The Physical Therapist

AS Critical Inquirer
 Critical inquiry is the process of applying the
principles of scientific methods to read and
interpret professional literature; participate in,
plan, and conduct research; evaluate outcomes
data; and assess new concepts and technologies.
 HISTORY
 Theprofession of physical therapy has
recognized the crucial roles of scientific
investigation and critical inquiry.

 Examples:
EXAMPLE 01:

 Theconstitution of the American Women’s Physical

Therapeutic Association, published in 1921, stated that :

“The purpose of the Association shall be to establish and

maintain a Professional And Scientific standard for those
engaged in the profession of Physical Therapeutics.”
 EXAMPLE 2:
 Alsoin 1921, P.T. Review, the first physical
therapy journal, began publication. The aims of
the journal were to provide a means by which
physicians and reconstruction aides could more
easily keep up with each others’ work and to
preserve the standards and advance the science of
the profession.
 EXAMPLE :3
 Mary McMillan acknowledged in her textbook, Therapeutic
Exercise and Massage, published in 1932.
 She noted that “since the second edition of this book was
published there has been a great deal of research in various
pathological conditions that are treated by physiotherapeutic
measures,” and explained that several chapters had been
revised so that “the student may be brought in touch with this
important phase of physiotherapy work.”
 EVIDENCE-BASED MEDICINE

The integration of the best research

evidence with clinical expertise and
patient values.
Sackett et al.,
 CLINICAL EXPERTISE
“the ability to use clinical skills and past
experiences to identify each patient’s unique
health state and diagnosis, as well as the risks
and benefits of potential interventions in the
context of the patient’s personal values and
expectations.”
 STEPS IN APPLYING EVIDENCE-BASED
MEDICINE

1.Convert the need for information into an

answerable question.
2. Track down the best evidence to answer that
question.
3. Critically appraise the evidence for validity,
impact, and usefulness in clinical practice.
4.Integrate the critical appraisal with clinical
expertise and the patient’s unique circumstances
and values.
5. Evaluate the effectiveness and efficiency of the
evidence-gathering process and seek ways to
improve these factors.
 6 DATABASE SOURCES OF EVIDENCE
FOR PRACTICE
Cochrane Collaboration (international nonprofit organization providing up-to-date information
on health care effects): http://hiru.mcmaster.ca/COCHRANE
● Bandolier (independent U.K. journal by Oxord scientists about evidence-based health care):
www.jr2.ox.ac.uk:80/Bandolier
● National Guideline Clearinghouse (database of evidence-based clinical practice guidelines and
related documents updated weekly by the Agency for Healthcare Research and Quality in partnership
with the American Medical Association and the American Association of Health Plans
Foundation): www.ngc.gov
● PEDro (international Physiotherapy Evidence Database providing rapid access to bibliographic
details and abstracts of randomized controlled trials, systematic reviews, and evidence-based
clinical practice guidelines in physiotherapy): www.pedro.fhs.usyd.edu.au/
● Hooked on Evidence (American Physical Therapy Association’s database containing current
research evidence on the effeciveness of physical therapy interventions:
www.apta.org/hookedonevidence/index.cfm
 OUTCOMES RESEARCH
Outcomes research is a term applied to different types of
health care research.
 One kind of outcomes research is conducted by
analyzing large administrative databases (e.g.,
Medicare) to explore such issues as utilization, costs,
morbidity, and mortality related to certain conditions or
interventions.
 Theterm outcomes research is also used for
studies that focus on the end result of health
care in terms of health status, disability, and
survival.
 Effectiveness studies address how well routine
clinical practices work in everyday practice, whereas
Efficacy studies, which are typically conducted as
randomized clinical trials in specialty centers with
discrete sampling of subjects, address whether
clinical practices can work in ideal situations. e,g.
presents a comparison of effectiveness and efficacy
studies of individuals with arthritis.
ROLES OF THE STAFF PHYSICAL THERAPIST
IN CRITICAL INQUIRY
 The critical inquiry role of the PT may not be as valued or as
evident as other roles.

