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PW Duncan, PT, PhD, FAPTA, FAHA, is Professor and Bette Busch Maniscalco Research Fellow, Doctor of Physical Therapy Division, Department of Community and Family Medicine, Duke University, and Senior Fellow, Duke Center for Clinical Health Policy Research, 2200 W Main St, Suite 220, Durham, NC 27705 (USA)
Address all correspondence to Dr Duncan at: pamela.duncan{at}duke.edu
Good stroke rehabilitation matters. Intense and organized stroke rehabilitation helps improve recovery and quality of life.1 For over a decade, there have been evidence-based recommendations for post–acute stroke care.2,3 Compliance with these best-practice recommendations improves functional outcome and decreases the probability of nursing home placement.4 Yet, even when most physical therapists recognize the importance of evidence-based practice and accept it as a responsibility, they are unaware of the clinical guidelines, do not implement the recommendations for assessment of outcomes, and do not routinely adopt the most proven therapies into routine practice. The chasm between what is recommended and what we do seems to widen every day.
Salbach and colleagues’ excellent study5 has identified several physical therapist–related factors that may limit translation of evidence into practice. Specifically, the effects of education level and time since graduation on evidence-based self- efficacy suggest that there are many experienced physical therapists who may not have the analytical skills or educational background to select and endorse evidence-based practices. As Salbach and colleagues suggest, there is a need to educate those who are more senior in their practice.
Barriers to compliance with evidence-based practice often are attributed to the practitioner. I often hear my academic colleagues say, "Physical therapist practice will become more evidence based when we have more doctorally trained physical therapists in practice." Although Salbach and colleagues’ results suggest that more recently prepared physical therapists and more highly educated physical therapists have more self-efficacy for evidence-based practice, we should not underestimate the complexities of implementing best practices for stroke rehabilitation.
Greenhalgh et al6 have developed a comprehensive conceptual model for considering the determinants of diffusion, dissemination, and implementation. These investigators have synthesized the literature on implementation and have identified the following key factors that will influence uptake of evidence-based recommendations: the intervention itself, the methods of communicating the evidence, the sociopolitical climate of the adopting agencies, the system-level factors, the system readiness for innovation, the characteristics of the adopter, and the implementation process.
Evaluating the scope of Salbach and colleagues’ results in the context of the Greenhalgh et al model,6 I would suggest that there are major organizational barriers disguised in the response that insufficient time is the major barrier to implementing evidence into practice. Is it really insufficient time, or is it inefficiency and lack of informatics to support standardized outcome measurements and clinical decision making?
Most importantly, some barriers to best practice may rest with our research-based interventions. Thirty-four percent of the responders to Salbach and colleagues’ survey suggested that research products are not clinically relevant and generalizable to routine care. These results suggest that researchers must: (1) examine restrictions in inclusion and exclusion criteria for participants, (2) evaluate the feasibility of implementing their interventions in clinical practice, and (3) select clinically relevant outcomes that may be valued by patients as well as insurers and health policy experts.
In conclusion, this well-designed and thoughtful study by Salbach and colleagues sheds some light on practitioner characteristics that may influence translation of evidence into practice. The results also challenge us to more systematically explore the complexities of implementing evidence-based practice. Educating practitioners may be a valid initial step, but it is far from sufficient for full implementation of evidence-based recommendations and interventions. Implementing evidence into clinical practice will need to involve cooperation and collaboration, from a variety of fields not traditionally associated with physical therapy. Relevant fields will include medical informatics, clinical decision making, organizational theory, social-behavioral change agents, health policy, finance, and marketing. Most importantly, successful implementation of evidence will include collaboration with multiple stakeholders from clinical practice settings, as well as patients and their families.
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  P. Q McGinnis, L. M Hack, K. Nixon-Cave, and S. L Michlovitz Factors That Influence the Clinical Decision Making of Physical Therapists in Choosing a Balance Assessment Approach Physical Therapy, March 1, 2009; 89(3): 233 - 247. [Abstract] [Full Text] [PDF]
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A. L Behrman and P. Plummer-D'Amato "What's in a Name?" Revisited Physical Therapy, January 1, 2008; 88(1): 6 - 9. [Full Text] [PDF]
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