evidence.

432

ge7esza4

A

secend

distinction

is

that

evidence-based

practice

emphasizes systematic and

critical

use ef evidence4).

It

involves

recording

questions

that

arise

in

clinical

prac-tice,

ranking

them

in

order of

importance,

and

then

tack-ling

them

in

an optimal way,

Evidence

is

chosen on

the

basis

of

its

probable

validity.

There

is

an emphasis en

deciding

if

the

intervention

will

_produce

the

desired

out-comes without unreasonable risks and at a reasonable cost.

This

differs

from

traditional

models of

practice

in

which

there

may

be

priority

given

to

elinical experience as a

form

of

evidence5)6), where research evidenee

is

often

happened

upon

rather

than

strategically sought out, and where appraisal of

the

quality

of clinicaL research

is

superficial or

does

not occur at all.

A

systematic approaeh

to

the

use

of evidence

helps

avoid

the

temptatien

to

attend only

to

that

evidenee which supports

pre-cen-ceived

ideas

of which

therapies

are effective.

An

implicit

assumption of

the

evidence-based

_practice

model

is

that

well-cenducted clinical research often

pro-vides

the

best

answers

to

clinical

questions.

That

is,

where

good

quality,

relevanz clinical research

is

available

it

usually

takes

precedence

ever

theory

or

_personal

expe-rience, even

the

theories

or experiences of experts7)

(but

see reference

8).

The

role of clinical experience, clinical wisdom and

intuition

is

primarily

in

making

best

use of

good

evidence

to

meet

individual

patients'

needs and

preferences.

The

requirement of "good evidence" necessarily

restricts

the

focus

in

evidence-based

practice

to

optima]ly

designed

clinical research,

The

optimal study

design

will

depend

on

the

clinical

question.

For

example,

the

best

evidence about

the

effects

of

therapy

is

previded

by

ran-domized

trials

or systematie reviews of randomized

tri-als7)9'i3)

{but

also

see

references

14,

15

and

the

ensuing

letters).

Questiens

about

diagnostic

tests

are usually

best

answered

by

studies

in

which

there

is

independent

(blind)

comparison

of

the

tesz

with a

"gold

standard"

test

4)i6).

Questions

about

prognosis

are

best

answered

by

studies

which

prospectively

monitor well-defined cohorts

from

an early and uniform

point

in

the

eourse of

their

condi-tion4)i7).

The

most

difficult

questions,

those

about

patients'

beliefs

and

the

meanings

they

attach

to

their

experi-ences, may

be

best

explored with carefully conducted

qualitative

researchi8)i9).

Evidence-based

practice

does

not

imply

that

clinical

decisions

should

be

made on the

basis

of clinical research

alone.

Key

proponents

of evidence-based

healthcare

have

emphastzed

that

the

evidence

provided

by

cUnical research must cemplement other sorts of

information,

such as

information

about

individual

patients'

specific

needs and

preferences4}8),

Good

clinicians are able

to

dis-es3otseese

cern

these

needs and

preferences.

In

the

best

models of evidence-based

_practiee,

evidence about

the

effects of

therapy

_{or

accuracy of

diagnestic

tests,

or of

_prognoses)

informs,

but

does

not

dominate

clinical

decision-making.

The

physical

therapist

draws

on

past

clinical experience

to

apply

the

results of research

to

the

care of

individ-ual

patients.

The

best

decisions

are made with the

patient,

not

in

journals

and

books.

Objections

to

Evidence-Based

Practice

The

_preceding

section

has

deseribed

a model of clini-eal

_practice

that

probably

differs

significantly

from

what

happens

in

even

the

most evidence-based clinical

set-tings.

Real-world

evidence-based

_practice

faces

significant

practical

diffcuLties,

In

addition,

legitimate

philesophical

and

theoretieal

objections

have

been

raised against mod-els of evidence-based

practice

(see,

for

example, refer-ences

20,

21).

