Researchers and Clinicians: A GrowingDivide or Narrowing Gap?Roy Bechtel, PT, PhD1

Joshua A. Cleland, DPT, PhD, OCS2

Britt Smith, MSPT, OCS, FAAOMPT3

J Orthop Sports Phys Ther 2006;36(7):451–461. doi:10.2519/jospt.2006.0108

This month’s guest editorial is unusual in its format (and length) in that it iscomposed of 3 separate contributions. What initially started as a letter to theeditor from Dr Bechtel was supplemented by related opinions from Dr Clelandand Mr Smith to evolve into a rich and timely discussion about the divide thatseems to exist between physical therapy research and clinical practice. Are

researchers clearly out of touch with clinical reality and do they have a complete disregard forclinical expertise despite the ‘‘claimed’’ daily success of clinicians? Are clinicians oblivious tothe ‘‘evidence’’ and reluctant to change their practice patterns despite research suggestingthat they should? The importance of the issue and the perspectives presented in the 3contributions below warrant a place on the ‘‘front page’’ instead of the back of the Journal,where items such as letters to the editor are typically found.

In my role as the editor of the JOSPT over the past 5 years, I have witnessed a clear change inthe contributors of articles and in the types of manuscripts submitted and published in theJournal, which makes me believe that at least some clinicians and researchers are close enoughto reach across the divide and shake hands. I hope that the following contributions by DrBechtel, Dr Cleland, and Mr Smith will help further accelerate the process of creatingmeaningful research and applying these results in daily clinical practice.

Guy Simoneau, PT, PhD, ATCEditor-in-Chief, JOSPT

GOT SCIENCE?

We have a problem in manual therapy, and perhaps in the whole profession of physicaltherapy. Our problem is the growing chasm between researchers on the one hand, andclinicians on the other. In my role as faculty member at a Research I institution, associatedwith a teaching Medical Center, I interact frequently with entry-level and postprofessionalphysical therapy students, as well as researchers and clinicians. Many of these acquaintances,especially postprofessional students and manual therapy clinicians, have for some time beenexpressing the opinion that their professional scholars have completely devalued clinicalexpertise as a part of evidence-based medicine (EBM). These clinicians generate clinicalhypotheses and make tentative diagnoses using the clinical tools of palpation and motiontesting, while physical therapy researchers have been unable to show that palpation andmotion testing meet acceptable standards for reliability and validity as clinical tools.3 It shouldbe noted that palpation has not been completely abandoned by the larger medical

1 Assistant Professor, University of Maryland School of Medicine, Department of Physical Therapy & Rehabilitation Science,Baltimore, MD.2 Physical Therapist, Rehabilitation Services, Concord Hospital, Concord, NH.3 Physical therapist/owner private practice, SOAR Physical Therapy, Grand Junction, CO.

Journal of Orthopaedic & Sports Physical Therapy 451

GU

ES

TE

DI

TO

RI

AL

community. For example, it has been shown that palpation rivals CT in the ability toaccurately detect pelvic ring fractures, yielding a sensitivity of .98 and a specificity of .94 in arecent study of patients with pelvic trauma.5 Physical therapy researchers tend to stand by thefindings reported in our literature and suggest that clinicians are simply ‘‘ignoring theevidence’’ and refusing to acknowledge their delusional beliefs for what they are. Clinicians,for their part, see the ‘‘evidence’’ every time they evaluate a patient, devise a treatment plan,and demonstrate gratifying results from their interventions. Clinicians wonder why researchersstubbornly believe it is impossible to do the things clinicians do, because clinicians are doingthese impossible things every day. The rift between scientists and clinicians needs to beaddressed, because it threatens the foundation of evidence-based practice and, therefore, itthreatens the entire profession.

Many factors have conspired to produce the current state of affairs. Foremost, the growingcost-control movement in health care has generated a search for standards to judge theefficacy and cost effectiveness of various interventions, so that precious health care dollars arenot wasted. This, in turn, has produced a new awareness of EBM as a tool to set standards.And the reliance on EBM has granted power to scientists to determine which physical therapyevaluations and treatments can be certified as meeting evidence-based criteria and, therefore,should be reimbursed by third parties. This practice has the potential to work well and tobenefit patients and the profession. Clearly, the principles of EBM are sound and I stronglysupport their application to our profession. The problems we encounter more often resultfrom forgetting EBM principles than from applying them. Three basic rules are commonlyoverlooked: (1) any statement about current understanding of concepts or processes must betime-limited, because we expect our knowledge base to change as more data are added overtime; (2) we must concern ourselves not only with the quality of the evidence, but also withthe strength of the evidence; and (3), as stated by Sackett,13 the definition of ‘‘Evidence-basedmedicine is the integration of best research evidence with clinical expertise and patient values’’ (myitalics).

