[ evidence in practice ]

STEVEN J. KAMPER1

Engaging With Research:

Linking Evidence With Practice
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J Orthop Sports Phys Ther 2018;48(6):512-513. doi:10.2519/jospt.2018.0701

T
his is the first in a series of brief overviews covering discrete of clinical practice, this could lead to
aspects of clinical research. The aim is to help clinicians clearly remembering the patients who did
become more proficient consumers of research and encourage spectacularly well (or spectacularly badly)
and less clearly remembering those with
appropriate incorporation of evidence into practice.
an average outcome. So, when it comes
Debates concerning the why and how research should be. So, it is important to time to apply previous experience to the
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

of evidence-based practice (EBP) occupy
thousands of words in textbooks and
journals and on the Internet. These dis-
cussions go beyond medicine into fields
as diverse as education, finance, and so-
cial policy, to name a few. Regardless of
your thoughts on EBP, there are at least
3 reasons why physical therapists should
engage with research evidence:
Journal of Orthopaedic & Sports Physical Therapy®
understand the potential limitations and
relevant biases.
Confirmation Bias
People tend to appraise and interpret
information such that it reinforces their
own beliefs. We overvalue information
that supports our beliefs, ignore or
forget information that contradicts them,
next patient, the most likely outcome may
be the one least likely to be recalled.
A related problem is that some
patients will engage with therapy, while
others will stop attending. Outcomes of
the latter patients are usually unknown.
Given the likelihood of confirmation bias,
it is probable that dropouts are assumed
to have done well (did not need more

1. The public expects medical care to be
based in science.
2. If physical therapy wants to call itself
a scientific profession, then relevant
evidence must be generated and used
in clinical practice.
3. Agencies that pay for services, such as
insurers and government bodies, are
increasingly making reimbursement
contingent on providing evidence-
based care.
Sometimes research results differ
substantially from your own experience
of the effectiveness of a particular
treatment. This presents a challenge and
begs the very reasonable question of why
a physical therapist should be expected to
prioritize evidence from a study over his
or her own clinical experience.
Information recalled from clinical
experience should be appraised and
assessed for bias, just as information from
and interpret ambiguous information
in a way that favors our views. This is
confirmation bias; it is not a character
flaw of an individual, nor is it an attempt
to justify one’s actions. It is a sort of
cognitive shortcut that our species has
developed for more efficient day-to-day
function. The problem is that it leads us
astray in certain situations. For example,
consider physical therapists who believe
that (1) they are good at their job and (2)
they have their patients’ best interests at
heart. What effect could confirmation
bias have on these physical therapists’
recollection of the effectiveness of their
treatments?
Recall Bias
People have a tendency to better
remember substantial or impressive
events, as opposed to average or more
common occurrences. In the context
treatment), though the opposite may be
true.
Clinical Observation
Let’s say that you treat a patient with
a particular intervention. The patient
sees you a few times and, after 3
weeks, is much improved. The simplest
interpretation is that what you did
was effective. The problem is that
the improvement may or may not be
because of the treatment. There is a
fundamental difference between change
in outcome (clinical change over time)
and treatment effect (clinical change
over time that is due to treatment). In
the clinic, you observe the change in
outcome over 3 weeks, but only a part
of that change is treatment effect. There
are a number of factors that contribute
to change in outcome, including those
below (FIGURE).

School of Public Health, University of Sydney, Camperdown, Australia; Centre for Pain, Health and Lifestyle, Australia. t Copyright ©2018 Journal of Orthopaedic & Sports Physical
1

Therapy®

512 | june 2018 | volume 48 | number 6 | journal of orthopaedic & sports physical therapy

 Natural History  Many conditions resolve
completely or to some extent on their 9

own, particularly acute conditions. For

8
example, a patient who presents with
pain, swelling, and limited function the

Change in Outcome (Observed in Clinic)

7
day after an ankle sprain will improve on
those outcomes over the next 2 weeks. 6 Natural history
This is the case whether the patient
receives intensive treatment, minimal 5
Downloaded from www.jospt.org at Health Sciences Library on June 2, 2018. For personal use only. No other uses without permission.

treatment, ineffective treatment, or

4
no treatment at all. Obviously, natural
Placebo
history varies according to condition, so
3
the proportion of change in outcome due Hawthorne

to natural history will vary from case to Treatment

2
case.
Regression to the Mean  Many conditions 1
follow an episodic or fluctuating course.
Patients have no symptoms or low-level 0
Baseline Week 1 Week 2 Week 3
symptoms most of the time, interspersed
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

by exacerbations or flare-ups. Back pain FIGURE. Deconstruction of outcome.

and neck pain are common examples.
People with these conditions generally
seek care when symptoms are at their
worst, that is, during an exacerbation.
Because symptom severity is typically
at or near its worst when they see a
clinician, the next fluctuation in severity
is most likely to be an improvement.
Journal of Orthopaedic & Sports Physical Therapy®
They can contribute to change in outcome
but are different from treatment effect.
Polite Patients Most clinicians try to
form a rapport with their patients. A
result is that many patients don’t want to
“disappoint” their therapist by failing to
respond to the therapist’s sincere efforts
recalled from clinical experience.
Similarly, EBP is not about picking
holes in published studies. It involves
carefully considering the nature and
magnitude of biases that apply to
all the information (from clinical
experience and from research) that a

In practice, this means they are more
likely to improve after a consultation,
regardless of intervention.
Placebo Effects Placebo effects are
most likely due to manipulation of
patient expectations and/or classical
conditioning. Irrespective of the
mechanism, placebo effects are attached
to, but distinct from, the actions of
any particular intervention; they are
“portable” across different interventions.
to help them. This desire on behalf of
patients can bias reports of outcome.
Patients may appear to (and state that
they) have improved more than they
really have.
Summary
Well-executed EBP does not dismiss
clinical experience. However, potential
biases must be considered when
appraising and applying information
clinician needs to consider in his or her
reasoning process.
There is a misconception that EBP
seeks to devolve clinical decision making
to a cookbook. In reality, EBP asks more
of clinicians, not less. It challenges them
to accept flaws in their reasoning and
recognize their own biases, and demands
that they develop the skills to find,
appraise, and integrate research evidence
into their practice. t

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journal of orthopaedic & sports physical therapy | volume 48 | number 6 | june 2018 | 513