July Article Discussion

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    • #3998
      Nick Law
      Participant

      Nick

      Sizer PS, Mauri MV, Learman K, Jones C, Gill N, Showalter CR, Brismee JM. Should evidence or sound clinical reasoning dictate patient care? J Man Manip Ther. 2016; 24(3):117-119

      In this opinion paper of sorts, the authors begin by citing that although the evidenced based practice model is composed of research integration, clinical expertise, and patient values and circumstances, it has been the published research domain that has recently exploded and received a greater deal of attention. They comment that although systematic reviews and meta-analysis’ provide the “highest” levels of evidence, giving the clinician great confidence in their findings, the results are often non conclusive and are not specific to individualized patients.

      In opposition to mere adherence to published evidence, authors propose a framework of practice embodied in the Evidence-Supported Practice wheel that is focused on the individual patient surrounded by the clinicians observations, judgments, and sound clinical reasoning. The “spokes” of the wheel that support appropriate behavior are various forms (e.g., randomized controlled trial, case study/series, meta-analysis, etc..) and domains (anatomy, pathophysiology, biomechanics) of evidence. Biopsychosocial factors comprise the “rim” of the wheel and serve as foundational elements. Finally, the clinicians systematic approach to management forms the “tire” of the wheel – the mode of delivery to the patient.

      The authors propose several advantages to their framework and model. First, each level of evidence is appropriately assessed and utilized without undue prioritization to the traditionally “higher” levels of evidence. Moreover, the biospychosocial factors that serve as the rim of the wheel are often not considered or captured in contemporary research publications. Finally, the clinician is urged to trust their own well informed clinical reasoning and judgments as opposed to only adhering to published evidence. In conclusion, the authors call for the therapist’s expertise and patient values to receive greater attention in opposition to sole reliance upon published evidence.

      Questions:
      1. Is the title of this article appropriate?
      2. Do you find the evidence-supported practice wheel to be helpful in providing a framework of practice, or simply confusing? Is the simple, 3 dimensional nature of EBP (published evidence, patient values, clinical expertise) inadequate?
      3. Can you provide an example when you provided care that was contrary to published evidenced?
      4. In your judgment, does the PT world at large place too much emphasis on published evidence or not enough?

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    • #4004
      Laura Halley
      Moderator

      Thanks for posting Nick.

      1) Are those two things so mutually exclusive? Isn’t the point of this article to say the exact opposite, that each component should be integrated equally?

      2) I understand where you’re coming from with the question, “Is it simply confusing?”. I agree and disagree. The previous framework breaks it down easily, generalizing the three main components into evidence, patient, and expertise. This is a easy concept to learn and teach. But, the authors are correct that it doesn’t include so many important factors like the differences between levels of evidence and including boopsychosocial as an overarching theme. But I feel like a big rationale for this framework is for students and teaching tools, so if you were a new student who was starting to learn this framework to practice, would you get overwhelmed with this new model that they are presenting and need to start with a more basic framework? Its the same with learning levels of evidence. As clinicians who routinely see and practice every day, we more readily can appreciate case reports and detailed studies for our own application. But if you don’t have a reference to relate the case studies to, I understand why the generalized RCTS and SRs are important to begin with. So, I’m playing the neutral card, I understand the importance for both models.

    • #4005
      omikutin
      Participant

      Thanks Nick!

      EBP should help guide care but not necessarily dictate care. I love how this article places emphasis on integrating EBP and biopsychosocial factors. I don’t think there should be an “or” in the title; however, it grabbed my attention.

      One of the many things that I appreciate about our practice is that anatomy will always be anatomy. There will be anomalies but it’s up to PTs to see if that’s relevant to our patient’s impairments, participation, and/ or function. One of my ortho professors always said KNOW kinesiology and anatomy it doesn’t change but research does. I’m been in clinics where a PT quoted cx extension is bad due to increased osteophytes based on some research article he read years ago. I disagreed. There are also PTs who will only do exercises that research deemed highly appropriate even though the patient just can’t do. If a patient is given an exercise then asking the patient “where do you feel it” is important. Athletes have thrown me off a ton of times; they are the best compensators I know. It’s important to know anatomy, give appropriate exercises, and make sure the patient feels what we are targeting.

      Research gives us ideas and I think more clinics could benefit from it. It’s a balance! I’m not the biggest fan of meta-analyses because of the inconclusiveness. However, they do a great job of complying evidence. I don’t always look at the conclusion but the RTCs may have some good information.

    • #4016
      Nick Law
      Participant

      Laura – yes, exactly. The point of the article is to show that evidence AND clinical reasoning dictate clinical care, and therefore I think the title is misleading. It simply continues to suggest the notion that the two are in conflict.

      Perhaps the evidence supported practice wheel really will be helpful to some, however to me I simply see nothing wrong or imbalanced or unhelpful about the three dimensioned nature of classic EBP – published evidence, clinical expertise, and patient values. I think that their diagram is simply trying to draw out several factors that I think are better left simply explained in written words than trying to diagram everything out.

      To answer my own last question, I think it depends on who the therapist is. I think that newer therapists such as myself are prone to more heavily rely on the most recently published evidence, whereas more experienced therapists seem vulnerable to simply doing what they have always done/achieved good results with. We younger therapists would do well to learn when to simply trust our own experience and expertise even when contrary to recent evidence, nevertheless continuing to reference and examine our methods with the available published evidence.

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