BECAUSE
 In the work of the PT, administrative and education
responsibilities become routine, but evidence-based practice
and participation in clinical research do not.
 In
1996, 93.4% of PTs surveyed reported no
work-related research activity,

 and in 2001 PTs reported spending an average

of 1% of their time each week on research or
critical inquiry.
Application and Critique of Research
 PTs can use research in two ways.
 One approach, evidence-based practice.
Increasingly, PTs’ education gives them the skills
to practice evidence-based physical therapy.
 However, only a small percentage of the
practice of physical therapy is supported by
evidence; therefore the traditional method,
independent critiquing of the literature,
continues to be the primary means of updating the
specific information needed for clinical practice.
The skills for traditional and evidence-
based strategies for critiquing the
literature typically are developed in
physical therapy school.
 Publication of Case Reports

 McEwen and colleagues have devised a

clinician’s guide to writing case reports.
 They identified the following steps:
1.Think. What is the focus of your case?
2. Search the literature. What new insights would your case offer to the
knowledge base?
3. Write. Of the following, begin by writing the section you know best but include
them all:
a. Describe the rationale behind the case (introduction)
b. Describe the patient or situation, the hypothesis, and the intervention (case
description)
c. Describe the outcome (outcomes)
d. Reflect on what happened (discussion)
4. Submit the case report for publication in a peer-reviewed publication.
The writing process provides clinicians the
opportunity to examine clinical observations
and reasoning, share their work with a larger
audience, and ultimately contribute to
improved patient care and the physical
therapy knowledge base.
 Collaboration in Clinical Research
 According to Fitzgerald and Delitto,research must
be done on patients in clinical settings if the
physical therapy profession is to document the
effectiveness of interventions accurately, validate
patient classification systems, and identify
prognostic indicators of functional limitations and
disability.
These researchers identified the following factors as crucial for clinicians
conducting clinical research:
 Facility or institutional resources

● Patient management issues

● Availability of target patient populations
● Maintenance of support from therapists, physicians, and institutional
review boards (IRBs)
● Research-related injuries or illness
● Ethical considerations involved in determining whether a protocol must
be modified or a project terminated
 Assessment of New Concepts and
Technology
 Harris,
recommended a strategy for
determining the scientific merit of
Nontraditional Physical Therapy
treatments that can also be applied to a
wide range of interventions, tests, and
measures.
The PT should determine whether:

1. The theories underlying the intervention or

instrument are supported by valid anatomical and
physiological evidence.

2. The intervention or instrument is designed for a

specific type of patient population.
 3. Potential side effects are presented
 4. Studies from peer-reviewed
journals that support the
intervention’s or instrument’s
efficacy are provided
5. The supportive peer-reviewed studies include
well-designed, randomized, controlled clinical
trials or well-designed single-subject experimental
studies
6. The proponents of the intervention or instrument
are open and willing in discussing its limitations
 Serving as a Research Subject
PTs may be called upon to serve as subjects in research studies. In
addition to a commitment to thoughtful, honest data collection,
the decision to participate involves consideration of the following:
● Value of the study to physical therapy
● Integrity of the research design
● Time required to participate
● Length of time to complete the study
● Ability to sustain interest and objectivity to project completion
ETHICAL AND LEGAL ISSUES IN
CRITICAL INQUIRY
 Inthe critical inquiry role, PTs must fulfill their
responsibility to society to protect research subjects and
their responsibility to individuals to protect their rights.

 These concepts are viewed from several perspectives,

including the APTA’s Code of Ethics and Guide for
Professional Conduct, the protection of human subjects
in research, the requirements of IRBs,
 APTA Code of Ethics and Guide for
Professional Conduct
 Principle 5 of the code places a duty on the PT to
“maintain and promote high standards for physical
therapy practice, education, and research.”
 Section 6.5A states that a PT “participating in
research shall abide by ethical standards governing
protection of human subjects and dissemination of
results.”
 Thenext section (6.5B) obligates PTs to
“support research activities that contribute
knowledge for improved patient care,”
 Other sections of the Guide for Professional
Conduct (GPC) and COE specifically address
the issues of truthfulness , autonomy and
consent GPC , and compliance with laws and
regulations (COE 3).
 Protection of Human Subjects
The Nuremberg Code outlined the basic principles of ethical research on
humans:
 voluntary participation;
 The disclosure of risks to subjects;
 The avoidance of injury and suffering;
 The prohibition of studies that put subjects at risk of death or disability;
 The right of subjects to terminate participation;
 The balancing of risks against societal benefits; and
 The responsibilities of the researcher.
 Institutional Review Boards
 IRBs are the mechanism by which institutions
determine whether the benefit to society from a
research study warrant the risk to individual
subjects in the study.
 An important feature of this process is the use of
IRBs to review research before it is implemented.
 Responsibilities of Clinical
Researchers
 PTs who participate in clinical research have a
responsibility to report results honestly and accurately, to
report both positive and negative results, and to comment
constructively on research literature.
 The APTA has developed a policy statement that
provides guidance on the issue of integrity in research.
 The recent EBP movement presents additional challenges.
THANKS