• Home
  • About
  • Blog
  • SMART
  • Community
  • Forum
  • Tools
  • Mobius
    • RunSmart
    • Podcast
    • Photos
  • Contact
Work With Me

Physiotherapy | Performance |  Mentorship |  Speaking | Events | SLP | News | Start

Evidence-Based Practice, Or How The Three-Legged Stool Fails Us

Sunday, 04 May 2014 14:53
  • View Comments
Evidence-Based Practice, Or How The Three-Legged Stool Fails Us click to see full-size image

Evidence-based. Evidence-informed. Best evidence. These are just a few of the catch phrases that litter the medical community these days. For every phrase, there is probably at least one analogy to best describe it. Perhaps the one that is most bothersome and annoying is that which is used for "evidence-based practice": the three-legged stool.

If you aren't familiar with it, the evidence-based practice stool stands on three legs. Each is considered to be equally important. The legs are best available research evidence, clinical expertise, and the patient's values, needs and preferences.

So how could I not support a model of evidence-based practice such as this? How could I become annoyed with such an analogy?

Evidence-based practice doesn't exist in a vacuum. There is no three-legged stool that functions optimally, in any office or home, unless it has a sound foundation upon which to place those three legs. That is the part that is readily forgotten.

Sure, we can make clinical decisions based on the best available research evidence - though the evidence is only as good as the study design. Buyer beware. We can emphasize the value and importance of countless years of clinical experience - let's just not use that as the primary means of validating a treatment intervention. Buyer beware - again. And of course we need to listen to the patient's values and preferences - though I think that it needs to be an "active" involvement on their part.

All well and good.

But the one area in which the stool is lacking is the floor upon which it rests. If you build a house on quicksand, we all know the results. The same is true if we put that three-legged stool on an unstable surface or a perilous foundation.

All is not lost: we can build a solid foundation given three key factors:

Scientific Plausibility: Does the treatment phenomenon proposed actually obey the laws of physics and have the scientific potential to exist in the world as we know it? I know that my chi is probably a little crooked, but so what? I was once told that using a foam roller created "elasticity" in the tissues; I am just not sure that science (nor collagen) would agree. If it doesn't obey science, then "Clinical Expertise" just isn't good enough - so put it to rest, please.

Anatomic Plausibility: Does the theory hold when you look at it from an anatomical perspective? My shifting cranial sutures demand anatomic plausibility. And then there is the iliotibial band. Are you really able to stretch this? Can you do so with one set of three 30 to 60 second stretches of dense connective tissue oh, every couple of days or before and after activity? Hell no. Don't believe me? Get into an anatomy laboratory at your nearest university and grab one - then let me know what you think.

Critical Thinking: Critical thinking and clinical reasoning are founded on an adherence to the scientific method. Beliefs must be left at the door. Please, no maintaining of contradictions based on logical fallacies. For example, we have plenty of data to confirm that the inter-rater reliability of many manual techniques - including palpation - is horrendous. Yes, we've had it for decades. Yet we continue to allow ourselves the liberty of using these tools repeatedly to "confirm" a diagnosis.

That three-legged stool of evidence-based practice is only as good as the foundation upon which we rest it. So let's get back to science and build a foundation that will truly support that stool. If we do, the stool can - and will - stand tall on its own.

Photo credits: Jesse.Millan

Related Articles By Allan Besselink
  • It's Playoff Time: Put Non-Evidence-Based Care On The Sidelines
  • When Scientific Evidence Is Ignored, Everyone Suffers
  • Clinical Reasoning: When Beliefs Trump Evidence

Did you enjoy this post?

If so, you will love my newsletter. Get blog updates delivered straight to your mailbox - along with exclusive content, updates, special events, and discounts!

Published in Subscribe to the RSS feed of Blog  Blog / Subscribe to the RSS feed of Smart Physio  Smart Physio
Tagged underevidencecommentaryclinical reasoninganatomy
blog comments powered by Disqus
back to top

Latest Blog Posts

  • A Pause For Many A Cause
  • Evolution Or Revolution?
  • The Homeostasis Of Writing
  • The Deafening Silence
  • Learning How To Live

Free Updates

Free Updates

Join Over 4800 Readers

Blog Menu

  • All Posts
    • Smart Physio
    • Rhubarb Diaries
  • Best Of The Blogs
  • Archive

Most Popular Posts

  • Three Common Examples Of Self Image, Self Sabotage, And Comfort Zones In Action
  • The Deafening Silence
  • Learning How To Live
  • McKenzie’s Derangement Syndrome In A World Of Pathoanatomy
  • Evolution Or Revolution?
  • The Homeostasis Of Writing
  • Patient Access To Physical Therapy And Groundhog Day
  • One Nation – Under Gold
  • The Flow Of Running, The Flow Of Life
  • Why HB 1263 Matters

Top 10 Smart Physio

  • Three Common Examples Of Self Image, Self Sabotage, And Comfort Zones In Action
  • The Deafening Silence
  • Learning How To Live
  • McKenzie’s Derangement Syndrome In A World Of Pathoanatomy
  • Evolution Or Revolution?
  • The Homeostasis Of Writing
  • Patient Access To Physical Therapy And Groundhog Day
  • The Flow Of Running, The Flow Of Life
  • Why HB 1263 Matters
  • Civil Rights And Your Health

Community Login






Forgot login?

Official Site

Help & FAQ

Help And FAQ
Terms And Conditions
Privacy Policy
Disclosures
Forum Rules

PT Blog Awards

Top 5 finalist in three categories: "Best Overall Blog", "Best PT Blog" and "Best Advocacy Blog".

Allan Besselink

Allan Besselink, PT, Dip.MDTAllan Besselink, PT, Dip.MDT has a unique voice in the world of sport and health care, one that has been defined by his experiences as physiotherapist, mentor, McKenzie practitioner, coach, innovator, author, educator, patient, and athlete. Read more about Allan, contact him, get updates via email, or connect with him on Twitter, Facebook, Google+ and LinkedIn.

RunSmart Book

Where To Buy RunSmartUp to 60% of runners will sustain an injury within any given year. Poor running mechanics, in conjunction with poor, ineffective and outdated training methods, can pose a significant injury risk. "RunSmart" was written to address these issues in the running community.

Featured Chapter

"Running Injuries: Etiology And Recovery- Based Treatment" (co-author Bridget Clark, PT) appears in the recently released third edition of "Clinical Orthopaedic Rehabilitation: An Evidence-Based Approach" by S. Brent Brotzman, MD and Robert C. Manske, PT.

License

Creative Commons License
This work is licensed under a CC BY-NC-ND License.

Visitors

Copyright 2013 Allan Besselink  | Terms Of Use | Privacy Policy |  Disclosure Policy | Powered By Mobius Intermedia