Thursday Thoughts: On Evidence Informed Practice | Modern Manual Therapy Blog

Thursday Thoughts: On Evidence Informed Practice

Yes, I stated that correctly, Not evidence-based practice–but evidence Informed practice; for the simple distinction that we are not basing our evaluation/treatment/intervention on the evidence alone, rather, we are using it to help inform our clinical decision making. Other factors, such as clinical experience and the PATIENT/CUSTOMER, (#Kaboom @Jerry_DurhamPT), are equally weighted, and sometimes not, depending on the situation. This has been, and continues to be, a topic of frequent debate in the Twitter-sphere. I have (surprise, surprise) been involved in a few of them. However, I don’t expect, depending on what side of the evidence-aisle you sit, that anything presented here will change anyone’s mind.  More than likely, it will either help confirm what you already believe, or motivate you to dig-in further to defend your current position. Still, it is not my intent to change minds with this. Thankfully, there are people out there much smarter than me who have unknowingly helped present my position more eloquently than I, so allow me to sample from them:

There are lies, damn lies, and statistics”–Mark Twain

Evidence-based medicine has faltered in its extension in how we translate evidence into clinical care. EBM has benefited clinical medicine tremendously and we need to use the evidence in the best way that we can. But when you’re seeing a patient and we need to make a one-time decision for that patient, I don’t think that EBM gives us the tools we need to decide whether a patient should necessarily choose one treatment over the other. The evidence should inform our clinical decision making, but we should not base it on the evidence and nothing else.”
To perform the best evidence, we need to synthesize the best evidence. Expert panels should come up with what the evidence states. The problem I have is where it gets into ‘thus, we recommend something vs. something else because it’s superior;’ because the patients are the ones that should always be on our forefront and patients have a lot of reasons why they might not want to choose what the evidence shows may be superior.“—Dr. Steven Stovitz, MD. For more on this, check out BJSM podcast from May 8, 2015:

EBM Triad
“EBM isn’t exclusively about the evidence. It’s based on it but not limited to it”–Paul Ingraham (@PainSci):

And this also from Paul: “For you clinicians: when confronted with evidence that’s a bummer, at odds with your experience, remember that your experience is a fully legit third of that EBM‬ equation. But! You must be very cautious not to lean too hard on your experience, because “you are the easiest person to fool” (Feynman). It’s only a third of the equation. Not two thirds. Not half. Just a third, roughly, give or take (probably always less than a third for younger professionals). And it’s never a very reliable third. Just like science, experience is difficult to interpret and often wrong.”  For the full article see here:
“In studying economics, or the human body and health, or the workings of the brain, (some people) tend to work with abstractions and simplifications, reducing highly complex and interactive problems into modules, formulas, tidy statistics…This can approach can yield a partial picture of reality…But with these simplifications, the living, breathing element is missing”–Robert Greene in Mastery

Many times the studies we cite to guide interventions for a given patient would have, in fact, been excluded that from the study!” Dr. Jeff Moore (@jeffmoredpt)

We treat humans, not statistics, and we should not forget that. We cannot be so focused on the PDF on our laptop that we forget about the human on our table.  Let the evidence guide you, but not blind you. Clinical experience, while full of bias and confounding variables, is absolutely paramount in treating the Sandys of the world.“–Dr. Justin Dunaway (@DrDunawayDPT).
And this, from Andrew Miles MSc, MPhil PhD and others, (my thanks to a physio from across the pond, Neil Maltby (@neil_maltby) for this reference): “The clinical interpretation of medical evidence advanced by the protagonists of EBM and their subjective abstraction into academic journals and guidelines and review are therefore valuable activities in their own right, but only in their contribution to the general scientific debate. Thus, clinical interpretations of medical evidence will differ and attempts to select one interpretation over another or attempts to ‘synthesize’ a third, subsequently declaring it as ‘truth’ are irresponsible and cannot be recognised as belonging to the scientific ability or methodological competency of any one group of clinical academics or practicing clinicians.

The essence of clinical practice is the provision of personal medical services through the mechanism of the consultation. The place of EBM, and science more broadly, is utterly subordinate to this. The advent of patient-centredness and shared clinical decision making and the rise in importance of genomics and translational sciences is rapidly marginalising EBM, so that the concept of EBM is losing influence as the promises and potential of personalised medicine are increasingly recognised. EBM was initially known as ‘clinical epidemiology’, the application of epidemiological data to clinical practice. That is what it was, what it always has been and that is what it remains.”
Here’s the full twenty-nine pages of “light” reading for those interested:

As always, thanks for reading. Comments and discussion welcome.

via Dr. Andrew Rothschild -

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

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