In the last twenty years the term “Evidence Based Medicine (EBM)” has spread into all areas of medicine and is often used for decision-making in the medical and public health sector. It is also used to verify the significance and/or the effectiveness of different therapies. The definition of EBM is to use the physician’s individual expertise, the patient’s needs and the best external evidence for each individual patient. Today, however, the term EBM is often wrongly used as a synonym for best “external evidence”. This leads not only to a misuse of evidence based medicine but suggests a fundamental misunderstanding of the model which was created by Gordon Guyatt, David Sackett and Archibald Cochrane. This problem becomes even greater the more social insurance institutions, public healthcare providers and politicians use external evidence alone as a main guideline for financing therapies in physical medicine and general rehabilitation without taking into account the physician’s expertise and the patient’s needs.The wrong interpretation of EBM can lead to the following problems: well established clinical therapies are either questioned or not granted and are therefore withheld from patients (for example physical pain management). Absence of evidence for individual therapy methods does not prove their ineffectiveness! In this short statement the significance of EBM in physical medicine and general rehabilitation will be analysed and discussed

Benjamin Süsoy

Christian Hofer

Christian Wiederer

Claudia Burmester

Eva-Maria Strasser

Friedrich Hartl

Gerold Ebenbichler

Günther Wiesinger

Hannah Fruhmann

Helmut Kern

Markus Praschak

Michael Quittan

Richard Crevenna

Samantha Burggraf

Stefan Loefler

Tatjana Paternostro-Sluga

Thomas Bochdansky

Veronika Fialka-Moser

Wolfgang Grestenberger

European Journal of Translational Myology

English

Crossref

Evidence Based Medicine in Physical Medicine and Rehabilitation 
European Journal Translational Myology - Basic Applied Myology 2013; 23 (4): 217-220 
- 217 - 
 
Evidence Based Medicine in Physical Medicine and Rehabilitation 
Helmut Kern (1,2), Stefan Loefler (2), Veronika Fialka-Moser (3,4), Tatjana 
Paternostro-Sluga (3,4), Richard Crevenna (3,4), Samantha Burggraf (2), Hannah 
Fruhmann (2), Christian Hofer (2), Claudia Burmester (1), Benjamin Süsoy (2), Eva-
Maria Strasser (10,11), Markus Praschak (11), Wolfgang Grestenberger (6), Friedrich 
Hartl (7), Gerold Ebenbichler (3,5), Günther Wiesinger (3), Thomas Bochdansky (8), 
Christian Wiederer (9), Michael Quittan (4,10,11) 
(1) Dept. of Physical Medicine and Rehabilitation, Wilhelminenspital, Vienna, 
Austria; (2) Ludwig Boltzmann Institute of Electrical Stimulation and Physical 
Rehabilitation, Vienna, Austria; (3) University Clinic of Physical Medicine, Medical 
University of Vienna, Austria; (4) Austrian Society for Physical Medicine & 
Rehabilitation (ÖGPMR); (5) Berufsverband der Österreichischen Fachärzte für 
Physikal. Medizin und Rehabilitation (BÖPMR), Vienna, Austria; (6) Fachgruppe 
Physikal. Medizin, Wiener Ärztekammer, Austria (7) Bundesfachgruppe Physikal. 
Medizin, Österreichische Ärztekammer, Austria; (8) Reha-Klinik Montafon, Schruns, 
Austria; (9) Kurhaus Bad Gleichenberg, Austria; (10) Dept. of Physical Medicine and 
Rehabilitation, Kaiser Franz Joseph Hospital, Vienna, Austria; (11) Karl Landsteiner 
Institut für Remobilisation und funktionale Gesundheit, Vienna, Austria;  
Abstract 
Evidence Based Medicine in Physical Medicine and Rehabilitation 
In the last twenty years the term “Evidence Based Medicine (EBM)” has spread into all areas 
of medicine and is often used for decision-making in the medical and public health sector. It is 
also used to verify the significance and/or the effectiveness of different therapies. 
The definition of EBM is to use the physician’s individual expertise, the patient’s needs and 
the best external evidence for each individual patient. Today, however, the term EBM is often 
wrongly used as a synonym for best “external evidence”. This leads not only to a misuse of 
evidence based medicine but suggests a fundamental misunderstanding of the model which 
was created by Gordon Guyatt, David Sackett and Archibald Cochrane. 
This problem becomes even greater the more social insurance institutions, public healthcare 
providers and politicians use external evidence alone as a main guideline for financing 
therapies in physical medicine and general rehabilitation without taking into account the 
physician’s expertise and the patient’s needs.The wrong interpretation of EBM can lead to the 
following problems: well established clinical therapies are either questioned or not granted and 
are therefore withheld from patients (for example physical pain management). 
Absence of evidence for individual therapy methods does not prove their ineffectiveness! 
In this short statement the significance of EBM in physical medicine and general rehabilitation 
will be analysed and discussed. 
Key Words: EBM, evidence based medicine, physical medicine, physiotherapy, rehabilitation 
European Journal Translational Myology - Basic Applied Myology 2013; 23 (4):217-220
Evidence Based Medicine in Physical Medicine and Rehabilitation 
European Journal Translational Myology - Basic Applied Myology 2013; 23 (4): 217-220 
- 217 - 
 