As more educational programs attempt to gain recognition for their faculty in academia, thereis greater specialization of faculty members as researchers with terminal degrees. To competesuccessfully for a shrinking pool of federal dollars, a single-minded concentration on theworld of research is required. We should remember that scientists are human beings and aresubject to all the frailties of the human condition. In today’s competitive environment, to dotheir jobs, scientists are required to generate continuous grant funding. While this goal is notnecessarily in opposition to doing high-quality research, it does tend to militate againstinnovation and in favor of doing ‘‘what worked before’’ to obtain renewed funding. Someskepticism of research on the part of clinicians may be justified. The end products of thecurrent status-quo approach to grant funding often fall short of accepted criteria for researchquality or are not generalizable to populations relevant to physical therapy care and, as aresult, must not be weighted heavily in drawing conclusions that affect patients. As pointedout by Sackett, a review of articles used in the prestigious American College of PhysiciansJournal Club from 1994 to 1998 showed that of the top-20 frequently cited journals, abstractsfrom the most cited journal (The New England Journal of Medicine) had the best quality rating,but met standards for validity less than 13% of the time.13

Partly to increase the diversity of grant funding, the NIH, in its ‘‘NIH Roadmap for MedicalResearch’’ initiatives, has created a theme of ‘‘Re-Engineering the Clinical ResearchEnterprise’’ to broaden the base of funded researchers by including more clinical scientistsworking directly with patients. This emphasis on a more patient-centered approach to clinicalresearch is also mirrored in the NIH’s admission that ‘‘There is a pressing need to betterquantify clinically important symptoms and outcomes, including pain, fatigue, and quality oflife.’’9 We forget the patient at our peril. Many physical therapy researchers today have beenwillingly hypnotized by the mantra of ‘‘evidence-based medicine,’’ defined as ‘‘the scientificliterature.’’ Clearly, adhering to only one of the principles of EBM (best evidence) is not areason for self-congratulation on anyone’s part, especially if scientists treat their evidence as

452 J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006

immutable truth instead of a time-limited capsule of current understanding, subject torevision as data warrant. Sackett13 suggests that any meta-analysis, or even a critical appraisalof literature evidence relevant to a clinical topic, should have a ‘‘shelf-life’’ of no more than 1year, at which time the evidence should be surveyed again. We all want to be ‘‘right’’ and seeour beliefs vindicated. This truism applies equally to clinicians as well as scientists. However,both groups need to be circumspect, especially when their beliefs contradict the evidenceprovided by the other.

Because the current healthcare environment has transferred significant amounts of decision-making power away from clinicians and given that power to scientists, a lack of circumspectionon the part of scientists will likely have a more far-reaching impact on the profession at thistime. In today’s healthcare environment, it is important for our scientists to keep an openmind when clinical evidence and research evidence conflict. Sometimes the conflict ariseswhen a visionary predicts events that cannot yet be measured by existing tools. Sometimes, theconflict arises when a scientist clinician puts the puzzle pieces together in a new way andarrives at a conclusion not supported by current literature. An example of the latter kind ofconflict is provided by the story of the bacterium h. pylori. Barry Marshall and J. RobinWarren were awarded the Nobel Prize in Medicine in 2005 for their discovery of therelationship between heliobacter pylori and stomach ulcers.7 During their research years inthe 1970s and early 1980s, the literature was replete with the presumed link between stomachulcers, acid production, and stress.2,10 It was Robin Warren who noticed the associationbetween his patients’ stomach ulcers and the presence of spiral-shaped bacteria andinflammation in the gastric mucosa. He and Marshall4 published their findings in the Lancetin 1984. Marshall and Warren encountered considerable skepticism from their colleagues,who relied on the evidence in the literature to downplay their groundbreaking discovery. Itwas not until 1994 that NIH issued a consensus document in which the role of h. pylori ingastric and duodenal ulcers was formally acknowledged.6

There is a similar story from particle physics that illustrates the influence that the lack ofappropriately sensitive tools can have on scientific advancement. In 1964, John Bachall1

predicted a flux density of solar neutrinos based on his assumptions about the process of solarenergy creation. Bachall’s predictions were considerably higher than those of other theoristsof the time. The ensuing experiments to detect solar neutrinos on planet earth found onlyabout one third of Bachall’s predicted neutrino density. In the face of this lack ofexperimental support, many physicists, following the ‘‘evidence,’’ declared that Bachall hadmade a mistake in his calculations. Bachall insisted on the correctness of his calculations. Ittook decades for physicists to discover that solar neutrinos can change state, assuming 1 of atleast 3 identities on their journey from the sun to earth. The detectors that had beenemployed in the early experiments were only designed to be sensitive to 1 kind of neutrino.The other 2 kinds were completely missed, accounting for the discrepancy between theoryand experiment.14

Manual therapy clinicians will no doubt be reminded of the classic research demonstratingpoor reliability of physical findings around the sacroiliac joint12 and the many subsequentstudies involving palpation in the pelvis and spine.11 Any good manual therapist can tell youthat their ability to palpate dysfunction is ‘‘good enough’’ to get the job done for theirpatients. This point alone should be motivation for scientists to avoid trumpeting theirnegative results too loudly. In a dynamic, scientifically-based profession such as PhysicalTherapy, the existence of this type of discrepancy should be a motivator to increasecooperation between clinicians and scientists in an effort to resolve the conflict, not a wedgeto drive us apart into warring camps. If physical therapy’s scientists smugly insist on theinability of clinicians to make differential diagnoses and devise efficacious treatments, andthird parties believe this ‘‘evidence,’’ the profession of physical therapy may well shrink to thevanishing point. This would be an unfortunate occurrence for society as well as for our ownprofession.

