Sullivan, Katherine J. PT, PhD
President, Neurology Section.
Address correspondence to: Katherine J. Sullivan, E-mail: firstname.lastname@example.org.
The use of clinical guidelines has become the prevailing method for guiding healthcare professional practice throughout the world.1 Clinical practice guidelines (CPGs) are developed to improve the process and outcomes of healthcare, whereas systematic reviews (SRs) use extensive literature search with selection and critical appraisal of primary research to provide quantitative summaries from high-quality clinical trials.2 The SRs are considered to be the highest level of research evidence in the evidence-based practice (EBP) model. The use of an EBP model is a widely adopted tenet of physical therapist practice and education today; however, despite the apparent wide-spread acceptance, the actual adoption of EBP within clinical physical therapy practice is limited.3 Most physical therapists are familiar with the definition of EBP as the interplay between application of the best available research evidence, clinical expertise, and the patient's perspective.4 However, a recent question on the neuromuscular listserve (NeuroPT@yahoo.groups) revealed several issues that may reflect the potential conflict between patient-centered care along with CPGs, and SRs, which are critical resources for the therapist who is attempting to practice with an evidence-based approach.
A recent editorial by Kwakkel5 reinforces several important principles of evidence-based practice in neurorehabilitation. He states that healthcare professionals should address patient-identified problems and set realistic goals based on controlled clinical trials with high methodological quality. Although many clinicians are willing to meet this expectation, the challenge for the physical therapist in the clinic is to efficiently access the best available research evidence based on patient diagnoses, disease severity, and stage of disease progress. One solution is to access CPG and SR summaries of research evidence. This is the most pragmatic solution for clinicians to efficiently access research evidence for their daily practice.6 CPGs and SRs are most helpful to the clinician if intervention effects are reported with patient-related factors such as severity and disease/injury progression (ie, acute, subacute, or chronic) so that clinicians can establish a functional prognosis that is most relevant to their individual patient.
CPGs have both benefits and limitations. The benefits of CPGs to clinicians and healthcare providers are that clinical guidelines can improve quality of care by updating outdated practices, decreasing unwarranted variation in clinical settings, and providing some level of standardization between clinicians, institutions, and regions of the country. On the other hand, CPGs can have substantial limitations. Recommendations in guidelines can be incorrect or out of date. Timely and in-depth updates of SRs (an essential element of CPGs) can be delayed or incomplete if the development group lacks resources. Guidelines, by design, incorporate clinical expertise; thus, the expert panel is inherently biased by their own opinions, clinical experiences, and potential conflicts of interest.7 Finally, CPG recommendations include SRs that summarize evidence from randomized controlled trials (RCTs) that are designed to answer specific questions on intervention effectiveness, under standardized conditions, with rigid exclusion and inclusion criteria to decrease variability in the defined population that is studied. Thus, recommendations from a CPG may accurately reflect the characteristics of a group of patients but may not reflect the priorities of an individual patient.
In addition to the importance of basing rehabilitation goals on evidence from controlled clinical trials, Kwakkel5 emphasizes the importance of appropriate selection of outcome measures for neurorehabilitation research. The World Health Organization's International Classification of Functioning, Disability, and Health (ICF)8 framework is an example of a framework developed to improve communication between care providers. This framework has been embraced by the international rehabilitation community and is gaining rapid adoption in the United States. The ICF is an effective model for demonstrating how multiple factors impact patient perspective such as the impact of a health condition on body function and structures, activities, and participation. In addition, the ICF includes modifying influences (ie, barrier or a facilitator to goal achievement) on individual outcomes such as one's personal contextual factors (eg, sex, age, coping style, and comorbidities) or environmental contextual factors (eg, family support, socioeconomic status, and access to healthcare). However, rehabilitation RCTs usually do not report the influence of contextual factors on patient outcomes but typically use outcome variables selected to detect treatment effects. For example, common measures used in neurorehabilitation RCTs include measures such as the Barthel Index, modified Rankin Scale, instrumental activities of daily living, walking velocity, or six-minute walk distance, which are considered “activity” measures in the ICF framework. Activity measures may be effective for RCTs that compare effectiveness of rehabilitation interventions. However, an activity measure may not reflect what is most important to an individual patient or their family members.
