Although EBM focuses on the medical research and literature and for the rest of this paper, evidence will be used interchangeably with medical research, there are many forms of evidence used in determining the actions of a practitioner in Evidenced Based Practice (EBP).  This paper focuses on the medical research and its importance in making EBM decisions, but clinicians must realize that there are other forms of evidence that must be considered as well (see Table 1).

EBP is a combination of information, patient values and physician’s experiences. It attempts to rank information and data resources into a hierarchy, based upon their clinical relevance and degree of bias that when combined with patient resources and practitioner resources can then be evaluated by individual practitioners as to their level, value and applicability for incorporation into their EBP protocols and questions that need upgrading and answering.

In an EBP, we use our existing knowledge of evidence in practice, our practice resources and the information supplied by the patient at hand to make immediate clinical decisions on first encounters, but then it is the responsibility of the EBP clinician to research the literature for more valuable evidence that may lead to better, more efficient, more cost effective care when applied to the case.

Using Hackett’s definition, an Evidence Based Practice (EBP) utilizes the best available evidence by Level and decides whether it applies to the clinical question at hand, when treating an isolated patient.  It allows for an organized set of protocols to be developed by a clinician that is always challenged by new evidence.  If the skills of the practitioner are equal, an EBP has better outcomes, fewer failures and sets loftier goals for care then one that doesn’t rely on evidence in practice.

When it comes to podiatric biomechanics, there are hundreds of additions to the literature, with more than 200 articles alone that conclude that there are benefits of custom foot orthotics.   Almost all of them were funded and/or performed by the very practitioners and researchers that would have the most to gain if their results were friendly towards the very theories or products they have a vested interest in.  Those with a theoretical interest in the forces and moments (BioPhysics) that act upon the segments of the foot and posture are not practicing or researching the structure, function and morphology (BioArchitecture) of the foot and posture theories favored by others (or vice versa), even though they may compliment or overlap each other, especially when it comes to Biomechanics.

I think Simon Spooner, a research Ph. D., who is also a practicing podiatrist, summed it up well when he said on The Podiatry Arena, “The reality is, we have studies showing certain orthoses reduce the symptoms associated with certain pathologies, in certain individuals, some of the time.  We even have studies that demonstrate an apparent reduction in the prevalence of certain pathologies in certain subject groups, at a certain time, in association with certain orthoses.   But it is unlikely that we will ever be certain that subject x didn’t succumb to pathology z due to our intervention”.

Merton Root, D.P.M., in the introduction to his classic 1977 biomechanics textbook, set a tone for establishing an evidence based practice when he stated “The practitioner must have the best possible basis for upon which to make treatment decisions. He cannot wait until sufficient research has been conducted to conclusively prove how the foot functions. Using the facts revealed by that research which has been completed and adding the logical reasoning based upon the requirements of each applicable basic science, a story of normal foot function develops which is coherent and exciting to those responsible for foot care.”

His words, when updated, still apply to the modern podiatrist trying to be a professional role model when it comes to Biomechanics.           

The future of medical practice in all of its phases, including Biomechanics, is rapidly moving towards an evidence based practice.  The prudent use of evidence combined with a focused understanding of patient specific needs and values allow practitioners to strengthen their ability to utilize their training and experience to provide a better standard of care when answering patient questions and rendering patient care.

In addition, EBP is more teachable, reproducible, researchable and effective than one that does not rely heavily on the evidence and patient values and needs.

References:

1. Timmermans S, Mauck A (2005). "The promises and pitfalls of evidence-based medicine". Health Aff (Millwood) 24 (1): 18–28.
2. Elstein AS (2004). "On the origins and development of evidence-based medicine and medical decision making". Inflamm. Res. 53 Suppl 2: S184–9.
3. Eddy DM (2005). "Evidence-based medicine: a unified approach". Health affairs (Project Hope) 24 (1): 9–17.
4. Gray J, Muir L: Evidence-based health care. Edinburgh: Churchill Livingstone. 1997.
5. Eddy DM (2005). "Evidence-based medicine: a unified approach". Health Aff (Millwood) 24 (1): 9–17.
6. El Dib RP, Atallah AN, Andriolo RB (August 2007). "Mapping the Cochrane evidence for decision making in health care". J Eval Clin Pract 13 (4): 689–92.
7. Ezzo J, Bausell B, Moerman DE, Berman B, Hadhazy V (2001). "Reviewing the reviews. How strong is the evidence? How clear are the conclusions?". Int J Technol Assess Health Care 17 (4): 457–466.
8. Atkins D, Best D, Briss PA, et al. (2004). "Grading quality of evidence and strength of recommendations". BMJ 328 (7454): 1490.
9. ScienceDirect – Editorial: Medical Hypotheses: Pursuing treatments that are not evidence based: How DSM IV clarifies, how it blinds psychiatrists to issues in need of investigation;Volume 72, May 2009, 491-498
10. Sackett DL, Straus S, Richardson S, Rosenberg W, Haynes B. Evidence based medicine: how to practice and teach EBM. 2nd ed. London: Churchill Livingston
11. Guyette, G: Evidence-based medicine. A new approach to teaching the practice of medicine". JAMA 268 (17): 2420–5. November 1992.

Next Installment: In Part III of this series, I will be discussing the Levels of Evidence as they pertain to Biomechanics EBP.

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