Roy Bechtel, PT, PhD

J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006 453

GU

ES

TE

DI

TO

RI

AL

REFERENCES1. Bahcall JN. Phys Rev Letters. 1964;12:300.2. Greenlaw R, Sheahan DG, DeLuca V, Miller D, Myerson D, Myerson P. Gastroduodenitis. A broader

concept of peptic ulcer disease. Dig Dis Sci. 1980;25:660-672.3. Hicks GE, Fritz JM, Delitto A, Mishock J. Interrater reliability of clinical examination measures for

identification of lumbar segmental instability. Arch Phys Med Rehabil. 2003;84:1858-1864.4. Marshall BJ, Warren JR. Unidentified curved bacilli in the stomach of patients with gastritis and peptic

ulceration. Lancet. 1984;1:1311-1315.5. McCormick JP, Morgan SJ, Smith WR. Clinical effectiveness of the physical examination in diagnosis

of posterior pelvic ring injuries. J Orthop Trauma. 2003;17:257-261.6. National Institutes of Health. Helicobacter pylori in peptic ulcer disease. JAMA. 1994;272:65-69.7. The Nobel Prize in Physiology or Medicine 2005. Available at: http://nobelprize.org/medicine/

laureates/2005/. Accessed 2005.9. Office of Portfolio Analysis and Strategic Initiatives. DHHS Nation Institutes of Health. NIH Roadmap

Initiatives. Available at: http://nihroadmap.nih.gov/initiatives.asp. Accessed April 6, 2006.10. Paffenbarger RS, Jr., Wing AL, Hyde RT. Chronic disease in former college students; 13. Early

precursors of peptic ulcer. Am J Epidemiol. 1974;100:307-315.11. Potter L, McCarthy C, Oldham J. Intraexaminer reliability of identifying a dysfunctional segment in

the thoracic and lumbar spine. J Manipulative Physiol Ther. 2006;29:203-207.12. Potter NA, Rothstein JM. Intertester reliability for selected clinical tests of the sacroiliac joint. Phys

Ther. 1985;65:1671-1675.13. Sackett DL, Straus SE, Richardson WS. Evidence-Based Medicine: How to Practice and Teach EBM.

2nd ed. Edinburgh, UK: Churchill Livingstone; 2000.14. Turner MS. Two theorists never in doubt. Physics Today. 2001;54:10.

VIEWPOINT ON GOT SCIENCE

I would like to thank Dr Simoneau for allowing me the opportunity to share my perspectiveon some of the issues raised by Dr Bechtel in his letter titled ‘‘Got Science?’’ As a provider ofclinical care, I have witnessed the paradigm shift to evidence-based practice (EBP) first hand.While Dr Bechtel believes that the chasm between researchers and clinicians may be thedownfall of EBP and could lead physical therapy ‘‘to shrink to the vanishing point,’’ I willprovide a slightly different viewpoint in the paragraphs below.

Dr Bechtel has outlined the 3 steps of EBP and has suggested that researchers have devalued‘‘expertise’’ as part of EBP. I respectfully disagree with this contention and believe researchersneed to further investigate the contributions of expertise in evidence based practice andimproving patient outcomes. A recent systematic review has shown that although it is expectedthat experienced physicians would have accumulated more knowledge and skills than theiryounger counterparts which should result in improved quality of care, this is not the case.5 Infact, Choudhry et al5 demonstrated that the amount of ‘‘experience’’ a physician possessedwas inversely related to the quality care that the physician provided.5 Although this systematicreview leads one to question the association between experience and outcomes, it onlyincluded physicians, which cannot be directly extrapolated to physical therapists. Physicaltherapy researchers, however, have also begun17,19 to investigate the contribution expertise inphysical therapist practice has on patient outcomes.

Experts in physical therapist practice are often considered those clinicians who possess certainvalues, communication skills, decision-making processes, specialty certification, and years ofpractice.13,18 Research has shown that more experienced physical therapists with orthopaedicor sports certifications demonstrate greater knowledge in managing musculoskeletal condi-tions than therapists without specialty certification.4 However, these defining criteria do notinfer that the labeled expert’s patients will achieve superior outcomes when compared tothose of novice clinicians.17,19

The basic tenets of EBP are not intended to devalue ‘‘expertise,’’ but rather trying todetermine what defines expertise based on patient-centered outcomes. As evidence-based

454 J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006

clinicians, we track outcomes on each patient in the clinic. These outcomes are used to showmeaningful differences in the patient’s functional status or lack thereof. The quality ofevidence is assimilated into each aspect of clinical decision making from diagnosis, using testsand measures that posses a degree of reliability and validity, to prognosis of expected outcomebased upon current literature and pattern recognition from clinical experience. Additionally,the point should be made that expertise alone is insufficient to assure optimal outcomes and,hence, the best available evidence should be incorporated into clinical decision making.5,19

I agree with Dr Bechtel’s comments that the medical community has not abandonedpalpation and would add that, based on the evidence, neither should the physical therapyprofession. Dr Bechtel has stated that physical therapy researchers have not shown thatmotion testing is either a reliable or a ‘‘valid’’ tool for basing clinical decisions and provides areference to Hicks et al.11 I agree that the Hicks et al11 study demonstrates low reliability formeasures of spinal segmental mobility; however, the article does not make any suggestions orinferences about the validity of these techniques. In fact, the authors stated ‘‘we did notexamine the validity of these findings, and therefore no conclusions can be drawn about thediagnostic accuracy of these tests.’’ In a follow-up study,8 some of the same researchersdemonstrated that although mobility testing of the lumbar spine has low reliability, it exhibitsdiagnostic utility in identifying the presence of radiographically confirmed lumbar instability.In this study8 the lack of hypomobility identified during intervertebral motion testingexhibited a positive likelihood ratio of 9.0, which results in a moderate shift in probability thata patient has lumbar instability.12 The same group of researchers9 recently investigated thepredictive validity of posteroanterior intervertebral mobility testing in a group of patients withlow back pain. Results demonstrated that despite questionable reliability of segmentalassessment in the lumbar spine, patients with hypomobility exhibited greater benefit from anintervention strategy including spinal manipulation and those who exhibited hypermobilitywere more likely to experience improvement with stabilization exercises. Contrary to DrBechtel’s statement, these studies suggest that mobility assessment of the lumbar spine meetsacceptable, evidence-based standards to be used in clinical practice. I do not believe that suchmisunderstandings of the evidence are related to the proposed disconnect between research-ers and clinicians but simply due to a lack of familiarity of the literature, which in itself isindeed a barrier to EBP.14