In

this

section we attempt

to

confront some of

the

objections

to

evidence-based

practice,

The

emphasis will

be

on objections

to

the

use

of

systematic reviews and

randomized controLled

trials

in

rnaking

decisions

about

therapy,

Our

conclusions will

be

that

there

are,

indeed,

some serious

practicaL

theoretical

and

philosophical

prob-lems

with evidence-based

practice,

Nonetheless,

evidence-based

practice

offers at

least

one

profound

advantage over a!ternative models of clinical

_practice

in

that

opti-mal use

is

made ef

the

least-biased

evidence

from

clini-cal research,

What

are

these

_practical,

theoretical

and

philosophical

objections

to

evidence-based

practice?

Evidence-based

practice

is

too

tiine-consuming

to

be

prac-tical

Even

with

practice

and optimal resources,

the

process

of

finding

and

critically appraising

the

best

evidence

per-taining

te

a single clinical

question

usually

takes

consid-erable

time.

As

a consequence,

it

is

not

practical

to

use

the

best

evidence

to

deal

with every uncertainty

that

arlses

in

every clinical encounter, and even

if

there

was

good

quality

evidence

to

answer allclinical

questions,

not all

practice

could

be

evidence-based.

Any

realistic model

of evidence-based

practice

must

invotve

prioritizing

clin-ical

questiens.

Time

shou!d

be

devoted

to

answering

questions

that

are commonly seen

in

practice,

have

important

censequences,

have

potential

for

either

bene-ficia!

or

harmful

treatment,

or

incur

considerable cest22).

How

much

time

is

and should

be

spent seeking out and appraising

the

evidence?

Most

physical

therapists

spend

little

time reading clinical research23) and,

because

few

physical

therapists

have

training

in

clinical appraisaL

NII-Electronic Library Service

Evidence-Based

reading

time

may

be

spent sub-optimally.

Rational

deter-mination of the amount of time

that

should

be

spent

seeking out and appraising evidence requires

information

both

about

the

effectiveness of current clinical

_practices

and about

how

much of an

improvement

in

effectiveness could

be

accrued

in

a

given

amount of

time

by

search-ing

for

and appraising

_papers.

Unfertunately,

data

on

these

issues

are elusive.

Our

view

is

that

much of

clin-ical

practice

is

far

from

optimally effective and

that

potentially

even modest amounts of

time

spent

in

the

judicious

application of evidence

to

clinical

decision

mak-ing

could substantially

improve

clinieal outcomes.

As

just

one example, exercise

is

_prescribed

with equal

frequen-cy

for

acute and chronic

low

back

_pain24)

but

systemat-ic

reviews

indicate

there

is

strong evidence

that

exer-cise

therapy

is

effective

for

chrenic,

but

not acute,

low

back

pain25)26}.

This

suggests

that

changes

in

exercise

prescriptien

practices

could significant}y

improve

out-comes

in

patients

with

low

back

pain,

We

expect

that

many

_practices

would converge rapidly on

this

outcome

if

scaree

time

was used

to

answer

key

clinical

questions.

Most

clinicians are

busy.

Where

can they

find

time

to seek and critically appraise

the

evidence

from

ctinical research?

There

are numerous

_{possibilities.}

Time

spent

in

formal

continuing educatien activities

(staff

seminars,

for

example) may

be

better

spent

by

individuals

or small

groups

of

_physical

therapists

answering

their

own

clini-cal

questions.

Depencling

on

the

clinical

setting,

case

con-ferences

eould

also

be

re-struetured

so

that

they

create

learning

experiences

for

staff

as well

as

deal

with

patient's

problems.

These

and other suggestions

have

been

made

by

Sackett

and colleagues4).

Time

spent

busi-ly

applying

ineffective

or

harmful

therapies

would

be

bet-ter

spent seeking out and critically appraising

best

evi-Physical

Therapy

433

dence,

Secondary

sources of

information

{such

as

the

clinical

practice

guidelines,

ACP

_Journal

_Club,

Evidence-Based

Medicine

and

Critically

Appraised

Papers

in

the

Australian

Journal

of

Physiotherapy)

distill

the

key

ings

of

high-quality

_papers.