 
 
 
Fig.1 Graphical illustration of the EBM Triad 
which represents the three areas of EBM 
 
 
 
Fig.2. Adapted illustration of the EBM Triad with 
EBM reduced to a minor part of external evidence 
 
Introduction - Definition and meaning of EBM  
 In the past 20 years the term “Evidence Based 
Medicine” (EBM) has spread into all domains of 
medicine and is often used for medical and health care 
decisions. 
According to the pioneers of EBM Gordon Guyatt and 
David Sackett, co-founders of the first international 
EBM working group ("evidence based medicine 
working group"), EBM is „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 and patient values with the 
best available external evidence from systematic 
research [9,23]. 
„By best available external clinical evidence we mean 
clinically relevant research, often from the basic 
sciences of medicine, but especially from patient 
centred clinical research …“[23]. 
Sackett demonstrated in BMJ 1996 how these three 
areas of EBM form the valuation of therapy methods 
and how they have to be evaluated for each individual 
patient. (Fig.1.) 
 
General and International Criticism relating to 
EBM 
 
Nowadays many protagonists both in medicine and 
health care policy use and discuss the term EBM and it 
is increasingly used for making decisions about 
medicine and health care. Today a particular therapy or 
treatment is often only considered to be correct if it 
bears the endorsement EBM, regardless whether all 
aspects of EBM have been taken into account [28]. 
 
EBM is discussed internationally because the term 
EBM is often wrongly used as a synonym for the 
„external scientific evidence“ without taking the 
clinical expertise and patient values into consideration. 
Another point of criticism is that EBM is understood as 
medicine which is based on results of studies which 
have to fulfil certain methodological requirements such 
as double-blind, randomised, controlled trials (RCTs). 
Studies of this kind are mainly used in the 
pharmacological sector for the approval of new 
pharmaceuticals and are not applicable for all medical 
treatments or therapies. Such double-blind trials are 
inappropriate for many questions in physical medicine.  
 
To reduce the scientific argumentation in medicine 
solely to the statistical results of RCTs and meta 
analyses restricts science and leads to a loss of 
knowledge. Nevertheless, this methodological  
approach to scientific results is defended almost 
ideologically [28]. 
Sackett's view is that RCTs and scientific reviews of 
RCTs provide reliable proof that therapies are more 
beneficial than harmful. However, he also points out 
that some questions about therapies do not require 
RCTs [23]. 
„Evidence based medicine is not restricted to 
randomised trials and meta-analyses“ [23]. 
 
Some who are not familiar with EBM only evaluate the 
Evidence Based Medicine in Physical Medicine and Rehabilitation 
European Journal Translational Myology - Basic Applied Myology 2013; 23 (4): 217-220 
- 218 - 
 
 
 
Fig.3. Detailed illustration of all 3 areas of the EBM-Triad with a table of important types of studies for "best 
external evidence". 
“external evidence” (Fig.2.). 
 However this is completely contrary to the concept of 
the “fathers” of EBM who consider all three areas to be 
equally important.  
The missunderstanding in the interpretation of EBM 
becomes obvious when considering the illustration of 
the EBM Triad of the Florida State University on the 
Cochrane homepage and differentiating the details of 
the three areas. (Abb.3) 
External evidence includes all types of studies. 
Therefore it is problematic to reduce the external 
evidence only to level 1 and 2 studies because a lot of 
knowledge is not taken into account.  
Internationally this condition is criticized consistently 
[20,30], as can best be shown by the graphic 
demonstration of the American Chiropractors 
Association. (Fig.3. table top right). 
Other types of studies should also be cited and 
assessed. In particular literature about fundamental 
scientific research which is listed in international peer 
reviewed journals with impact points should be taken 
into consideration. 
However this would require a greater effort during the 
assessment of external evidence, than if the search for 
literature were limited to RCTs and meta analyses in 
order to propagate results of more superficial work as 
"evidence" or “no evidence”. 
A restriction of the assessment of external evidence to 
RCTs und meta analyses is misleading and 
unscientific. 
Often the search for literature is limited to a few 
electronic databases such as Pubmed, Medline, 
Cochrane Homepage, Embase etc. and to a time frame 
of the last 15-20 years. Older literature or literature 
which can only be found in books, printed journals or 
cannot be found electronically is often ignored. 
The statistical significance level should also be taken 
into account. The fact that it is possible to get a 
statistically significant result with a large sample size 
which can be clinically irrelevant should be taken into 
consideration [27]. Therefore it is absolutely necessary 
to question the physiological reasonableness and 
clinical relevance of individual studies or reviews. 
Rating agencies such as the Cochrane Centre or Health 
Technology Agencies claim to get over this problem 
through statistical analyses and filter out knowledge 
which the “normal” physician is not capable of. 
However proof for the effectivity of this procedure in 
terms of improving the physical condition of the 
population has not yet been confirmed [28]. If 
appropriate therapies are determined only that way, the 
doctor’s work would be devalued and reduced ad 
absurdum.  
If you look at RCTs and meta analyses closely 
following problems can be seen: 
El Dib reported that in 96% of 1024 Cochrane reviews 
no exact statement is made [6]. 
Epstein demonstrated in BMJ 2007 that in 124 meta 
analyses about antihypertensive therapies only 55% 
show positive results but a positive conclusion is made 
in 92% of the studies. This seems to depend on the 
industrial sponsors of the studies [7].   
Evidence Based Medicine in Physical Medicine and Rehabilitation 
European Journal Translational Myology - Basic Applied Myology 2013; 23 (4): 217-220 
- 219 - 
 