Clinical research is continually providing more data to support effective and efficientmanagement strategies. However, the translation of evidence to practice is an unpredictableand often stagnant process.2 So the question becomes, why is the gap between evidence andclinical practice so large? While a number of reasons for this gap have been identified,14 aresistance among clinicians to change behaviors is among the foremost barriers.10 Essentially,as Dr Bechtel mentioned, clinicians are often accused by researchers as ‘‘ignoring theevidence.’’ In fact, it has been demonstrated that expert clinicians are often resistant tochanging their practice patterns even when their treatment approaches have been disproven.1

Taking the opposite path, or following the evidence, would likely improve patient outcomeswhile simultaneously reducing healthcare costs in many situations.

Dr Bechtel reports that clinicians see the ‘‘evidence with every patient they treat’’ and theirmanual skills are ‘‘good enough’’ to get the ‘‘job done for their patients.’’ All too often I haveheard the same claims, ‘‘Why should I change when my patients do great?’’ I then alwayswonder how these clinicians are measuring that level of greatness. Often the response is ‘‘mypatients are simply getting better’’ or, as described by Dr Bechtel, clinicians are achieving‘‘gratifying results.’’ However, without measuring patient improvements with validated out-come tools, one can not be certain that a true change in patient status has occurred.16 Ifindeed your and other clinicians’ patient outcomes are ‘‘great’’ or ‘‘gratifying,’’ then what isthe harm in collecting some data (ie, use of outcomes tools at baseline and discharge) tosupport this contention? For example, clinicians managing patients with low back pain canuse the Oswestry Disability Questionnaire, a reliable and valid measure of patient perceiveddisability, to measure if a particular patient has experienced a true change in status.7

Based on the evidence,10 it appears that instituting a change in behaviors of practicingclinicians is one of the biggest barriers to successful integration of EBP, rather than theresearchers’ neglect of the value of clinical expertise. While some clinicians are quick to adopt

J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006 455

GU

ES

TE

DI

TO

RI

AL

change, there are others who are resistant and solely rely on clinical experience rather thanattempting to incorporate evidence.2 I am in agreement with Dr Bechtel that all 3components of EBP must be integrated into clinical practice to be successful. Just as DrBechtel suggests, complete reliance on evidence without consideration of patient values andclinician expertise is not an accurate portrayal of EBP, and complete reliance on clinicalexperience without including knowledge and application of evidence to clinical care is alsoincomplete adherence to the principles of EBP.

So the question then becomes, how do we institute change and assure the translation ofevidence to clinical practice? Although popular to physical therapists and other healthcareproviders, continuing education courses may not be the most effective method to instillchange in practice patterns and optimize outcomes.6 I believe this is where researchers andclinicians need to continue to work together to produce evidence to support best care andclinicians translating the evidence to clinical practice. This will mandate that practicingclinicians assure that our fellow colleagues are accountable to best practice and integratingevidence into clinical decision making.3 As Dr Bechtel has mentioned, much of our evidenceis not perfect. Although the volume and quality of emerging evidence in many areas ofphysical therapist practice is mounting rapidly, I agree that there are still many areas whereevidence is sparse. However, rather than waiting for the ‘‘perfect evidence,’’ I propose thatclinicians follow the approach advocated by Reinertsen,15 who suggests that clinicians shouldact on the research evidence that is available, and that they use patient-centered outcomestools to determine what interventions are effective for a particular patient and whichinterventions are not.

In summation, I would like to again thank Dr Simoneau for the opportunity to respond to DrBechtel’s letter and provide a viewpoint from a practicing clinician. Dr Bechtel believes thatthe growing chasm between researchers and clinicians may threaten the profession of physicaltherapy. However, I have personally witnessed improved collegial relationships betweenresearchers and clinicians and have had the opportunity to work closely with a number ofphysical therapy researchers to produce evidence and improve patient care. In contrast to DrBechtel’s viewpoint, I argue that it is the abyss between the available research identifyingcurrent best practice and the implementation of the evidence to clinical practice by usclinicians, including a resistance to change daily clinical behavior, which is potentially morelikely to threaten the profession of physical therapy.

Joshua A. Cleland, DPT, PhD, OCS

REFERENCES1. Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC. A comparison of results of meta-analyses

of randomized control trials and recommendations of clinical experts. Treatments for myocardialinfarction. JAMA. 1992;268:240-248.

2. Berwick DM. Disseminating innovations in health care. JAMA. 2003;289:1969-1975.3. Childs JD, Whitman JM. Advancing physical therapy practice: the accountable practitioner. J Orthop

Sports Phys Ther. 2005;35:624-627.4. Childs JD, Whitman JM, Sizer PS, Pugia ML, Flynn TW, Delitto A. A description of physical therapists’

knowledge in managing musculoskeletal conditions. BMC Musculoskelet Disord. 2005;6:32.5. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical

experience and quality of health care. Ann Intern Med. 2005;142:260-273.6. Davis D, O’Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal

continuing medical education: do conferences, workshops, rounds, and other traditional continuingeducation activities change physician behavior or health care outcomes? JAMA. 1999;282:867-874.

7. Fritz JM, Irrgang JJ. A comparison of a modified Oswestry Low Back Pain Disability Questionnaireand the Quebec Back Pain Disability Scale. Phys Ther. 2001;81:776-788.