Consequently

_they

ly

provide

a significant

time-saving

mechanism

for

_busy

PractitionersZ7}2S).

7}tere

is

not enough evidence

Ideally,

at

teast

from

a

purely

professional

point

of

view, there would

be

_good

clinical

research answering

all

important

clinical

_questions.

Of

eourse,

that

is

not

_the

case.

It

has

been

claimed

that

there

is

not enough

dence

to

_practice

evidence-based

_physical

therapyZ9).

How

rnuch clinical research exists and

hew

rnuch can

it

assist

clinical

decision

making?

It

ls

difficuit

to

quantify

the

volume of ciinica[ research

in

physical

therapy,

However

it

is

possible

to

estimate,

at

least

rQughly,

the

number of relevant randomized

als and

systematic

reviews.

The

Centre

for

Based

Physicai

Therapy,

with assistance

from,

among

others,

the

Rehabilitation

and

Related

Therapies

Field

of

the

Cochrane

CoLlaboration,

has

attempted

to

identify

al]

randomized controlled trials and systematic reviews

in

physical

therapy

and collate

these

on

the

Physiotherapy

Evidence

Database

{PEDro/

httpi!fwww.pedro.ihs.usyd.

edu.au).

At

the

time

of

writing

3,152

randomized

or

randomized

trials

and

514

systematic

reviews

had

been

identified

(see

al$o references

_3,

_30).

More

than

200

domized

trials

and systematic reviews on

PEDro

_pertain

to

each ef the

folaowing

subdisciplines of

physical

py:

cardiothoracics, continence and women"s

health,

gerontology,

musculoskeletal, neurology, orthopedics and

Musculoskeletal

Gerontology

Cardiothoracics

Neurology

Orthopaedics

Sports

Women's

Health

Paediatrics

Ergonomics

Other

Fig.1

Number

available

(reprinted

O

200

400

600

800

1000

Number

of

records

of randomized controtled trials and systematic reviews

in

each

physical

therapy

sub-discipline

ln

April

2002

434

mp#fftzeeg3otseese

covL-oomL.-oLooE=c

¢

>-.--tusE=o

2500

2000

1500

1OOO

500

Fig.

2

o19551960

1965

19701975

1980

Year

Cumuiative

number of randomized

reviews

in

_physical

therapy

by

year

reference

[3},

with permission}

1985

1990

1995

2000

controlled trials and systematic

{reprinted

from

Figure

1,

p,

44

of

eligibility

criteria

random

allocation

concealedallocation

groups

similar at

baseline

subject

b[indjng

therapist

blinding

assessor

blinding

<

15%

dropouts

intention-to-treatanalysis

between-groupstatisticalcomparisons

point

measures

and

variability

data

Fig.

3

o

20

40

60

80

%

of

randomized

controHed

trials

Percentage

ofrated randomlzed controlled

trials

that

satisfied each

item

of

the

PEDre

scale

(reprTnted

from

Figure

4,

p.

45

ofreference

E3],

with

permissien)

sports

(Fig.

1)3).

This

is

eneugh

to

tackle

many

funda-mental clinical

questions,

though

there

are not

yet

enough

trials

in

most areas of

physical

therapy

to

pro-vide convincing replication on every

permutation

ef

ther-apy

in

every setting

for

every

patient

group.

In

some areas of

physical

therapy,

the

volume of

trials

and reviews

is

not sufficient

to

have

any real

impact

on

clin-ical

practice.

However,

given

the

exponential rate ef

pub-lication

of clinical

trials

and systematic reviews

in

phys-ical

therapy,

{Fig.

2)3)

this

will almost certainly change

in

the

near

future.

It

is

like]y

that

most clinicians

have

not read allof the

high

quality

evidence

that

pertains

to

their

own clinical

questions.

In

this

sense at

least

there

is

an abundance

of evidence.