Hence, for the clinician attempting to use an evidence-based approach, two potential conflicts arise from the recommendations by Kwakkel. First, research evidence for the therapist is often derived from high-quality, controlled trials in which the selection of outcome measures is based on the research question and not a clinical question. Thus, SRs or CPGs often are not sufficiently patient-specific to be useful for physical therapist care that is provided to an individual patient.7 The second conflict for the clinician practicing using an evidence-based approach arises from the mismatch between the research evidence and the patient's perspective. Typically, the outcomes of interest to the patient relates to daily functions such as returning to work or school, being able to resume caring for the family, or being less of a burden on family members. How does the physical therapist resolve the conflict between research evidence from clinical recommendations in CPGs or SRs and patient-centered care where the patient's perspective and multiple interrelated factors are addressed between the patient, their family, and the therapist? How can the rehabilitation scientists conduct clinical trials in rehabilitation that are relevant to the clinician and their patient?
As rehabilitation professionals, physical therapist, and other members of the rehabilitation team provide a very complex intervention that extends beyond that which can be extracted from a CPG or SR. According to Whyte et al,9 the complexity of the rehabilitation process needs a more systematic and phased approach to increase the likelihood that clinical rehabilitation research is well designed and implemented. Furthermore, the relevance of rehabilitation research needs to occur at the level of the person not the therapy. Thus, the ICF model is not only the most appropriate framework for outcome selection but also is the only framework that addresses the patient's perspective (ie, the person with disability and the treatment recipient) compared with the researcher's perspective.10
Physical therapists assess the interaction between individuals and their healthcare needs related to movement dysfunction. The most meaningful outcomes for our patients with physical disability are to maximize their participation and health.Based on the current state of evidence in rehabilitation research, the best research evidence to be gleaned from rehabilitation RCTs is to derive principles of therapeutic delivery that can guide therapists as they interact with their patient to make an informed, shared decision about the best plan of care to meet individual patient needs. The clinician who uses an evidence-based approach applies the current principles that seem to be supported by current understanding of neuroplasticity and learning. Thus, interventions that involve the acquisition or reacquisition of motor skills that are applied with specificity and intensity and dosed to meet the therapeutic outcome determined by the physical therapist (ie, strength, endurance, and functional training) are more effective than the interventions typically done in the past.
The responsibility of physical therapists is to read CPGs, SRs, and well-designed RCTs to derive therapeutic principles to guide practice; it is the responsibility of all healthcare professionals to be informed. Thus, the well-informed, clinician takes the evidence from the best available research, the perspectives and realities of the real world in which their patients live in, and applies their clinical expertise to take care of a person with movement dysfunction; one individual at a time.
1.Woolf SH, Grol R, Hutchinson A, et al. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ
2.Cook DJ, Greengold NL, Ellrodt AG, et al. The relation between systematic reviews and practice guidelines. Ann Intern Med
3.Salbach NM, Jaglal SB, Korner-Bitensky N, et al. Practitioner and organizational barriers to evidence-based practice of physical therapists for people with stroke. Phys Ther
4.Straus SE. Evidence-Based Medicine: How to Practice and Teach EBM
. Edinburgh/New York: Elsevier/Churchill Livingstone; 2005.
5.Kwakkel G. Towards integrative neurorehabilitation science. Physiother Res Int
6.Tilson JK, Settle SM, Sullivan KJ. Application of evidence-based practice strategies: current trends in walking recovery interventions poststroke. Topics Stroke Rehabil
7.Shaneyfelt TM, Centor RM. Reassessment of clinical practice guidelines: go gently into that good night. JAMA
8.World Health Organization. International Classification of Functioning, Disability and Health: ICF
. Geneva, Switzerland: WHO; 2001.
9.Whyte J, Gordon W, Gonzalez Rothi LJ. A phased developmental approach to neurorehabilitation research: the science of knowledge building. Arch Phys Med Rehabil
10.Brown M. Perspectives on outcome: what disability insiders and outsiders each bring to the assessment table. Arch Phys Med Rehabil