8. Fritz JM, Piva SR, Childs JD. Accuracy of the clinical examination to predict radiographic instabilityof the lumbar spine. Eur Spine J. 2005;14:743-750.

9. Fritz JM, Whitman JM, Childs JD. Lumbar spine segmental mobility assessment: an examination ofvalidity for determining intervention strategies in patients with low back pain. Arch Phys MedRehabil. 2005;86:1745-1752.

10. Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, Grilli R, Harvey E, Oxman A,O’Brien MA. Changing provider behavior: an overview of systematic reviews of interventions. MedCare. 2001;38(Suppl 2):II2-45.

456 J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006

11. Hicks GE, Fritz JM, Delitto A, Mishock J. Interrater reliability of clinical examination measures foridentification of lumbar segmental instability. Arch Phys Med Rehabil. 2003;84:1858-1864.

12. Jaeschke R, Guyatt GH, Sackett DL. Users’ guides to the medical literature. III. How to use an articleabout a diagnostic test. B. What are the results and will they help me in caring for my patients? TheEvidence-Based Medicine Working Group. JAMA. 1994;271:703-707.

13. Jensen GM, Gwyer J, Shepard KF. Expert practice in physical therapy. Phys Ther. 2000;80:28-43;discussion 44-52.

14. Maher CG, Sherrington C, Elkins M, Herbert RD, Moseley AM. Challenges for evidence-basedphysical therapy: accessing and interpreting high-quality evidence on therapy. Phys Ther.2004;84:644-654.

15. Reinertsen JL. Zen and the art of physician autonomy maintenance. Ann Intern Med. 2003;138:992-995.

16. Resnik L, Dobrzykowski E. Guide to outcomes measurement for patients with low back painsyndromes. J Orthop Sports Phys Ther. 2003;33:307-316; discussion 317-308.

17. Resnik L, Jensen GM. Using clinical outcomes to explore the theory of expert practice in physicaltherapy. Phys Ther. 2003;83:1090-1106.

18. Shepard KF, Hack LM, Gwyer J, Jensen GM. Describing expert practice in physical therapy. QualHealth Res. 1999;9:746-758.

19. Whitman JM, Fritz JM, Childs JD. The influence of experience and specialty certifications on clinicaloutcomes for patients with low back pain treated within a standardized physical therapy managementprogram. J Orthop Sports Phys Ther. 2004;34:662-672; discussion 672-665.

GOT CLINIC?

Thank you for this opportunity to join the conversation about research and clinical practice.Dr Bechtel outlines his view that there is a growing chasm between researchers on the onehand, and clinicians on the other. My career and experience as a physical therapist inorthopaedic private practice leads me to an opposite conclusion. I believe researchers aredirecting research agendas that draw from, and inform, our clinical practice. Dr Bechtelstates, ‘‘Many of these acquaintances, especially postprofessional students and manual therapyclinicians, have for some time been expressing the opinion that their professional scholarshave completely devalued clinical expertise as a part of evidence-based medicine (EBM).’’ DrDiFabio, past editor-in-chief of the JOSPT, and others have leveled similar charges againstEBM.9,10,11,44,45,46 Historically, EBM proponents ‘devalued’ expertise in early, awkwardattempts to articulate the content and context of EBM. EBM de-emphasized expert opinion asa reaction to the culture of expert opinion in medicine. EBM offers the clinician a moreegalitarian approach to the dialogue on clinical decision making by directing the focus to theevidence at hand rather than opinion handed down from experience. Descriptions of EBMtypically place expert opinion at the bottom of the hierarchy of evidence.18

Tonelli45 describes the epistemic differences between expert opinion and evidence with theformer being a complex type of knowledge and not just empirical evidence from practice andseparate from empirical evidence from research. His central point is that expert opinion andexpertise is that it is ‘‘the multifaceted medical knowledge that forms a better basis for patientcare than the finding of even the most rigorous clinical research.’’ Tonelli beckons us tounderstand and integrate expert opinion in the model of EBM. He notes that expertise ‘‘willremain a necessary component of the provision of optimal medical care.’’45 The expertclinician is the best person to integrate research and new knowledge, skills in practice, andthe full context of the patient’s experience of illness. Haynes et al,19 in an updated model ofEBM, have placed clinical expertise in the center of the EBM clinical experience. They state,‘‘the term EBM was developed to encourage practitioners and patients to pay due respect—nomore, no less—to current best evidence in making decisions.’’19 Clinical expertise requiresknowledge about the patient’s circumstances, management options and resources, risks andbenefits, costs, inconveniences, and patients preferences and values.17 Indeed, Devereaux etal8 have called for expertise-based randomized controlled trials (RCTs) to enhance thevalidity, feasibility, and ethical integrity of RCTs.8 Clearly, researchers and EBM proponents arevaluing and lauding clinical expertise, not devaluing or deriding the clinical expert.

I find it ironic that Dr Bechtel cites an article by Hicks et al as an example,21 when theseauthors are in the process of developing a robust, valid, and reliable, classification system forpatients with low back pain, which was first proposed by Delitto et al7 in 1995 and haschanged how I regard and treat patients with acute low back pain. Dr Hicks is the lead author

J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006 457

GU

ES

TE

DI

TO

RI

AL

of a study identifying the elements of a clinical prediction rule for patients with low back painlikely to respond to stabilization training.20 Researchers are now intensively working withclinicians and clinical networks to examine the application of this classification system toclinical practice.14,15 These researchers are asking and answering clinical questions I havepondered for most of my career, including, but not limited to, the reliability and validity ofmotion palpation in examination of low back pain.