It

is

probably

reasonable

te

expect al]

prac-tising

therapists

to

be

aware of

key

trials

and reviews

in

their

area of

_practice.

1}ie

evidence

is

not

_good

enough

Certain

features

of clinical

trials

{such

as concealment

of randomisation,

blinding

of subjects and asses$ors, and adequacy of

follew-up}

tend

to

be

associated with small-er effect sizes, suggesting

trials

which

have

these

fea-tures

tend

to

be

less

biased:Si),

Other

trials

iack

these

features,

and so we should expect

that,

on average,

they

will

be

biased.

In

physical

therapy,

the

typical

random-ized

trial

laeks

concealment of allocation and

has

unblind-ed

_patients,

assessors and

therapists,

but

does

have

ade-quate

follow-up

(Fig.

3}3),

There

must

be

real concern about

the

capacity of

the

ryplcal trialto

_provide

an

unbi-ased

picture

of

the

effects of

therapy.

Fortunately,

the

NII-Electronic Library Service

Eviclence-Based

Trials

on

PEDre

are scored

for

methodological

quality

and

the

median

PEDro

score

for

randomized

trials

in

physical

therapy

has

crept up

from

3flO

in

the

I960s

to

its

current value of

5flO.

Systematic

reviews

{such

as

those

conducted

by

the

Cochrane

Collaboration)

synthesize

the

findings

of

clini-cal

trials,

Ideally,

systematic reviews weuld objectively assess

trial

quality

and

then

pool

the

findings

of

high

quality

studies

to

provide

less

biased

and more

precise

estimates of

the

effects of

therapy.

However,

there

are some real

difficulties

that

arise when an attempt

is

made

to

systematically review clinical

trials

in

all areas of

health

care.

Three

such

preblems

are

discussed

below.

The

first

two

issues

are a]so relevant

te

readers of

indi-vLdual clinical

trlals.

L

Pub]ication

bias,

This

is

the

bias

that

arises

because

trials

with

positive

findings

are more

likely

to

be

pubEshed

than

trials

with negative

findings.

A

sequence

is

that

positive

studies are more

likely

to

be

reviewed, and reviews are

likeLy

to

contain

ed estimates of

treatment

effects32),

Although

it

is

often assumed

that

exhaustive searching reduces

the

potentiat

for

publication

bias,

it

is

possibie

that

this

actually

increases

the

potentiul

for

bias

by

ing

lower

quality

studies

in

the

review33).

There

are

currently no completely satisfactery solutions

te

the

problem

of

_pttblication

biasU4}.

2.

Scoring

of study

_quality.

SystemaLic

reviews must

take

account

of

study

_quality

if

they are

to

_produce

unbiased estimates of

the

effects of

treatment.

However,

methods

for

assessing

trial

_quality

have

not

yet

been

futly

validated3i)35), se we cannot

yet

be

sure that mechanisms

fer

rating study

quality

are

truly

abge

to

discriminate

between

trials

that

are and are not

likely

to

be

biased.

How

potentially

biased

does

a study

have

te

be

before

it

should no

longer

be

used

fer

clinical

sien-making?

The

answer should

depend

on

the

degree

of confidence

that

is

held

in

other

tion

that

pertains

to

the

clinical

question

at

hand,

As

a working

prineiple,

the

threshold

of

quality

should

be

that

the

study must

be

able

to

provide

more certainty

than

the

reader already

has.

Our

opinion

is

that,

in

practice,

there

will usually

be

tle

point

in

reading clinical

trials

that

do

not employ

true

randomisation,

have

reasonable

levels

of

up, and

blind

assessors.

3.

Synthesis

of

findings.

Idealty,

systematic reviews are

accompanied

by

meta-analyses

that

provide

pooled

estimates of treatment effects.

However,

sis

is

enly

indicated

when

the

individual

studies are

Physical

Therapy

435

of sufficient

quality

and when

there

is

sufficient

homogeneity

of

interventions,

outcomes and

findings

acress studies.

