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a
randomized controlled trials
It must be remembered that the RCT was
developed for use in the pharmaceutical industry
Manual Therapy (2001) 6(4), 195–196
# 2001 Harcourt Publishers Ltd
ary
Grade II: strong evidence from at least one pro-
perly designed randomized controlled
trial of appropriate size
Grade III: evidence from well-designed trials
without randomization, single group
pre-post, cohort, time series or matched
case-controlled studies
Grade IV: evidence from well-designed non-experi-
with single drug administration being monitored
carefully before drugs were released for prescription.
Because of the large number of variables that can
impact on a clinical intervention the RCT may not
always be the best methodology for evaluating the
ecacy of many of the modalities and multi-
modalities used in clinical practice. Interestingly,
even in the well-developed research activities of the
Editorial
Evidence-based practice – getting a grip
Evidence-based practice is the buzz phrase of the late
90s and is set to grow significantly in this present
decade. This is prompted by government directives,
health service mandates, clinician’s professional
and ethical responsibilities, and patient’s (and their
advocates) demands and requirements. Within the
chronological growth of the health professions,
evidence-based practice is still in it’s infancy and
there are several reasons for this.
Firstly, and importantly, each of the health
professions are at a different stage of development
in their production of the ‘evidence’ on which
practice can be based. Secondly, there has been an
uneven escalation in evidence-based practice world-
wide as a result of variations in methodology,
variable access by clinicians to the evidence, varia-
tions in clinical practice and different levels of ability
amongst clinicians in finding the evidence. Opportu-
nities for clinicians to deliver evidence-based care
may be limited by variations in clinical autonomy and
in access to treatment and examination technologies
(such as ultrasound scanning and muscle testing
equipment).
In the ideal clinical setting, what does evidence-
based practice really mean? Hicks (1997) states that
evidence-based care ‘takes place when decisions that
affect the care of patients are taken with due weight
accorded to all valid, relevant information’. Moore
et al. (1995) have indicated there is a hierarchy of
evidence, ranging from clinical experience right up
to the randomized controlled trial (RCT) as shown
below:
Grade I: strong evidence from at least one syste-
matic review of multiple well-designed
doi:10.1054/math.2001.0427, available online at http://www.idealibr
mental studies from more than one
centre or research group
195
nd finding a balance
Grade V: opinions of respected authorities, based
on clinical evidence, descriptive studies or
reports of expert committees.
This information is important since research into
physiotherapy practice really only began in earnest in
the late 1970s. Before this, the majority of the
research conducted to determine the ecacy of
physiotherapy had been planned and instigated by
other professions not necessarily cognizant of phy-
siotherapy practice. In many countries the develop-
ment of an all-graduate physiotherapy profession has
meant that graduates have acquired the skills
necessary to produce ‘the evidence’, and slowly but
surely more evidence is being produced and pub-
lished. This growth however, must be seen in
perspective. The physiotherapy profession in the
UK for example, was founded in 1895 and clinical
practice was, at that time, based on unresearched
modalities largely developed and advocated by the
medical profession. Since this foundation, as with
other professions, the numbers of modalities in use
has grown substantially and not all of these, by any
means, have Grade 1 evidence to support them.
However, as modalities have been built into practice
over time, some evidence for their use has accumu-
lated. This evidence has ranged from clinical obser-
vations to the results of the randomized controlled
trials. If every modality used in physiotherapy
practice was researched using a randomized con-
trolled trial, using an appropriate power with a
subject follow up of 2 years, we would probably have
to wait 20 years before the majority of modalities in
current use, disregarding new treatment develop-
ments, could be fully researched and evaluated.
.com on
pharmacy and medical professions, there is still little
known about the effects of combinations of drugs, for
example in mental health (Byck 1975, Young et al.
1996). It is hardly surprising then that the effective-
ness of combined physiotherapy treatment often
remains unclear.
Evidence-based practice is forcing a positive
change in the healthcare culture, clinicians are
appropriately asking fundamental questions as to
whether they are providing the most effective and
ecient care. However, the danger now is that
clinicians seeking out appropriate evidence are faced
with only a few Grade I RCT studies on which to
base their practice. Thus, they may opt to use or may
be pressured by their hospital governance team to use
the only modality which has been shown in a single
RCT to be effective for subjects with the global
‘diagnostic label’ in question. In addition, the
clinician may pay no heed to other evidence, albeit
embrace modalities which have been shown to be
effective. We must all be responsible for providing
and publicising the evidence; no matter from where in
the hierarchy it emerges. We need to discover new
ways of finding the evidence, which are amenable to
everyday clinical practice. We have a lot of evidence
to gather, a lot of ground to make up. Importantly,
we must avoid the ‘Evidence-based practice technique
syndrome’ where every patient with a certain
diagnostic label, for example low back pain, is
examined and regardless of what the findings are, is
placed in a stabilising muscle re-education group or
an aerobic activity group, simply because they have
low back pain. If clinicians do this, the examination
process will become a farce, clinical reasoning skills
will be lost and clinicians themselves will become little
more than technicians who can be replaced by a
196 Manual Therapy
at a lower level in the hierarchy, which may well
support a number of modalities potentially useful if
applied singularly or in combination in the manage-
ment of the ‘whole patient’ and their uniquely
presenting syndrome. Our professions will be lost if
clinicians choose to abandon, or are pressured into
abandoning, their well-developed examination and
clinical reasoning skills in favour of simply treating a
diagnostic label, for example low back pain by
applying indiscriminately a modality, because it has
been shown to be effective by a single randomized
controlled trial for a specific and homogenous group
of low back pain sufferers. Therapists must manage
the ‘whole patient’ embracing a multiplicity of clinical
problems. If they do not, other professions who lack
our clinical and scientific background will be quick to
step into the fray and will have no compunction in
managing patients with what could be seen as an easy
‘recipe book’ treatment for success.
There is no doubt that we must instantly abandon
modalities which have been found to be ineffective,
but we must avoid abandoning techniques for which
inconclusive evidence exists and we must firmly
Manual Therapy (2001) 6(4), 195–196
cheaper workforce.
The evidence that does exist does so as a result of
the hard work of researchers who have tried to move
practice forward and enhance it. If research is used in
the wrong way, these researchers will have worked in
vain and in the end, it will be the patient and the
health service that will lose out, and so will our
professions. Let us allfind a balance and quickly.
Ann Moore, Editor
Nikki Petty, Senior Lecturer in Physiotherapy,
University of Brighton
References
Byck R 1975 Drugs used in the treatment of affective disorders. In:
The Pharmacological basis of therapeutics. Eds Goodman LS,
Gilman A. 5th edn London, Bailliere Tindall
Hicks N 1997 Evidence-based health care. Bandolier 4(39): 8
Moore A, McQuay H, Gray JAM (eds) 1995 Evidence-based
everything. Bandolier 1(12): 1
Young LT, Li PP, Kamble A, Siu KP, Warsh JJ 1996 Lack of effect
of antidepressants on mononuclear leukocyte G-protein levels
or function in depressed outpatients. Journal of Affective
Disorders 39: 201–207
# 2001 Harcourt Publishers Ltd
	References