Dr Bechtel’s comments about the specialization of faculty, competition for grant monies, andthe proliferation of reconstituted, unoriginal papers may reflect the situation at some physicaltherapy programs. When considering the proliferation of EBM articles and number ofpublications needed to achieve tenure, Paul Shekelle, PhD, MD has joked that EBM mightrepresent an ‘‘academic jobs-work program.’’41 I have not witnessed the problem of academictrivialism in physical therapy education programs, as described by Dr Bechtel. The 2 programsI have recent experience with as an instructor, Northern Arizona University (NAU) and RegisUniversity, are exemplars of academia working hand-in-glove with the clinic. Both programshave faculties full of the beautiful hybrid: clinician-researchers. Their research agendas standas monuments to research guided by clinical questions. Investigations of the mechanics of thefoot at NAU have reshaped the agenda for the investigation and application of orthotics inthe care of foot and ankle disorders in our profession, and in podiatry.31,32,33,48 Members ofthe Regis University faculty are part of a team of clinician researchers who have developedand validated a clinical prediction rule for spinal manipulation of patients with acute low backpain,4,12 investigated treatment of spinal stenosis,6,13,16 and looked into the role of experience,expertise, and clinical decision-making.5,49 These researchers and others have reframed thedialogue about physical therapy care for patients with low back pain. I doubt I have the onlyexposure to clinician-scientists examining the most important issues in our clinical practicetoday.

Dr Bechtel cites the Nobel laureates, Marshall and Warren, and their discovery of therelationship of stomach ulcers and the bacteria heliobacter pylori30,36,37 as a fascinatingexample of the difficulties in science to have a new discovery accepted by the scientificcommunity. Science by nature (human nature) is conservative. A read of Thomas Kuhn’s TheStructure of Scientific Revolutions reinforces the notion that science is slow to accept new ideasand proofs.23 I recently discussed the h. pylori discovery with an 81-year old retiredobstetrician who taught on a medical school faculty in the Midwest. As a clinician, he had hadan incredulous reaction to the early papers published on the h. pylori and ulcers. He said itwas many years before he became convinced of the findings. Isn’t the story of Marshall andWarren as much about clinicians questioning new ‘‘evidence’’ as researchers resisting change?

Antman et al1 published a fascinating and disturbing analysis comparing a meta-analysis ofrandomized controlled trials of drug interventions compared to references in textbooks byclinical experts.1 The authors found that there were discrepancies between the meta-analyticpatterns of conclusive evidence for effectiveness or ineffectiveness in the randomized trialsand the recommendations of review articles and textbooks. Experts often failed to mentionimportant advances or exhibited delays in recommending effective preventive measures.Indeed, the time lag was over 10 years before a majority of ‘expert’-generated reference (ie,textbooks) reached concordance with evidence from RCTs! Antman et al noted, ‘‘In somecases, treatments that have no effect on mortality (ie, ineffective treatments) or are potentiallyharmful, continued to be recommended by several clinical experts.’’ Tanenbaum cited a NewYork Times interview with David Sackett, MD,44 who, when asked to comment on the artfulnessof clinical medicine in treating individual patients, stated, ‘‘Art kills.’’ And here is a clearevidence that art has killed in the recent past!

Many times in my career I have felt our profession recapitulates the history of medicine.Medicine went through a transformative period in the 19th century as the emerging medicalscience opened new vistas of therapeutics with the emerging fields of pathology andphysiology, aseptic technique and germ theory, and scientific reasoning in clinical practice.Clinicians may not be delusional, but they are stubborn in adhering to practices and beliefsthat are demonstrated to be invalid or dangerous. King22 gives examples of good clinicalobservation and reasoning for physicians’ use of bloodletting in clinical practice throughoutthe ages; however, in 1828 Pierre Louis reported his outcomes study of bloodletting that

458 J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006

demonstrated the higher morbidity and mortality rates of those treated with this regime.29 Hepublished this research as a book in 1835, which was translated into English and published inthe United States in 1836. Louis’ work was slow to be accepted by the medical community.Indeed, William Osler, MD, included blood letting as a therapeutic procedure in his manyeditions of his tome, The Principles and Practice of Medicine (1892).2 Manual therapists, like their19th-century counterparts, are often resistant to new, validated ideas and they are reluctant todiscard old, untested ideas.

Many manual therapists have paid tuition and patiently learned practices and principles(often discarded models from other professions [eg, osteopathy]) that have not beenvalidated or frankly shown to be invalid. Dr Mitchell’s model of sacroiliac motion,37 with hismany axes of rotation and proposed guiding principles of treatment, is an example of animaginative but unrealistic biomechanical explanation of sacroiliac joint (SIJ) evaluation andtreatment. Dr Bechtel uses the SIJ as an example of a region of treatment where scientificinvestigation has demonstrated poor reliability of physical findings and palpation.38,39 Hestates, ‘‘Any good manual therapist can tell you that their ability to palpate dysfunction is‘good enough’ to get the job done for their patients.’’ Manual therapists perceive that theypalpate and determine ‘dysfunction’ in the pelvis. Tullberg et al47 examined the validity ofmotion palpation of the SIJ with roentgen stereophoto-grammetric analysis, which failed toidentify any change in bony position identified with clinical examination. Sturresson et al,42,43

using the same radiographic techniques, demonstrated the hip flexion test and the straddleposition for the examination of motion of the SIJ has little motion, leading these authors toconclude that this motion test is not a reasonable physical examination tool. Blomberg3

summarized that these studies demonstrate that motion palpation is invalid as an indicator ofosseous motion; however, the normalization of the clinical test findings may indicate anothermechanism or phenomenon involved (eg, neural reflexive) rather than osteokinematics. Thisclinician-researcher cautioned not to ‘‘throw the baby out with the bathwater’’ and completelyabandon palpation motion tests, which might demonstrate clinical utility as markers ofchange.3 Laslett et al,27 following Potter and Rothstein, have demonstrated good reliabilitywhen pain provocation is coupled with palpation testing in clinical examination of LBP. Theyhave validated and demonstrated fair reliability of many of these tests of the lumbopelvicregion.24,25,26,50 Researchers are critically examining the tools of clinical practice, notdismissing these tools outright. Scrutiny of clinical practice might demonstrate elements ofpractice that must be abandoned (as with blood-letting in the 19th century), or validate andilluminate the important elements of practice.

