Healthcare professionals must make critical clinical decisions in their daily practice to achieve positive patient health outcomes. Evidence-based practice (EBP) is one method that can guide the decision-making process. Described by Sackett [1] as ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’, the EBP approach is claimed to be a practical process to improve clinical outcomes. This article will discuss the current position of EBP in healthcare and consider the appropriateness of its utilization in the fields of complementary and alternative medicine (CAM), in particular, myotherapy.
Applications of Evidence-Based Practice
Evidence-based practice (EBP) has evolved from the evidence-based medicine (EBM) movement of the late twentieth century, which stressed that medical practitioners should emphasize the best high-quality evidence to assess the risks and benefits of treatment options and ultimately guide effective practice [2].
EBP has a broader perspective than EBM and emphasizes not only the quality of evidence but also incorporates a clinician’s professional expertise and patient preferences into the decision-making process. Initially designed for the medical profession, EBP proponents claim the process is also beneficial to other areas of healthcare, such as nursing, allied health and CAM therapies. Tertiary degrees such as nursing [3], chiropractic [4] and myotherapy [5] do include EBP modules in their curriculum. It is worth noting that myotherapists can gain professional registration with either a bachelor’s degree or an advanced diploma qualification. The two-year advanced diploma does not strongly focus on EBP based on this author’s experience (who completed the sports myotherapy advanced diploma in 2015) or when viewing the current course structure online [6].
EBP is claimed to promote the highest quality patient care, reduce costs, improve health outcomes and enhance clinician empowerment [7]. As a tool, EBP is guided by a seven-step process that involves cultivating a spirit of enquiry, using the PICOT format to devise clinical questions [7], researching the best quality evidence, critically appraising that evidence, integrating evidence with clinical expertise and patient preferences, evaluating and circulating any EBP outcomes with other healthcare professionals [8]. Despite these claims, several health experts argue that EBP is impractical and is a model better utilised in theory than practice. Nevo and Slonim [9] argue that inadequate time, training and supervision restrictions will often lead to reduced effectiveness of EBP. Moreover, the specific emphasis on ‘best evidence’ can lead to disregarding patient preferences and clinical expertise. Nevo and Slonim-Nevo propose a more relaxed ‘evidence-informed practice’ process, which has less emphasis on evidence and may be adequate for areas of healthcare that blend art with science [9]. Notwithstanding, the current EPB process advocates that clinicians combine different types of evidence into their decision-making process. Melnyk and Fineout-Overholt [7] declare that external evidence, such as randomised control trials (RCTs) can and should integrate with internal evidence such as that generated within clinical practice.
Melnyk and Fineout-Overholt state that the implementation of EBP is still rare in many healthcare settings, even though research evidence is more readily available to practitioners than ever before [7]. Practitioner competency in EBP is weak, and many healthcare institutions remain steeped in non-EBP tradition. This can make individuals and organizations reluctant to change. Verloo, Desmedt and Morin found that less than half of practicing nurses and allied health partitioners received any EBP training within their formal training [10]. This number will hopefully increase if EBP continues to be a valued component of tertiary curriculums.
There is an apparent lack of research regarding EBP prevalence in myotherapy. Myotherapy is a small and relatively new CAM profession in Australia that specializes in managing musculoskeletal pain and dysfunction. According to the Institute of Registered Myotherapists of Australia [11], only 19% of practicing myotherapists have a bachelor-level degree or higher. Verloo et al. [10] found a strong association between education levels and EBP implementation rates among nurses and allied health providers in Switzerland. It is reasonable to suggest that these findings are relevant to various complementary therapists in Australia who practice with different levels of qualification. Due to its strong emphasis on evidence, EBP can highlight both the risks and benefits of health practices. Highlighting safety and efficacy information is particularly crucial for those clinicians who are not up to date with current research and rely on older studies that may be outdated or have been deemed ineffective since they finished their training. The seven-step process involved with EBP is likely to encourage high-quality professional development and self-reflection to the practitioner if the evidence contradicts an existing belief.
There are some obstacles that may prevent EBP implementation in some settings. Lack of EBP training and knowledge is the primary obstacle to overcome. As has already been discussed, many practitioners are unlikely to have received EBP training in their formal qualifications, and some who received EBP training may not have a firm grasp of the theory or receive adequate support to implement the practice. Lack of time in the clinical setting may also inhibit EBP implementation [7].
Kirmayer [12] states that the call for EBP implementation in CAM faces limitations due to the overemphasis on systematic reviews and RCTs. Kirmayer claims an inherent bias associated with research that favours Western medicine ahead of most CAM modalities. Vickers [13], on the other hand, disagrees and argues that EBP is not at odds with CAM as the process should give sharp focus to clinician expertise and patient preferences. Implementing EBP into myotherapy practice will be a valuable process to improve clinical outcomes and practitioner competency. There are several treatment modalities used by myotherapists that are not grounded in sound evidence. Dry-needling for low back pain, for instance, is a popular form of treatment that, according to a recent systematic review [14], lacks safety and efficacy evidence.
The EBP process encourages myotherapists to question their current practices and, in this example, weigh the risks and benefits with patient preferences and the clinician’s experience. If new research identifies a heightened risk of dry needling or other myotherapy techniques, the practitioner can identify and acknowledge these risks and treatment techniques will evolve. If the EBP process is taken out of context and leads to the dismissal of practitioner expertise and patient values, then it is unlikely to be accepted or particularly useful for myotherapists. The necessity for improved EBP training should be reinforced at all levels of healthcare training, including the advanced diploma level, in which most myotherapists are qualified. Myotherapists working in a team environment will have success implementing EBP as discussions about clinical outcomes will be shared with other health practitioners, and expertise can be utilized. Myotherapists often have adequate access to research databases such as the Cochrane Library and other systematic review databases. This helps to facilitate a healthy EBP environment, as Melnyk and Fineout-Overholt have recommended in their research [15].
Evidence-based practice will likely continue to be a controversial model in the healthcare setting as it is clear that several limitations can prevent practitioners from utilising the process in their daily practice. For myotherapists, one of the major limiting factors is the absence of EBP training and education in their early careers. This is likely to change as more practitioners receive bachelor-level training, which includes EBP modules. If EBP is learned with a critical approach, myotherapists will be able to acknowledge the benefits and potential pitfalls of the process and be able to integrate EBP into their questioning and decision-making processes. Understanding clinical risks, treatment benefits, patient values and practitioner expertise should undoubtedly lead to better clinical outcomes.
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