Physical Therapist As Critical Inquirer

PROFESSIONAL PRACTICE IN
PHYSICAL THERAPY
The physical Therapist as Critical
Inquirer
Critical inquiry
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.
The Interactive Guide to Physical Therapist Practice with

Catalog of Tests and Measures (2002)1
THE HISTORY OF CRITICAL
INQUIRY
• The constitution 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.”
• In 1921, P.T. Review, the first physical therapy journal, began
publication.
• Mary McMillan acknowledged the importance of this aspect of
physical therapy in the preface to the third edition of her
textbook, Therapeutic Exercise and Massage, published in 1932
• In the 1993 McMillan Lecture, Gary Soderberg again addressed
the need for development of the science of physical therapy
THE HISTORY OF CRITICAL
INQUIRY
• The American Physical Therapy Association (APTA)
has taken major steps to advance the science of the
profession, including:
• formation of the Foundation for Physical Therapy
• Publication of a clinical research agenda
• Creation of a clinical research network
• The Hooked on Evidence grass-roots initiative to
develop a database for evidence in physical therapy
EVIDENCE-BASED MEDICINE
Evidence -based medicine (EBM) is the integration of the best
research evidence with clinical expertise and patient values.
The popularity of EBP has emerged from clinicians’ realization

of the following:
● They need new information on a daily basis.
● They lack the time to find and assimilate new information.
● Traditional information resources often are out of date,
wrong, and overwhelming in volume.
● A disparity exists between clinical judgment, which increases
with experience, and “current, relevant” information, which
decreases with experience.
THE FOUNDATION FOR
PHYSICAL THERAPY
The Foundation for Physical Therapy was established in
1979 as a national, independent, nonprofit corporation to
support the research needs of the physical therapy
profession in three areas:
● Scientific research, to create a solid platform for future
clinical research
● Clinical research, to assess the efficacy of physical
therapy interventions and to help define best practice
● Health services research, to assess the effectiveness of
physical therapy practice in the emerginghealth care
delivery models
CLINICAL RESEARCH
NETWORKS
A clinical research network (CRN) brings universities,
hospitals, clinics, and other institutions together to
share resources and work to answer questions
important to the physical therapy profession. It
provides physical therapists with the opportunity to
use a network of resources to conduct research.
HOOKED ON EVIDENCE
Hooked on Evidence is a national initiative by the
American Physical Therapy Association (APTA) to
develop a database on the effectiveness of physical therapy
interventions.
• The goal is to give clinicians quick, easy access to the
knowledge available from current research.
• Hooked on Evidence is a work in progress; it depends on
volunteer physical therapists to search
 The literature on a particular topic,
 Retrieve relevant articles from peer-reviewed literature
 Summarize the data and findings
 Send the review to the APTA for inclusion in the database.
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.
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.
• The term outcomes research also is used for studies that
focus on the end result of health care in terms of health
status, disability, and survival.
DATABASE SOURCES OF
EVIDENCE FOR PRACTICE
 Cochrane Collaboration (
http://hiru.mcmaster.ca/COCHRANE
 Bandolier www.jr2.ox.ac.uk:80/Bandolier
 National Guideline Clearinghouse : www.ngc.gov
 PEDro : www.pedro.fhs.usyd.edu.au/
 Hooked on Evidence :
www.apta.org/hookedonevidence/index.cfm
CRITERIA FOR CRITICAL
INQUIRY
• Participate in the design and implementation of decision-making
guidelines.
• Demonstrate clinical decision-making skills, including clinical
reasoning, clinical judgment, and reflective practice.
• Evaluate published studies related to physical therapy practice,
research, and education.
• Secure and critically evaluate information related to new and
established techniques and technology, legislation, policy, and
environments related to patient or client care.
• Participate in scholarly activities to contribute to the body of physical
therapy knowledge (e.g., case reports, collaborative research).
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.
• In 1996, 93.4% of PTs surveyed reported no work-related research
activity
The following sections explore five remaining aspects of critical inquiry
that do not overlap with the PTs’ other roles:
 A user of research,
 A publisher of case reports
 A collaborator in clinical research studies
 An assessor of new concepts and technology
 A research subject.
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.
Collaboration in Clinical Research
The researchers identified the following factors as crucial for clinicians
conducting clinical research, whether independently, in collaboration
with a CRN, or with faculty members in a local physical therapy
program:
● Facility or institutional resources
● Patient management issues
● Availability of target patient populations
● Acquisition and 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
In the critical inquiry role, PTs must fulfill their responsibility to
society to protect research subjects .
Principle 5&6 of the code places a duty on the PT to
• “maintain and promote high standards for physical therapy
practice, education, and research their rights”.
• “PTs participating in research shall abide by ethical standards
governing protection of human subjects and dissemination of
results.”
• “PTs to support research activities that contribute knowledge for
improved patient care”
Protection of Human Subjects
The Nuremberg Code of 1947 outlined the basic principles of
ethical research on humans:
• Voluntary participation;
• The disclosure of risks to subjects;
• A design that merits any risks the subjects face
• 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;
• 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. In practice, this means that an
individual who wants to conduct a research study must prepare
an application that describes the proposed study, outlining the
nature of the research and describing the risks and benefits, the
ways in which subjects will be recruited and informed consent
will be obtained, and other relevant information.
Subjects vs. Patients
The role of the PT in critical inquiry is markedly different,
because the primary intent of the researcher is to advance
knowledge through work with subjects
the intent of the PT in the patient/client management role
is to promote the best interests of the patient.
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
To comment constructively on research literature.
BE PROFESSIONAL
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PROFESSIONAL PRACTICE IN

The Interactive Guide to Physical Therapist Practice with

The popularity of EBP has emerged from clinicians’ realization

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