PRACTICE-BASED EVIDENCE IN REHABILITATION
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Practice-Based Evidence in Rehabilitation: A Review of the Literature
Student name, OTS
Department of Occupational Therapy, University of Florida
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Dr. Capstone Coordinator (if grader)
Site mentor if helped with this
Date
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PRACTICE-BASED EVIDENCE IN REHABILITATION
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Practice-Based Evidence in Rehabilitation: A Review of the Literature
The use of research in rehabilitation is a critical component of effective treatment for
clients. Emerging healthcare professionals are taught the importance of integrating evidencebased practice when planning interventions for clients. Evidence-based medicine is defined as:
"the conscientious, explicit, and judicious use of current best evidence in making decisions about
the care of individual patients. The practice of evidence based medicine means integrating
individual clinical expertise with the best available external clinical evidence from systematic
research" (Sackett et. al, 1996). Randomized control trials are of the highest evidence of research
and have a very important place in evidence-based practice. However, this type of research has
limitations in that the populations of these studies are often very specific and generalizability is
not always accurate or possible (Clay, 2010). Therefore, it is important to supplement our range
of evidence with other types of research. Swisher (2010) states that practice-based evidence is
where: “the real, messy, complicated world is not controlled. Instead, real world practice is
documented and measured, just as it occurs, “warts” and all. It is the process of measurement and
tracking that matters, not controlling how practice is delivered. This allows us to answer a
different, but no less important, question than “does X cause Y?” (Missing citation) Practicebased evidence is also a way that clinicians can contribute to research. The purpose of this
review is to explore how practice-based evidence can positively impact rehabilitation
intervention outcomes for clients. Additionally, how this can encourage more participation of
clinicians in research.
Methods
This literature review sought to answer the following question: how does the use of
practice-based evidence impact intervention outcomes for adults receiving rehabilitation? Two
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databases were utilized in this review: PubMed and CINAHL. Figure 1 outlines the search
Commented [SR1]: Reword in more active language
methods and the process by which the articles were found and were narrowed down. The final
search terms used in the databases were “practice based evidence” AND “rehabilitation” AND
“outcomes”. Initially, the search yielded 59 total articles, combined, from the two databases.
Commented [SR2]: Double check numbers here with
figure
After duplicate articles were removed, there were 37 articles remaining. The results were then
refined using limiters, including: date published (last 10 years), subjects (adults), and language
(English), which left 22 articles. Articles were excluded from this review if they were not related
to physical rehabilitation (occupational therapy, physical therapy, or speech language pathology).
With all exclusions considered, seven total studies were used for this review.
Results
Commented [KM3]: What were criteria for choosing the
7 articles and not the other potential?
Seven articles were carefully chosen to be included for this literature review. From the
articles, three themes were found that highlight the strengths of practice-based evidence that can
lead to better outcomes for patients as well as availability of research for clinicians:
generalizability of information, clinician participation, and extensive information leading to
further research. Table 1 summarizes the articles found including the authors, purpose of the
study, type of study, and a brief overview. There were a variety of types of studies that were
Commented [KM4]: should include how many for each
type
included in this review, including: review of the literature, prospective observational study, and
retrospective analysis. More information on the articles included can be found in table 1.
Findings
Generalizability of Information
Many articles spoke on the benefits of practice-based evidence in that it is conducted in a
natural setting without the strict controls constricting other types of research, such as randomized
controlled trials. Kersten et. al (2010) states: “A key strength of the PBE methodology is that it
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includes the measurement of patients treated in routine practice, rather than in specially
controlled circumstances, and the inclusion of virtually every patient contributes to a more
naturalistic view.” Another article further highlights this idea, “The strength of the PBE
methodology is its ability to examine a rehabilitation process occurring in a natural setting
without extensive exclusion criteria and to identify the elements of that process that are related
most strongly to positive outcome after rehabilitation” (Whiteneck et. al, 2010). This naturalistic
design and inclusivity of patients allow for ease with application to practice for clinicians,
“because of how PBE studies are conducted, their findings are readily translatable into practice”
(Horn et. al, 2012). In a study by Christoforou et. al (2018), the researchers investigated the
effectiveness of a community-implemented falls prevention referral service. Individuals who
completed their program, Steady Steps, had improvements in outcome variables, such as: balance
Commented [KM5]: colon use here is not APA
confidence and quality of life. The authors wrote, “practice-based approach enabled us to better
Commented [KM6]: need to add page and proper intext
citation
capture what is truly happening in practice at the point of referral…”
Clinician Participation
Another important strength of practice-based evidence is clinician participation. Because
the studies are conducted in a naturalistic setting, it is critical to have the contributions from
clinicians. This can allow for clinicians to trust the information found and they may be even
more likely to use this information in their own practice. Horn et. al (2012) states, “Front-line
clinicians often challenge the conventional wisdom and welcome the PBE approach as a method
to test their ideas. Moreover, with clinicians fully participating in PBE studies, clinicians outside
the study are more likely to address and, when appropriate, embrace counterintuitive findings.”
