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Behaviors of an EBP Practitioner

I am in the final week of facilitating an online course that is the first course in our Transition DPT program at Regis University. Clinicians from all different backgrounds and experience levels have been exploring the principles of evidence-based practice. Recently, I asked them to think about these questions: “How would you know if someone was a true evidence-based practitioner? What are the specific behaviors consistent with evidence-based practice?” Here is just a sampling of some of the better responses. I am submitting this as a catalyst for further discussion here.

Someone is an evidence-based practitioner if they:

1. can provide a brief history of the development of EBP principles.
2. can articulate the definition and main principles of EBP.
3. differentiate foreground and background questions related to patient management.
4. can effectively frame a question that increases the likelihood of a successful literature search.
5. can perform both primary and secondary literature searches, and can select the database that will most efficiently answer their clinical question.
6. think in terms of probability when making clinical decisions.
7. understand the importance of the diagnostic process in classifying patients into groups that improve management decisions.
8. have a working knowledge of various test characteristics such as sensitivity, specificity, predictive value, likelihood ratios, responsiveness, risk, number needed to treat, and accuracy.
9. use a screening exam, history, and physical exam processes that emphasize questions and tests that are likely to efficiently and effectively classify (diagnosis) the patient, and similarly, eliminate components that do NOT assist in this process.
10. incorporate prognostic factors into clinical decision-making.
11. use hierarchy or levels of evidence to determine value of evidence in patient-centered decision-making.
12. incorporate patient values, needs and desires into clinical decision-making.
13. can articulate the strength of evidence for high-volume interventions in their particular practice setting.
14. are familiar with the process for establishing a clinical guideline and/or prediction rule and knows if they exist for these high-volume interventions.
15. are familiar with and use validated, patient-centered outcome measures for high-volume conditions.
16. monitor their clinical outcomes and compare their outcomes with existing literature, if available.
17. not only know the evidence, but put it into action.
18. take time to be a reflective practitioner who is devoted to maintaining knowledge of current best practice, and can mentor others in the process.
19. have the ability to integrate the principles of EBP and the hierarchy of evidence in the selection and standardization of continuing education courses being offered for practicing clinicians.
20. are able to answer a patient’s inquiry or address an dilemma with a thorough search of the literature, identifying current best evidence and a summarizing for the patient in a timely manner.
21. annotate documents (e.g. letters to doctors & 3rd parties) with evidence references to support assertions about patient care.
22. place colleagues in positions to learn and grow first.
23. strive towards efficient and effective time management.
24. will understand that new developments from research may confirm, modify, or simplify their current approach being used that was once developed by previous evidence based research.
25. will consider the role of psychosocial aspects and how that may affect patients both emotionally and physiologically.
26. balance preparedness with opportunism (paraphrased from Sackett).
27. recognize the clinical experience component of the EBP paradigm and collaborate with experienced fellow professionals in an effort to provide the best care for the patient.
28. anticipate change and sees their practice as dynamic.
29. will understand the difference between "what should work" and "what does work", and will advocate for the the latter, and finally

30. know that EBP is not a four-letter word.

Tim Noteboom, PT, PhD (& the 47 students in DPT 770 Professional Development)

the more things change, the more they stay the same....

Over the last few weeks, a disproportionate amount of time has been spent by many of us trying to navigate thru the exemption process bestowed upon us by CMS.  We are told that in order to circumvent the "theater of the absurdity" more commonly known  as the combination speech and physical therapy $1740 cap that we have some hoops and ladders to navigate (side note:  which is more complicated-Medicare part D drug benefit for patients or the cap exemption process to PT's?).

My back of the envelope analysis shows that as long as you are willing to go thru the maze, anything and everything qualifies as an exemption. As this article points out, the potential savings of having such a process versus complete abolishing of the cap is meaningless from a CMS budgetary perspective.  Is this surprising?  Didn't many private sector insurance companies go from tightly controlled utilization review driven policies to one of loosening the reins based largely on the fact that monitoring costs (e.g. approval processes) drive up costs rather than lower them. 

In addition to not lowering costs for the CMS budget, the process drives up costs for us the providers which in essence lowers are reimbursement rate (oh yeah, a cut-didn't we have to deal with that as well?).  Would you rather have a cut in pay or a cap?  Trick question-they both are equivalent.