I disagree with Dr Bechtel’s assessment that we have a problem in manual therapy and,perhaps, in the whole profession of physical therapy, with the growing chasm betweenresearchers on the one hand and clinicians on the other. I have witnessed the opposite in my25-year career in physical therapy. Researchers today are asking clinically relevant questionsand answering many of these questions. Our journals have moved from publishing study afterstudy on biological plausibility of our interventions and trivial explorations of EMG activity inabductor hallucis,34 to patient-oriented and clinically relevant investigations, commentaries,and editorials in virtually every issue. My opinion is that the chasm has now narrowed to thepoint where the researchers are standing shoulder-to-shoulder with clinicians to investigateclinical practice.

Shaughnessy et al40 give us a wonderful metaphor of medicine and evidence-based practice(EBP): music. The best medical practice, like the best music, melds technical skill andexpertise with individual artistry. The new paradigm of evidence-based medicine and theapparently conflicting concept of clinical experience represent 2 aspects of medicine. Tomany physicians, evidence-based medicine seems rigid, highly structured, and uninspiring—asstilted and regimented as a poorly performed Bach fugue. In contrast, economists, academics,and health authorities view the enigmatic and seemingly unpredictable use of clinicalexperience as analogous to punk rock: uncontrollable, chaotic, and obeying few rules. Thebest medical practice is similar to neither baroque music nor grunge music: instead it is likegood jazz, combining technical mastery with the artistry of focused personal improvisation.Clinical jazz combines the structure supplied by patient-oriented evidence with the physician’sclinical experience to manage situations of uncertainty, instability, uniqueness, and conflictingvalues.40

J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006 459

GU

ES

TE

DI

TO

RI

AL

EBM and EBP have grown out of this integration of clinical practice, clinical science, andfundamental research. My opinion is that the onus lies with clinicians who are not examiningand synthesizing the literature into clinical practice, not embracing new informationtechnology, and not reflecting on the changing healthcare environment. I enjoin manualphysical therapists to be evidence-based clinicians and to work with our research colleagues toexplain, enrich, and improve clinical practice. Clinical researchers are bringing the clinicalevidence in spades. Now, clinicians need to listen: got science and got clinic.

Britt Smith, MSPT, OCS, FAAOMPT

REFERENCES1. Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC. A comparison of results of meta-analyses

of randomized control trials and recommendations of clinical experts. Treatments for myocardialinfarction. JAMA. 1992;268:240-248.

2. Bliss MW. Osler: A Life in Medicine. Toronto, Canada: University of Toronto Press; 1999.3. Blomberg S. The Annual Conference of the American Academy of Orthopaedic Manual Physical

Therapists. Charlottesville, VA: American Academy of Orthopaedic Manual Physical Therapists; 2003.4. Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain

most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004;141:920-928.

5. Childs JD, Whitman JM, Sizer PS, Pugia ML, Flynn TW, Delitto A. A description of physical therapists’knowledge in managing musculoskeletal conditions. BMC Musculoskelet Disord. 2005;6:32.

6. Cleland JA, Fritz JM, Whitman JM, Childs JD, Palmer JA. The use of a lumbar spine manipulationtechnique by physical therapists in patients who satisfy a clinical prediction rule: a case series.J Orthop Sports Phys Ther. 2006;36:209-214.

7. Delitto A, Erhard RE, Bowling RW. A treatment-based classification approach to low back syndrome:identifying and staging patients for conservative treatment. Phys Ther. 1995;75:470-485; discussion485-479.

8. Devereaux PJ, Bhandari M, Clarke M, et al. Need for expertise based randomised controlled trials.Bmj. 2005;330:88.

9. DiFabio RP. Editor-in-Chief Replies. J Orthop Sports Phys Ther. 2000;30:99-100.10. DiFabio RP. The myth of evidence-based practice. J Orthop Sports Phys Ther. 1999;29:632-634.11. DiFabio RP. What is ’evidence’? J Orthop Sports Phys Ther. 2000;30:52-55.12. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain

who demonstrate short-term improvement with spinal manipulation. Spine. 2002;27:2835-2843.13. Flynn TW, Fritz JM, Wainner RS, Whitman JM. The audible pop is not necessary for successful spinal

high-velocity thrust manipulation in individuals with low back pain. Arch Phys Med Rehabil.2003;84:1057-1060.

14. Fritz JM, Brennan GP, Clifford SN, Hunter SJ, Thackeray A. An examination of the reliability of aclassification algorithm for subgrouping patients with low back pain. Spine. 2006;31:77-82.

15. Fritz JM, Brennan GP, Leaman H. Does the evidence for spinal manipulation translate into betteroutcomes in routine clinical care for patients with occupational low back pain? A case-control study.Spine J. 2006;6:289-295.

16. Fritz JM, Whitman JM, Childs JD. Lumbar spine segmental mobility assessment: an examination ofvalidity for determining intervention strategies in patients with low back pain. Arch Phys MedRehabil. 2005;86:1745-1752.