When

heterogeneity

precludes

analysis, some authors cenduct "Ievels of evidence"

syntheses

in

which

the

quality

of evidence

porting

a conclusion

is

rated according

to

a

termined

scale of study

quality

and consistency of

findings.

Unfortunately

the

findings

ef

levels

of

dence

syntheses may

depend

heavily

on

the

rating

system used, and may

be

unduly sensitive

te

the

findings

of

individual

studies36),

These

three

problems

(publication

bias,

and

the

culties

in

assessing

trial

quality

and synthesising

trial

findings)

lirrLit

our confidence

in

the

cenclusions of

domized

trials

and systematic reviews.

Nonetheless,

they

sheuld

be

put

in

perspective:

other sources of

tion

about

the

effects of

therapies

such as clinical

rience er

theory

or unconzrolled studies are

probably

prone

to

more serious

bias.

Mttny

readers are unabte

to

discriminate

between,

studies

which a,re

_probabty

vatid and

those

tvhich are

_probabty

not

Almost

all methodological surveys and most

atic reviews

in

physical

therapy

have

decried

the

ity

of

published

research

(eg,

reference

37).

This

is

tially

_problematic

because

many

_physical

therapists

do

not

have

sufficient

training

in

research methodolegy

to

confidentiy

distinguish

between

studies of

high

and

low

quality.

There

is

a risk of many readers

being

mis]ead

by

potentially

biased

studies.

The

evenzual so}utien must

be

that

physical

therapists

will

deveLop

the

skills

to

critically appraise clinieal

research.

Most

undergraduate curricula now

teach

research methods and

increasingly

more explicitly

teach

critical appraisal of clinical research, so

in

the

near

future

we may

be

able

to

expect new

_graduates

to

have

basic

criticat appraisal skills.

Those

who

have

already

ated will

have

to seek out

training

in

skills of critical

appraisaHf

they

are

to

practise

evidence-based

physical

therapy.

It

is

to

be

hoped

that

they

do

so with

the

same

enthusiasm

that

most

physical

therapists

apply

to

the

developmenl/

of other clinical skills.

Some

simple strategies may enhance

physical

pists'

abilities

to

distinguish

between

high

and

Low

ity

evidence.

These

include

the use of methodological

ters"

4)3S)

or use of methodological ratings

from

the

PEDro

database

to

screen out

low

_quality

research.

Secondary

sources of

publicatien,

such as

those

referred

to

earlier,

can

perferm

much of

the

work of critical appraisal

fer

clinicians who

lack

critical appraisal skills.

Some

of

these,

436

ge"utideV

sueh as

Cochrane

Systematic

Reviews,

are

quite

uni-formly

of

high

qualtty

and can

generally

be

censidered

to

provide

an unbiased synthesis of

the

Literature,

Onty

patient-centpmed

research can reatly

tete

us about

peoples'

experiences

We

want clinicat

trials

to

tell

us about

how

much a

therapy

affects a

_patient

in

terms

that

matter

to

patients.

A

problem

with clinical

trials

is

that

they

only measure outcomes

that

the

experimenter

perceives

as

important

and

they

do

not

permit

complete expression of what

patients

feel

when

given

a

particular

therapyS)i8)39),

At

ene

level

many

trials

do

measure

the

effects of

therapy

in

terms

that

patients

themselves

deem

to

be

important

Many

trials

now measure eutcomes such as

"global

perceived

effect" or

"preference

for

treatment''

because

it

is

thought

that

measurement of

these

out-comes

gives

patients

the

opportunity

to

assign

appre-priate

weighting to their

feelings

of

their

respenses to

therapy.

Nonetheless,

these

single-dimensional outcomes

provide

little

opportunity

for

patients

to

express

the

breadth

of

their

feelings

about the effects of

therapies40),

The

need

for

patient-centered

outcomes

in

clinical

tri-als suggests one

important

way

(but

not

the

only way)

in

which

qualitative

and

_quantitative

research can

com-plement

each other

in

evidence-based

_practiee.