Practice-based evidence often requires a team of individuals, “PBE study in rehabilitation is
assembling a diverse project team with multiple areas of relevant expertise including
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Commented [KM7]: this quotation is too long to be
provided in-text; APA requires block quotations at this
length – also need more adequate use of APA citation of
quotations from published materials -
PRACTICE-BASED EVIDENCE IN REHABILITATION
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multidisciplinary rehabilitation care providers” (Horn et. al, 2012).
Commented [KM8]: citation, page needed – this is true
throughout
Extensive Information Leading to Further Research
Commented [KM9]: very long paragraph – needs to be
broken up
Because practice-based evidence is an observational type of study it often yields a lot of
information. In one study, Whiteneck et. al (2013) used a practice-based evidence design to
investigate spinal cord injury rehabilitation and discusses, in depth, the use of this methodology.
This article reports that this was “…an observational study and that neither positive nor negative
associations can be interpreted as reflecting a causal link without additional investigation.”
However also states “The application of PBE methodology in the SCIRehab study provided
Commented [KM10]: who also states? this is a sentence
fragment
extensive information about the process of inpatient SCI rehabilitation.” Although practice-based
evidence cannot yield causation, it does yield a lot of information regarding interventions and
outcomes. Additionally, many of the practice-based evidence articles discuss the idea that this
type of methodology lends itself to further research that can be done, perhaps in a more
controlled manner for a higher level of evidence. In an article by Siebens et. al (2016), the
authors looked at variation in rehabilitation treatment patterns for hip fracture treated with
arthroplasty. In this study, the researchers found a lot of varying information among the practice
settings. In all of this information, the researchers stated, “This is among the first reports to
present this level of detail on the content of therapy treatments for patients with hip fracture. The
results include insightful observations that suggest hypotheses and questions for future work.”
They go on to mention they would like to further investigate ideas such as: exposures to OT
bathing and home programs, low volumes of intermediate and advanced ADLs, role of family
contact, etc. Hammond et. al (2015) share that the results from their study on group therapy use
on outcomes of inpatient rehabilitation after traumatic brain injuries was broad and more detailed
and specific research should be conducted to get additional information on group therapy on
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overall outcomes. However, this article was able to get some helpful and abundant information
regarding group therapy for TBI during inpatient rehabilitation due to the nature of the design of
the study and was able to find that there is significant variation in this type of therapy across sites
(10 inpatient rehab centers were utilized). Practice-based evidence often has a very large sample
size and therefore is able to yield a plethora of helpful data, “PBE studies to date have involved
very large number of patients (as in thousands)” (Kersten et. al, 2010).
Conclusion
In conclusion, the articles examined demonstrate that practice-based evidence can have a
positive impact on outcomes in three ways: generalizability of information, clinician
participation, and extensive information leading to further research. Because the studies have
found that this type of research lends itself to greater generalizability, it can be easier for
clinicians to successfully implement findings into their own practice. The studies include many
participants in a naturalistic setting that may allow clinicians to feel more confident in applying
the findings in their intervention planning. This in itself increases research being utilized in
practice and can lend to better outcomes for patients. Clinician participation in research is critical
so that practicing clinicians seeking articles are able to know what interventions are currently
actually being done in the field and if they work or not. Increased participation by clinicians in
research not only increases the quality of care given to patients, but can also increase confidence
in clinicians as they do their own searches of the literature. Clinicians may be more inclined to
take from studies that are done heavily by practicing clinicians. Lastly, the extensive amount of
information that can come from practice-based evidence is crucial. Not only is it information that
clinicians can use (even if it doesn’t merit causation), it lends itself to even more research that
can be done. Getting the initial information/data through practice-based evidence, can allow for
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Commented [KM11]: I’m not sure they demonstrate,
perhaps: indicate, suggest, provide evidence as to the
potential for
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more focused and helpful studies to be completed in a more controlled manner. One limitation
from this review is that, although seven articles were included, some of them had overlapping
studies and authorship due to the limited amount of research in this area.
Commented [SR12]: Use third person or neural “the
information form this …..
I will use the information from this study as a helpful guide in promoting increased
participation of clinicians in research. This information highlights the importance of practicebased evidence in rehabilitation. I will further investigate the methodology in hopes of breaking
it down more to create a guide on how clinicians can be contributing to this type of research in a
larger way. My presentation will focus on how clinicians can be contributing to research so that
we can expand practice-based evidence in the field of occupational therapy.
