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Explaining the need for evidence-based practice

By Craig R. Denegar, PhD, ATC, PT, Susan Foreman Saliba, PhD, ATC, PT, and Ethan Saliba, PhD, ATC, PT


Health care is complex, costly, and essential. The cost of health care can be assessed not only in terms of money spent but also in terms of time required of patients and providers. The challenge across health care is to provide the care necessary to optimize treatment outcome in the most efficient manner. The challenges facing the health care system of patients, providers, and payers are no less a concern in athletic training than in other health care disciplines. To meet these challenges, treatment regimens need to be analyzed and compared based on the outcomes and costs of care. Those treatments not demonstrated to improve outcomes should be abandoned from general practice. For example, Deyo et al. (1990a) reported that TENS as a sole intervention is ineffective in the management of chronic low back pain. This does not mean that a particular modality like TENS is of no value. Further study of some treatments may be warranted to identify medical conditions, circumstances, or populations (patients without contraindications treated for pain associated with acute rib fracture) for which the treatment is effective (Oncel et al. 2002). New evidence should be evaluated and, when appropriate, should change how individuals practice. Moreover, new research and systematic reviews of existing research may also result in new practice recommendations for all clinicians.

Numerous tools have been developed to assess the outcomes of treatment with medications and surgery as well as modality application and therapeutic exercises. Assessment of treatment outcomes often includes clinician-derived measures such as changes in range of motion and strength. However, information provided by patients regarding levels of pain, functional limitations, and perceived disability is also vital. Reports of treatment outcomes based on clinician assessments and patient self-assessments are increasingly available to guide the clinician’s selection of effective treatments with therapeutic modalities and exercises. The certified athletic trainer must develop the ability to identify pertinent literature, assess the validity of the conclusions drawn by investigators, and judge the extent to which the results of clinical trials generalize to the people they treat.

At this point you may question why published clinical trials are important to modality use specifically and health care in general. When an injured athlete under your care reports improvement, you can be certain that treatment you provided was beneficial. Unfortunately, that is not the case! Many factors can lead to improvements associated with care rendered by certified athletic trainers and all other health care providers. In many situations, improvement occurs with the passage of time (natural history of the condition). Simple reassurance that a condition is not serious and that the athlete will recover, and similar efforts to reassure and empathize, can result in perceived improvement. True placebo and the effects of other interventions such as exercise may also explain the perceived benefits of modality application.

Given that many factors may contribute to reports of improvement and demonstrable functional recovery, how does the clinician decide how to best treat the patient? Searching the literature for clinical trials on treatments of various conditions can yield valuable information, and this process is introduced in the next section. The literature, unfortunately, is lacking in many areas of athletic health care; and while success in managing nonathletic patients provides some evidence of efficacy, the generalization to athletic populations may not be possible. Clearly a great deal of research is needed to better define those treatments that are truly beneficial in the management of specific athletic injuries. This is not laboratory research but rather research that must be conducted in the practice setting and must involve the clinicians providing care.

This is an excerpt from Therapeutic Modalities for Musculoskeletal Injuries, Third Edition.




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