Jan 29, 2015Evidence-Based Practice: What Does It Mean for You?
EBP is more than a buzz word in athletic training today. It’s an approach to healthcare that can increase your clinical value and effectiveness.
Greg Frounfelter, DPT, ATC, CSCS, is a staff physical therapist at Baldwin (Wis.) Area Medical Center and is active in the Wisconsin chapter of the NSCA. He can be reached at: [email protected].
In today’s information-overload society, athletic trainers must be able to justify every treatment we provide. This demand can come from athletes themselves, who through the Internet have greater access than ever to information about their healthcare options. It can also come from third-party payers, such as health insurance companies, who may ask, “Why should we pay for this treatment?” or “Is there a more cost-effective alternative?” Questions like these, along with a basic desire to provide the best care possible, have led to a new age of evidence-based practice (EBP) in athletic training.
In the simplest terms, EBP means we should treat each patient based on what science has shown to be the best intervention for his or her specific condition and circumstances. Traditionally, we rely on teachers and mentors to show us which treatment approaches meet this standard. And of course, we can supplement this knowledge with scientific literature, clinical experience, and a host of other sources.
There are different levels of evidence that can inform our judgment of what constitutes the best treatment under EBP. The first level is consensus or expert opinion. For example, when deciding whether to apply ice or heat to an acute injury, virtually all ATCs would agree that ice is usually the most appropriate choice. Simple experience and what we learned as students is enough to make us confident in this decision.
The next level of evidence consists of well-designed studies and research. Non-randomized clinical trials, non-quantitative literature reviews with appropriate research strategies and substantiated conclusions, clinical cohort and case studies, and high-quality historical, non-controlled studies are examples of this type of evidence.
As part of your athletic training education, you should learn how to discern whether a study meets basic criteria for credibility, and how to weigh different studies based on their design and the way they’re performed. In the practical world, I have found research at this level to be a significant impetus for change. I often read about something in a scientific journal, and based on my assessment of its validity, I may start to incorporate the new knowledge into my practice.
The highest level of evidence involves randomized, controlled trials and meta-analysis. These are the tools used in the medical world when accurate results are most essential, such as when evaluating experimental medications. Meta-analysis involves a quantitative literature review that uses comprehensive research strategies and statistical tools to draw conclusions. This level of research targets clinical interventions and their outcomes, looking to make connections across various independent research projects and labs.
Once you’re in a professional setting and responsible for deciding how to treat athletes, how can you integrate the concept of EBP? I re-commend the following five steps to support an evidence-based approach to athlete care:
1. Formulate focused, answerable questions regarding the clinical issue at hand. 2. Find the best evidence to answer those questions. 3. Critically appraise all available evidence and relevant information. 4. Determine the best course of action based on the evidence and information, and act accordingly. 5. Evaluate your performance and the effectiveness of the treatment.
Let’s look at how to apply these steps in practice. Imagine you’re a certified athletic trainer, and an athlete comes to you with an injury. You do an initial evaluation and determine what the problem is, but you’re not sure how best to treat it because you’ve never seen this type of injury firsthand.
At this time, it would be appropriate to leave the athletic training room and search a trusted online medical database (more on that later) to find what the literature suggests is the best treatment option. You can then return to the athlete and confidently begin treatment.
The above scenario, of course, assumes perfect working conditions: You have plenty of time, the athlete is patient, and your database search quickly reveals a satisfactory answer. In the real world, this may not always be the case, and that’s when you need to get creative.
For example, if the athlete isn’t patient, you can apply basic RICE or perhaps electrical stimulation while you conduct your research. Or, if the circumstances permit, you can schedule a treatment with the athlete later that day, giving you some time to conduct needed research. In any case, you should always remember step five: Evaluate the short- and long-term response to whatever treatment you choose, and make sure your intervention was effective. This is how you build valuable clinical experience.
Where exactly do you look when conducting research? The Internet is the most efficient way to find information, but it’s essential to rely only on trusted sources. I recommend the Cochrane Library (www.cochrane.us, click on “Cochrane Library”), the National Guideline Clearinghouse (www.guideline.gov), and PEDro (Physiotherapy Evidence Database, www.pedro.fhs.usyd.edu.au), all of which have helped me find the best treatment options for various conditions and injuries. Other sources, such as WebMD (www.webmd.com) and PubMed/Medline (www.pubmed.gov), are trustworthy and provide access to massive amounts of peer-reviewed literature.
Incorporating EBP involves hard work and a commitment to always learning more–it means constantly reassessing our methods, asking questions, seeking answers, and critically evaluating the information we receive. But all this effort carries great rewards. It enhances our credibility and value as healthcare professionals, and most importantly, helps us to improve treatment outcomes for the athletes we serve.