Will some providers that are busy enough simply ignore medicare patients who arguably need our services the most (aah, the unintended consequences of bad policy).

Along these same lines (the cost of "monitoring costs" thru administrative tasking), there is some compelling evidence (I just remembered that this is an EBP site!) about the impact of using administrative data to determine health care quality a.k.a report cards.   

When Evidence Meets the Patient

This article was in the NY Times a couple of days ago about a physician's perspective on convincing her  elderly mother to exercise .....a good example of another challenge of implementing EBP.....

Dale

Josh Cleland is the newest PhD in Physical Therapy!

The Evidence in Motion Team would like to extend our sincere congratulations to Dr. Josh Cleland. Today, he successfully defended his dissertation work titled "Development of a Clinical Prediction Rule to Identify Patients with Neck Pain Likely to Benefit from Thoracic Spine Manipulation and a Range of Motion Exercise" and was subsequently awarded a Doctor of Philosophy degree (PhD). Josh, your research and educational accomplishments have already made a tremendous positive impact on our profession. Your hard work and committment represents the very best in our profession and will insure that our best days (and those of our patients) remain ahead. Our profession is fortunate to have you as a colleague and friend.

We can't say thanks enough for your committment to evidence-based physical therapist practice. Here's a toast, my friend, to a job very well done. EIM bloggers, feel free to take the opportunity to pass on your congratulations to Josh via comments.

The Evidence in Motion Team

Upcoming Evidence in Motion Courses!

 Check out upcoming Evidence in Motion courses currently open for registration!

Evidence-based Examination and Selected Interventions for Patients with Knee Disorders

February 24-26, 2006 - THIS WEEK!
Syracuse, New York (USA)

Evidence-based Examination and Selected Interventions for Patients with Lumbopelvic Spine and Hip Disorders

March 18-19, 2006 - COMING SOON!
Atlanta, GA (USA)

April 1-2, 2006
Salt Lake City, UT (USA)

April 1-2, 2006
Louisville, KY (USA)

April 29-30, 2006
Denver, CO (USA)

Evidence-based Examination and Selected Interventions for Patients with Cervical Spine Disorders

March 4-5, 2006 - NEXT WEEK!
Victoria, BC (Canada)

April 1-2, 2006
Tucson, AZ (USA)

May 20-21, 2006
Concord, NH (USA)

June 3-4, 2006
Fairhope, AL (USA)

Join your colleagues in evidence-based courses that integrate your clinical expertise with the most the current perspectives in physical therapy clinical examination and interventions. Extensive hands-on lab sessions are included. Participants will be awarded 15 contact hours (1.5 CEUs).

We encourage early registration to insure a seat. Visit us on the web at www.evidenceinmotion.com to get more details, learn about other 2006 course dates and locations. Register online today!

Feel free to post a comment to this post on the blog or email us at courses@evidenceinmotion.com if you have any questions or need additional information. Consider passing this post on as an email to your colleagues who might benefit from this information. Hope to see you at an Evidence in Motion course in 2006! We sincerely thank you for joining with us to translate evidence into practice.

The Evidence in Motion Team

Chiros on TV Ad Campaign

It will be interesting to see how this chiropractic public media campaign influences public opinion. They are asking for contributions of $300 per month for 1 year, equating to a $3600 committment. Is this a further indication as to the worry in the chiropractic community regarding the growth of physical therapy. Or, is it yet another example of a forward thinking and proactive effort to influence public opinion. In an age of consumer driven health care, the approach just might well work. Time will tell. Thoughts and comments are welcome.

John

Latest Research on Knee OA Falls Short of the Podium

Efficacy of physiotherapy management of knee joint osteoarthritis:  A randomized, double blind, placebo controlled trial.    Bennell KL, et al Ann Rheum Dis. 2005;64:906-912.

The Bennell study1 examined the effectiveness of the treatment of knee OA with a “novel” program consisting of exercise, massage, and patellar taping compared with a placebo group.  The study design was a well structured  randomized, double blind, placebo controlled trial. Inclusion criteria were based on the American College of Rheumatology’s clinical and radiological criteria for OA.  Exclusion criteria were appropriate for the study interventions, including any condition compromising the use of tape for anterior knee pain (e.g. allergies, BMI > 336 kg/m2).