Qualitative

research can

inform

the

designers

of clinical

trials

about what consumers see as

the

important

issues

when choosing

therapiesiS).

Such

censiderations

_probably

should

be,

but

rarely are,

paramount.

thidence-based

p7iu]tice

removes

the

clinicat

decision-making role

from

ctinicians and

_gives

it

to

managers

There

is

a view

that

evidence-based

_practice

takes

clin-ical

decision-making

out of clinicians'

hands,

In

our view,

this

is

not

intrinsically

wrong:

there

is

no

intrinsie

right of

therapists

to

be

solely responsible

for

clinical

decision-making.

Instead,

the

_{justification}

for

clinician-as-decision-maker

lies

in

the

reasonable expectatien

that

this

pro-vides

the

best

possible

care alld outcomes,

Nonetheless,

Sackett

and colleagues

have

argued

that

evidence-based

practice

does

not subjugate

responsibili-ty

for

clinical

decision-making4i}.

Instead,

it

emphasizes

the

role of clinicians

in

using evidence

to

answer

their

own clinieal

_preblems,

and removes

the

constraint of

tra-dition

from

clinicai

practice,

In

evidence-based

_practice

the

responsibility

for

clinical

decisiens

is

taken

away

from

how-to

textbooks

and

devolved

to

indiviclual

practition-ers and

their

patients.

ca30tsca8

£

What

Does

the

Evidence

Say?

The

massive recent

growth

in

the

number of

ran-domized

trials

and systematic reviews

has

provided

us with a wealth of

information

to

guide

clinical

practice.

In

_particular,

there

is

now much

information

about

the

effects of

physicai

therapy

interventions.

In

this

sectien we

briefly

summarise

findings

from

ran-domized

trials and systematic reviews of

the

effective-ness of a range of

physical

therapy

interventions,

The

best

evidenee confirms

the

value of some current

phys-ical

therapy

practices

and

the

ineffectiveness

of others.

Some

little-used

interventions

have

been

found

to

pro-duce

remarkably

benefieial

effects.

Chronic

muscutosketetat

_pain

Musculoskeletal

disorders

are

the

most common cause of chronic

incapacity

in

industrialized

countries42).

Fortunately,

some of

the

most

impertant

advances

in

physical

therapy

have

been

in

the

management

of

these

problems,

parLicularly

chronic

Iow

back

_pain,

osteoarthri-tis

of

the

hip

and

knee,

and rheumateid arthritis.

There

is

strong evidence

from

recent studies

that

sim-ple

interventions

provided

soon after symptom onset can

prevent

the

development

of chronic

back

_pain.

For

exam-ple,

the

provision

of reassurance about

the

self-limiting nature

of

mest

low

back

_pain

and advice

to

return

to

normal activity

as

soon

as

possible

increases

the

rate ef return

to

work

for

workers with

lew

back

pain43}.

On

the

ether

hand,

encouraging rest

is

_probably

harmfu143)").

Traditionally

the

mainstays ef

_physical

therapy

man-agement of musculoskeletal

_pain

have

been

massage, manual

therapy

_{that

is,

manipulation and

joint

mobi-lization),

electrotherapy

(such

as

therapeutlc

ultrasound,

shortwave

diathermy

and

low-energy

Iaser}

and

thera-peutic

exercise.

Current

evidence

paints

a

mixed

_picture

of

the

effects ef

these

interventions.

There

has

been

lit-tle

rigorous research

into

the effects of massage45}, se

the

clinicai

benefits

of massage,

if

any, remain unsub-stantiated46),

Manual

therapy

is

more effective

than

place-bo

in

relieving

low

back

pain

but

it

is

not

yet

clear

if

it

is

more effective

than

other

_physical

therapy

treat-ments26).

Most

electrotherapies

probably

have

little

more

than

_placebo

effects47}.

The

most

_positive

findings

come

from

recent studies of

therapeutic

exercise.