17. Guyatt G. Evidence-based medicine: past, present and future. McMaster Univ Med J. 1995;152:27-32.

18. Hadorn DC, Baker D, Hodges JS, Hicks N. Rating the quality of evidence for clinical practiceguidelines. J Clin Epidemiol. 1996;49:749-754.

19. Haynes RB, Devereaux PJ, Guyatt GH. Physicians’ and patients’ choices in evidence based practice.Bmj. 2002;324:1350.

20. Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule fordetermining which patients with low back pain will respond to a stabilization exercise program. ArchPhys Med Rehabil. 2005;86:1753-1762.

21. Hicks GE, Fritz JM, Delitto A, Mishock J. Interrater reliability of clinical examination measures foridentification of lumbar segmental instability. Arch Phys Med Rehabil. 2003;84:1858-1864.

22. King LS. Medical Thinking: A Historical Preface. Princeton, NJ: Princeton University Press; 1982.23. Kuhn T. The Structure of Scientific Revolutions. Chicago, IL: University of Chicago Press; 1962.24. Laslett M. The value of the physical examination in diagnosis of painful sacroiliac joint pathologies.

Spine. 1998;23:962-964.

460 J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006

25. Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individualprovocation tests and composites of tests. Man Ther. 2005;10:207-218.

26. Laslett M, McDonald B, Tropp H, Aprill CN, Oberg B. Agreement between diagnoses reached byclinical examination and available reference standards: a prospective study of 216 patients withlumbopelvic pain. BMC Musculoskelet Disord. 2005;6:28.

27. Laslett M, Williams M. The reliability of selected pain provocation tests for sacroiliac joint pathology.Spine. 1994;19:1243-1249.

28. Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: A validity study ofa McKenzie evaluation and sacroiliac provocation tests. Aust J Physiother. 2003;49:89-97.

29. Louis PCA. Recherches sur les effets de la saigné́e dans quelques maladies inflammatoires et surl’action de l’é́mé́tique et des vé́sicatoires dans la pneumonie. Paris, France: Librairie de l’Acadé́mieRoyale de Medicine; 1835.

30. Marshall BJ, Warren JR. Unidentified curved bacilli in the stomach of patients with gastritis and pepticulceration. Lancet. 1984;1:1311-1315.

31. McPoil TG, Cornwall MW. The effect of foot orthoses on transverse tibial rotation during walking.J Am Podiatr Med Assoc. 2000;90:2-11.

32. McPoil TG, Cornwall MW. Use of the longitudinal arch angle to predict dynamic foot posture inwalking. J Am Podiatr Med Assoc. 2005;95:114-120.

33. McPoil TG, Hunt GC. Evaluation and management of foot and ankle disorders: present problems andfuture directions. J Orthop Sports Phys Ther. 1995;21:381-388.

34. Middaugh SJ. EMG feedback as a muscle reeducation technique: a controlled study. Phys Ther.1978;58:15-22.

35. Mitchell F. Structural Pelvic Function. Academy of Applied Osteopathy Yearbook. Carmel, CA:Academy of Applied Osteopathy; 1965.

36. National Institutes of Health. Helicobacter pylori in peptic ulcer disease. JAMA. 1994;272:65-69.37. The Nobel Prize in Physiology or Medicine 2005. Available at: http://nobelprize.org/medicine/

laureates/2005/. Accessed 2005.38. Potter L, McCarthy C, Oldham J. Intraexaminer reliability of identifying a dysfunctional segment in

the thoracic and lumbar spine. J Manipulative Physiol Ther. 2006;29:203-207.39. Potter NA, Rothstein JM. Intertester reliability for selected clinical tests of the sacroiliac joint. Phys

Ther. 1985;65:1671-1675.40. Shaughnessy AF, Slawson DC, Becker L. Clinical jazz: harmonizing clinical experience and

evidence-based medicine. J Fam Pract. 1998;47:425-428.41. Shekelle P. Evidence-Based Practice: Focus on Low Back Pain. Denver, CO: Western Slope Study

Group; 2000.42. Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of movements of the sacroiliac joints

during the standing hip flexion test. Spine. 2000;25:364-368.43. Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of the movements of the sacroiliac

joints in the reciprocal straddle position. Spine. 2000;25:214-217.44. Tanenbaum SJ. Evidence and expertise: the challenge of the outcomes movement to medical

professionalism. Acad Med. 1999;74:757-763.45. Tonelli MR In defense of expert opinion. Acad Med. 1999;74:1187-1192.46. Tonelli MR The philosophical limits of evidence-based medicine. Acad Med. 1998;73:1234-1240.47. Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the

sacroiliac joint. A roentgen stereophotogrammetric analysis. Spine. 1998;23:1124-1128; discussion1129.

48. Vicenzino B, Franettovich M, McPoil T, Russell T, Skardoon G. Initial effects of anti-pronation tape onthe medial longitudinal arch during walking and running. Br J Sports Med. 2005;39:939-943;discussion 943.

49. Whitman JM, Fritz JM, Childs JD. The influence of experience and specialty certifications on clinicaloutcomes for patients with low back pain treated within a standardized physical therapy managementprogram. J Orthop Sports Phys Ther. 2004;34:662-672; discussion 672-665.

50. Young S, Aprill C, Laslett M. Correlation of clinical examination characteristics with three sources ofchronic low back pain. Spine J. 2003;3:460-465.

J Orthop Sports Phys Ther • Volume 36 • Number 7 • July 2006 461

GU

ES

TE

DI

TO

RI

AL