The treatment group received a standardized treatment without individualization which included massage to the quads, isometric hip exercises focusing on glut and adductors during both static and dynamic activities (emphasis on motor control, not strengthening), and thoracic spine mobilization.  The placebo group received sham US. The study was conducted for a 12-week period, with randomization of 140 persons (73 to the PT group, 67 to the placebo group), with 124 participants completing the study (59 PT group, 65 placebo group). Drop-out rates were 18% (13 persons) in the PT group and 3% (2 persons)in the placebo group).1 The results of the study found no difference in primary outcomes (visual analogue scale (VAS)) or secondary outcomes [Questionnaires: WOMAC scores, knee pain scale and a numerical VAS (restriction of activity), Short Form 36 item general health questionnaire (SF-36), assessment of quality of life (AQoL) index) between the two groups; Step test; Isometric quad strength (Kin-Com Dynamometer at knee flexion of 60 o)]1

We are particularly concerned about the following elements of the study:

1.  The use of thoracic mobilization ‘performed while sitting with symptomatic leg extended and elevated on a chair.’  How reflective of our practice is this maneuver? The study is presented as a representative RCT in the genre of Deyle et al 2000 & Deyle et al 2005.2,3  Deyle et al 2000 is most comparable: An RCT of a manual therapy plus exercise program vs. a placebo intervention.2 This included manual therapy to the knee, ankle, hip, spine, and pelvis, depending on the exam findings. Deyle et al 2000 presented a physical therapy intervention that is very close to actual practice of manual therapy in the clinic. The manual therapy techniques are well described and applied to ‘common knee impairments addressed by manual therapy,’ including loss of knee extension and flexion, patellar glides, muscle tightness.2,3 Bennell et al 2005 provided no discussion of rationale or biological plausibility for the ‘novel’ intervention of thoracic mobilization.
The technique is applied as a protocol, and not at the therapists’ discretion, so a wash-out effect would be expected in the group (i.e. the technique applied to inappropriate subjects. We don’t understand the use of the technique and we don’t find this technique is representative of standard manual therapy practice for the treatment of knee OA.1

2. What is the evidence for soft tissue massage of the knee?  Was the goal of this intervention to improve patellar mobility, soft tissue dysfunction or simply to relax the tissues?  It is difficult to determine the appropriateness of the technique because Bennell et al 2005 did not provide an adequate description of the intervention. 

3. Knee taping (McConnell) for patellar adjustments.  Hinman et al 2003 demonstrated excellent improvements in OA knee pain with a taping regime compared to a ‘placebo’ taping technique.4  Quilty et al 2003 indeed, identified patients with knee osteoarthritis with a predominant patello-femoral component.5 The failure to demonstrate effectiveness in the Bennell et al 2005 study might represent a ‘wash-out’ effect, vis-à-vis the failure to identify a subgroup of ‘responders’ to the technique or a more discrete application of the technique, as determined by the 10 experienced PT’s.

4. The exercise program emphasized motor control (including balance and proprioception) previously used in a study for anterior knee pain patients.5  The outcomes were as we might expect; not much strength gain based on the exercise protocol.  It was the same approach for all patients and utilized a low number of reps (5) with little or no resistance beyond body weight.  Deyle et al 2000 & 2005 used a standardized strengthening program applying strength principles (e.g. adequate resistance, appropriate numbers of repetitions (e.g. sets of 10 reps with 6-sec hold times) with support from the literature.6,7,8,9 Why did Bennell et al pick this program for OA knees, particularly when the Quilty et al 2003 study had no ‘overall effect’ with anterior knee pain patients?  What evidence is there that you can reduce pain or improve quadriceps force production in OA knees with strictly a motor control approach to exercise?