Many

trials

and

several reviews

have

now shown

that

exercise can

produce

clinically worthwhile reductions

in

the

disabili-ty

and

handicap

associated with chronic

low

back

pain,

osteoarthritis of

the

hip

and

knee,

and rheumatoid

arthri-tis26)4S)4g).

effec-NII-Electronic Library Service

Evidence-Based

tive

in

contemporary clinical

trials

differ

from

tradition-al exercise

in

twe

important

ways,

First

contemporary

practice

is

to

consider

fermal

exercise

pregrams

as

_part

of a more

global

_process

of `activity

prescription'

involv-ing

astructured return

to

normal

home,

werk and social activities.

Second,

where

_previously

the

biological

sci-ences

_provided

an exclusive

theoretical

basis

for

exer-cise

_{prescriptien,}

contemporary

programs

now alse

draw

from

behavioral

sciences.

Many

exercise

programs

now explicitly

incorporate

_principles

of cognitive-behavioral

therapysc).

With

this

approaeh,

patients

are

taught

to

exercise to

_quotas

rather

than

as symptoms

_permit,

spe-cific rewards

are

provided

when exercise

_quotas

er

activ-ity

_goals

are met, and

pain

behaviors

are not rewarded

by

therapist

attention.

Stress

urina7:y

incontinence

About

25%

of women experience

involuntary

loss

of

urine,

and

abeut

2.5%

report

this

causes much

bether

or a

_great

_problem5i).

The

_problem

of urinary

incontinence

in

women,

including

_genuine

stress urinary

incontinence,

can

be

treated

effectively with

_pelvic

floor

muscle

train-ing52).

Pelvic

floor

muscle

training

with weighted vaginal

cones

(weights

inserted

into

the

vagina}

substantially

increases

probability

ef cure or

improvement

compared

to

ne-exercise control conditions53).

An

important

recent

trial

of

the

effects of

pelvic

floor

muscle

training

for

women with

_genuine

stress urinary

incontinence

has

shewn

that

six months of

training

with

8

near-maximal

pelvic

floor

muscle contractions

thrice

daily

_produces

large

reductions

in

the

risk of

incontinence-related

prob-Iems

with

social

life,

sex

life

and

_physical

activity54).

In

this

sample

<mean

duration

of symptoms

10

_years),

absolute reductions

in

risk of each of

these

_problems

exceeded

35%,

implying

that

at

least

one

in

three

women

experiences

each

of

these

benefits

from

exercise,

It

is

not clear

if

training

with weighted cones,

biofeedback

(electromyographic

feedback

of

pelvic

floor

muscle

activ-ity)

or electrical stimulation

_produces

better

outcomes compared

to

pelvic

fioor

muscle

training

alone52)54}

(but

see reference

55}.

nfovement

dyojltnction

resulting

,1hom

stroke

In

terms

of

disability-adjusted

life

_years,

stroke ranks as

the

sixth

highest

cause ef

burden

of

disease

world-wicle and

is

the

single most

important

cause oE severe

disability

in

people

living

in

their

own

homes56}.

Multidisciplinary

rehabilitation

_programs

reduce

the

odds of

death

or

institutionalized

care and

the

odds of

death

or

dependency

after stroke

_(odcls

ratios of

O.80

and

O.78),

probably

partly

by

reducing

physical

disability57),

_There

Physical

Therapy

₄₃₇

is

seme evidence

that

_physical

training

reduces

ty,

and

that

more

training

_produces

better

eutcomes58}59).

Seme

specific methods of

training

show

promise,

altheugh

the

extent of

the

evidence relating

to

these

metheds

is

Iimited

to

a

few

high

quality

trials.

One

simple strategy

is

to

constrain

the

unaffected

upper

Iimb

to

''force" use

of

the

affected upper

limb60).

Another

effective strategy

is

to

suspend

patients

In

a

harness

above a

treadmilt

to

enable

practice

of walking with

_partial

body

weight

Port6T).