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References
Christoforou, A., Van der Linden, M. L., & Koufaki, P. (2018). Short-term effectiveness of a
community-implemented falls prevention referral service. Disability and
rehabilitation, 40(20), 2466–2474. https://doi.org/10.1080/09638288.2017.1337241
Clay, R. (2010, September). More than one way to measure. Retrieved April 04, 2021, from
https://www.apa.org/monitor/2010/09/trials
Hammond, F. M., Barrett, R., Dijkers, M. P., Zanca, J. M., Horn, S. D., Smout, R. J., Guerrier,
T., Hauser, E., & Dunning, M. R. (2015). Group Therapy Use and Its Impact on the
Outcomes of Inpatient Rehabilitation After Traumatic Brain Injury: Data From Traumatic
Brain Injury-Practice Based Evidence Project. Archives of physical medicine and
rehabilitation, 96( 8 Suppl), S282–92.e5. https://doi.org/10.1016/j.apmr.2014.11.029
Horn, S. D., DeJong, G., & Deutscher, D. (2012). Practice-based evidence research in
rehabilitation: an alternative to randomized controlled trials and traditional observational
studies. Archives of physical medicine and rehabilitation, 93(8 Suppl), S127–S137.
https://doi.org/10.1016/j.apmr.2011.10.031
Kersten, P., Ellis-Hill, C., McPherson, K. M., & Harrington, R. (2010). Beyond the RCT understanding the relationship between interventions, individuals and outcome - the
example of neurological rehabilitation. Disability and rehabilitation, 32(12), 1028–1034.
https://doi.org/10.3109/09638281003775568
Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996).
Evidence based medicine: what it is and what it isn’t. BMJ : British Medical Journal,
312(7023), 71–72.
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Siebens, H. C., Sharkey, P., Aronow, H. U., Deutscher, D., Roberts, P., Munin, M. C., Radnay,
C. S., & Horn, S. D. (2016). Variation in Rehabilitation Treatment Patterns for Hip
Fracture Treated With Arthroplasty. PM & R : the journal of injury, function, and
rehabilitation, 8(3), 191–207.
Swisher A. K. (2010). Practice-based evidence. Cardiopulmonary physical therapy
journal, 21(2), 4.
Whiteneck, G., & Gassaway, J. (2010). SCIRehab: a model for rehabilitation research using
comprehensive person, process and outcome data. Disability and rehabilitation, 32(12),
1035–1042. https://doi.org/10.3109/09638281003775584
Whiteneck, G. G., & Gassaway, J. (2013). SCIRehab uses practice-based evidence methodology
to associate patient and treatment characteristics with outcomes. Archives of physical
medicine and rehabilitation, 94(4 Suppl), S67–S74.
https://doi.org/10.1016/j.apmr.2012.12.022
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Appendix
Figure 1.
Identification
PRISMA Diagram
Records identified through
database searching
(n = 30 )
Additional records identified
through other sources
(n = 29)
Included
Eligibility
Screening
Records after duplicates removed
(n = 37 )
Records screened
(n = 37 )
Records excluded
(n = 15 )
Full-text articles assessed
for eligibility
(n =22)
Full-text articles excluded,
with reasons
(n = 14 )
Studies included
(n = 7)
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses:
The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097
For more information, visit www.prisma-statement.org.
Commented [SR13]: Make your own figure as might
not have permission to use this, this is not the correct
APA format for Figure
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PRACTICE-BASED EVIDENCE IN REHABILITATION
Table 1.
Literature Review Matrix
Author
Title
Purpose
Paula Kersten,
et. al, 2010
"explore such issues
Beyond the RCT including the complexity
understanding the
of rehabilitation
relationship between interventions,
interventions,
heterogeneity of
individuals and
populations, selective
outcome - the
research samples and
example of
multiple understandings
neurological
and perspectives of
rehabilitation
benefits"
Susan D. Horn,
et. al, 2012
Practice-Based
Evidence Research
in Rehabilitation:
An
Alternative to
Randomized
Controlled Trials
and Traditional
Observational
Studies
Type of study
Critical review of
the literature
"give examples of how
PBE designs
have been used in various
rehabilitation areas to
determine
better treatments for
Review of the
specific types of patients." literature
Comments/outcomes/implications
This study discusses the use of randomized control trials
versus alternative types of studies (i.e. practice based
evidence (PBE), qualitative studies, etc.). It found that we
should be aiming for a variety of different types of research
and include more practice-based evidence/qualitative studies
to allow for increased carryover of knowledge for clinicians.