Bennell et al represent an excellent group of researchers and clinicians, who have contributed greatly to the literature in physical therapy on the treatment of patients’ with knee pain. We are puzzled by this study, which appears to have the greatest value in demonstrating the powerful impact of the placebo effect.  Indeed, the study appears to be a comparison of one placebo intervention to another placebo intervention, as the authors are using a highly implausible intervention of thoracic mobilization and comparing it to a sham US.  What is the rationale for the study?
Thank you,
CJ Cebul, PT
Sandra Do PT
Scott Frazier, PT
Terry Gebhardt, MPT, OCS, CSCS
Britt Smith MSPT, OCS, FAAOMPT
Julie M. Whitman, PT, DSc, OCS, FAAOMPT

Download bennell_et_al_an_rheum_dis_2005.pdf

References
1 Bennell KL, et al. Efficacy of physiotherapy management of knee joint osteoarthritis: A randomized, double blind, placebo controlled trial. Ann Rheum Dis. 2005;64:906-912.
2 Deyle GD, et al. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee: A randomized controlled trial. Ann of Intern Med. 2000;132:173-180.
3 Deyle GD, et al. Physical therapy treatment effectiveness for osteoarthritis of the knee: A randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. Phys Ther. 2005; 85:1301-1317.
4 Hinman RS, Crossley K, McConnell J, Bennell K. Efficacy of knee tape in the management of knee osteoarthritis: A blinded randomized controlled trial. BMJ.2003;327:135-138.
5 Quilty B, Tucker M, Campbell R, Dieppe P. Physical therapy, including quadriceps exercises and patellar taping, for knee osteoarthritis with predominant patello-femoral joint involvement: Randomized controlled trial. J Rheumatol.2003;30:1311-1317.
6 Wallin D, Ekblom B, Gralin R, Nordenborg T. Imporvement of muscle flexibility. A comparison between techniques. Am J Sports Med. 1985;12:263-268.
7 Hicks JE. Exercise for patients with inflammatory arthritis. J of Musculoskel Med. 1989;6:40-61.
8 DiNubile NA. Strength training. Clin Sports Med.1991;10:33-62.
9 Bandy WD, Irion JM. The effect of time on static stretch on the flexibility of the hamstring muscles. Phys Ther. 1994;74:845-850.

Shoulder Clinical Prediction Rule

Hello all.  I don't post on here as much as I would like, but here is an article that caught my attention, and I thought this was the crowd with to share it.

I apologize if this has already been posted, as I did not do an especially thorough archival check...   

Download shoulder_prognosis.pdf

Acupressure Beats Physical Therapy in Chronic LBP

Attached is a study just published online in the BMJ suugesting that acupressure was effective in improving pain, function, and disability in patients with chronic LBP (>4 months) compared to physical therapy. Patients received 6 visits of either acupressure or physical therapy over a 1 month period. One acupressure therapist provided each session of acupressure treatment to ensure standardization of technique and consistent experience. A variety of physical therapists participated in the study, providing ill-defined interventions such as pelvic manual traction, spinal manipulation, thermotherapy, infrared light therapy, electrical stimulation, and exercise therapy, as decided by the physical therapist. What physical therapy interventions patients actually received was not described. Outcomes remained significant at 6 months.

Perhaps one conclusion from this study is that we should consider using acupressure techniques for certain patients with LBP. There may well be some value to this, especially for patients with chronic LBP. Or is it that simple? The study avoided variation across practitioners for acupressure by using only one therapist, which equates to a more standardized care process and enhanced internal validity. Physical therapy was left to the individual therapist's discretion, although standardized procedures were apparently established a priori. Perhaps there is an additional lesson here about the benefits of standardizing care and the potential downside of 'discretion' (ie, presumably doing whatever you want)?

It will be interesting to hear everyone's thoughts given that this study will receive widespread attention because of its publication in the BMJ.

John

Download Hsieh-BMJ-2005-AcupressureBeatsPhysTherRCT.pdf

EIM Blogger Adam Rufa is 'Squidooing'

In a recent post, Larry encouraged us to check out Squidoo, a new service started by marketing guru and author Seth Godin that permits anyone (the 'LensMaster') the ability to easily author and create a web page of content (a 'lens') on a topic about which they are knowledgeable (or at least think they are knowledgeable).

One of our active EIM bloggers, Adam Rufa, has done just that, providing a nice digest of interesting content related to EBP in physical therapy. Check out his lens at http://www.squidoo.com/physicaltherapy/. I would encourage our readers to add this lens' RSS feed to your favorite RSS news reader to remain abreast of any updates that Adam makes in coming months.

Thanks, Adam, for providing us a great example of 'squidooing' in physical therapy, helping to evangelize evidence-based physical therapist practice to the world.

John