Acute

and ciironic respiratory

disectse

The

role of

_physieal

therapy

in

_prevention

and

agement of

pulmonary

disease

has

been

debated

fer

decades,

Publication

of several

important

systematic

reviews and clinical

trials

has

clarified

the

situation what.

Pre-

and

post-surgical

prophytactic

chest

physical

apy reduces morbidity

fellewing

major abdominal

surgery62)63),

For

example,

Olsen

and colleagues showed

that

prophylactic

chest

_physical

therapy

reduced

the

dence

of

pulmonary

complications after major abdominal

surgery

from

27%

to

6%63).

This

implies

that

on

age, one

pulmonary

complieation

is

_prevented

for

every

five

patients

treated,

It

is

not

_yet

clear which specific

interventions

are most effective,

Prephylactic

chest

icat

therapy

has

li[tle

effect when reutinely administered

following

coronary artery

bypass

surgery or minor

abdominal surgery, or

during

the

intubation

period

lewing

routine cardiac surgery

(eg,

referenee

64),

This

is

consistent with

the

position

that

prophylactic

ehest

ical

therapy

is

of most

benefit

to

_patients

at

the

highest

risk of

post-operative

eomplications63).

Pulmonary

rehabilitation

_programs

typically

invelve

upper and

tower

body

exercise

(usually

treadmill

ing

or stationary cycling), and may

include

ventilatory

_'

muscle

training,

counseling and education.

A

recent

tematic

review cenfirms

the

view

that

_pulmonary

bilitation

pregrams

can

increase

walking

distance

and

health-related

quality

of

life

in

_peeple

with asthma and

chronic obstructive

puimonary

disease65).

A

recent

trial

indicates

that

rehabilitation may

alse

reduee

duration

of

hospitalisation,

but

not number of medical consultations66).

An

important

and relatively new

intervention

is

the

application ef nocturnat ventilatory support to

_patients

with sieep-disordered

_breathing,

_particularty

_patients

with chronic obstructive

_pulmenary

_disease,

cular

diseases

or

injury,

er cystic

_fibrosis.

_Nocturnal

assisted

ventilation

produces

large

reductions

in

one-year

mortality and

hypoventilation-related

symptoms67).

43s

mp"utthl

Prevention

offo,tts

in

the

elderty

One

in

three

elder

_people

fall

at

least

once a

_year68),

There

is

strellg evidence that multifaceted

interventions

targeting

identified

risk

factors

reduce

falls

risk

in

older

peopte69).

Well

designed

studies suggest

that

it

is

sary

to

prescribe

such

interventions

for

about eight

ple

Lo

prevent

one

fall

per

year

in a commun]ty

･

70)

taIlg

.

Knewn

risk

factors

for

falls

such as weakness of

lower

limb

muscles and

poor

balance

are

potentially

modifiable

by

exercise, so

physiotherapists

and others

have

vided exercise

programmcs

for

older

people

at risk of

falling.

Several

trials

and reviews conc]ude

that

exercise

can reduce risk ef

falLs69)7t).

One

individually

tailored

home

based

strength and

balance

training

prescribed

by

trained

heaith

_{professionals}

has

been

found

effective

in

four

trials72).

Summary

and

Conclusions

Evidence-based

practice

involves

the systematie and

critical use of

high

quality

c[inical research

for

clinical

decision

making.

The

increase

hi

the

volume and

ty

of clinical research

in

physical

therapy

has

meant

that

there

is

now eneugh research

to

support clinical

sien-making.

Several

objections

have

been

raised against

based

practice.

Most

of these ebjections

have

some

basis

in

fact.

Nonetheless,

the

legitimate

objections

to

based

practice

have

to

be

weighed against

the

obvious

benefit

of

basing

clinical

decision-making

en

high

ty

research.

There

are now many randomized

trials

supporting

the

effectiveness of

key

physiotherapy

interventions,

ularly

those

interventions

involving

exercise,

These

als

provide

the

research

infrastructure

that

justifies

the

profession

of

_physical

therapy.

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AM,

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