This study compares randomized control trials,
observational claims data, and practice based evidence
studies. It defines practice based evidence as: "PBE methods
address comparative effectiveness of treatments by creating
a comprehensive set of patient, treatment, and outcome
variables and analyzing them to identify treatments that are
associated with better outcomes for specific types of
patients." It also highlights the idea that practice-based
evidence relies on the knowledge of clinicians and on their
experiences. "PBE methods work best in situations where
one wishes to study existing clinical practice." This study
states that PBE can be a great addition to our current body of
research, especially with regard to clinical decision-making.
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Gale G
Whiteneck, et.
al, 2013
SCIRehab Uses
Practice-Based
Evidence
Methodology to
Associate Patient
and Treatment
Characteristics With
Outcomes
Gale Whiteneck,
et. al, 2010
SCIRehab: a model
for rehabilitation
research using
comprehensive
person, process and
outcome data
"To describe the
application of practicebased evidence (PBE)
methodology to spinal
cord injury (SCI)
rehabilitation in the
SCIRehab study, and to
summarize associations of
patient characteristics and
treatment interventions to
outcomes"
"This article aims to
present a comprehensive
conceptual model of the
SCIRehab project, which
merges the International
Classification of
Functioning, Disability,
and Health (ICF) focus on
outcomes with the
practice-based evidence
(PBE) research design,
which focuses on process
and also quantifies person
and outcomes details."
Short-term
effectiveness of a
communityimplemented falls
prevention referral
service
"To evaluate the
effectiveness of the 16week evidence-based
Steady Steps exercise
referral scheme at
improving physical
function, balance
confidence, and quality of
Andrea
Christoforou, et.
al, 2018
Prospective
observational study
This article looks at PBE in the scope of SCI rehabilitation.
This study states that PBE in the case of SCI has been able
to add to the scope of practice/evidence immensely. This is
particularly related to inpatient rehabilitation. "The PBE
methodology has 2 basic strategies to control for differences
in patient needs. The first approach is to statistically control
for patient demo- graphic and injury characteristics by
including those variables in regression analyses before
entering treatment variables. The second approach is to
analyze subgroups of patients with common injury
characteristics and thus, common treatment needs."
prospective
observational study
This study looks at the strength of using PBE with regard to
the SCI population. It states that "PBE acquires that ability
by collecting very detailed person, process and outcome data
on large numbers of cases." It describes the need for PBE as
a means to complement RCT, not replace them.
A nonexperimental,
practice-based
study involving a
retrospective
analysis of
participant
outcomes.
This study utilized a practice-based methodology, testing
effectiveness of a community-implemented falls prevention
referral service. The results showed clinically meaningful
improvements observed in individuals who completed the
evidence- based Steady Steps program. Although the authors
provide disclaimers that this study uses a non-experimental
design, it gives hope that practice-based evidence can be
very useful for clinical decision making.
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life (QoL) of communitydwelling older adults at
risk of falling."
Hilary C.
Siebens, et. al,
2016
Flora
M.Hammond, et.
al, 2015
Variation in
Rehabilitation
Treatment Patterns
for Hip Fracture
Treated With
Arthroplasty.
Group Therapy Use
and Its Impact on
the Outcomes of
Inpatient
Rehabilitation After
Traumatic Brain
Injury: Data From
Traumatic Brain
Injury–Practice
Based Evidence
Project
"To document in detail
the physical and
occupational therapy
treatment activities for
inpatient hip fracture
rehabilitation among 3
patient subgroups
distinguished by their
early rate of functional
recovery between time of
surgery to rehabilitation
admission."
"To describe the amount
and content of group
therapies provided during
inpatient rehabilitation for
traumatic brain injury
(TBI), and to assess the
relations of group therapy
with patient, injury, and
treatment factors and
outcomes"
Multicenter
prospective
observational
cohort, practicebased evidence,
study
This study looks at the variation of treatment for hip
fractures with arthroplasty utilizing practice-based evidence
approach. This study yielded variations in OT/PT treatment
patterns for this population. This was a very powerful study
as it "is the first PBE-CPI rehabilitation study in which all
PT and OT treatment activities are reported in a single table.
This facilitates thinking about an individual patient’s care by
both disciplines." This is a very interesting article in that it
allows us to look at both PT and OT outcomes within the
practice-based evidence realm. This type of research is
critical for clinicians to learn and understand best practice.
Prospective
observational
cohort
This study utilizes an evidence based practice framework to
look at group therapy for TBI patients in inpatient rehab.
This study showed quite a bit of variety in outcomes when
comparing differences in treatment at inpatient rehab
facilities. I think this is an important finding in the context of
utilizing practice based evidence in that it shows that it is
critical to know what is going on at different facilities and
how this is benefiting patients in the real world.
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