Apart from this, it becomes evident that negative 
clinical study results are, for a variety of reasons, 
published much less frequently [25]. 
„Good doctors use both individual clinical expertise 
and the best available external evidence, and neither 
alone is enough. Without clinical expertise, practice 
risks becoming tyrannised by evidence, for even 
excellent external evidence may be inapplicable to or 
inappropriate for an individual patient“ [23]. 
 
 
EBM – in Physical Rehabilitation Medicine 
 
The national committee of American Chiropraticians 
worked out a national guideline which indicates that 
not only RCTs and meta analyses should be used to 
assess external evidence, but also all other types of 
studies, in particular the results of scientific and 
clinical basic research [20]. 
Limiting assessment based on RCTs and meta analyses 
with level 1 or 2 per se must be seen just as critically 
as limiting the time frame of analyses for guidelines to 
the last few years. Especially in the domain of physical 
medicine and general rehabilitation many proven 
therapies such as massage, electrical therapy and 
ultrasound are documented in older studies published 
in books and are therefore not used in assessments 
[2,3,5,8,10-16,18,19,21,22,26]. 
The biological variability of the human being is the 
reason why, in the field of medicine, results even from 
high level studies can never describe the effect of an 
intervention as precisely as in mathematical or physical 
studies [28]. Wichert believes that the use of complex 
mathematical methods do not change anything in this 
biological variability [28].   
Reasons for the limited number of RCTs and meta 
analyses in the medical field in comparison to drug 
studies are a combination of the variability of the 
methods, the applied parameters (e.g. stimulation-
parameters, patient collective, compliance, blinding) 
and the biological variability of human and 
environmental factors [26].   
Another problem which complicates the carrying out 
of large scale studies in physical medicine is the lack 
of financial support in contrast to the support given to 
the development of pharmaceuticals because there are 
no companies which invest in this sector of medicine. 
A further serious weakness in the present assessment 
of physical treatment methods is that studies which 
examine the combination of different therapies are not 
taken into consideration. Precisely these combination 
therapies are used in daily practice in patients’ interests 
because they have proven themselves clinically to be 
effective and more beneficial [17,26]. RCTs in which 
solely monotherapies are analyzed, do not allow any 
reliable statements about the treatment with 
combination therapies and therefore lead to 
inconsistent conclusions. 
Another reason for the absence of level 1 studies is that 
some of the physical treatments such as massage and 
electrical therapy do not allow pure placebo groups and 
double blind studies are often difficult or even 
impossible [17]. 
“Absence of evidence is not evidence of absence” [1]. 
The absence of external evidence for individual forms 
of therapies is not proof of their ineffectiveness. 
Nevertheless, many of those responsible draw the 
wrong conclusion [4,29]. 
This problem becomes even more relevant the more  
social insurance companies and politicians use the 
wrong interpretation of EBM as decision criterion for 
therapy guidelines and their economic evaluation. 
It is unethical and unscientific if the physician’s 
clinical experience and the patient's needs as well as 
the scientific basic research of physical therapies are 
ignored. 
Because of the wrong interpretation of EBM well 
established clinical therapies (e.g. physical pain 
management) may be questioned, not approved and 
withheld from the patients. 
 
Evaluative authorities (e.g. experts of the social 
insurance companies, Austrian example: 
„Sozialversicherungsträger (SV)“, Hauptverband der 
SV)  should not make the mistake of assessing only the 
scientific “external evidence” without taking all parts 
of EBM into consideration as required by Gordon 
Guyatt and David Sackett. 
In the end it is the doctor who evaluates the present 
best scientific literature for the individual patient’s 
treatment [23]. 
 
Acknowledgement 
Thanks to all researchers for their support. 
 
Corresponding Author 
Prim. Univ.-Prof. DDr. Helmut Kern, Institut für 
Physikalische Medizin und Rehabilitation, 
Wilhelminenspital, Montleartstraße 37, A-1160 Wien, 
Österreich 
e-mail: wil.pys.kern-forschung@wienkav.at.  
 
Literature 
[1] Alderson P. Absence of evidence is not 
evidence f absence. BMJ. 2004;328(7438):476–
477. 
[2] Boncompagni S, Kern H, Rossini K, Hofer C, 
Mayr W, Carraro U, et al. Structural 
differentiation of skeletal muscle fibers in the 
Evidence Based Medicine in Physical Medicine and Rehabilitation 
European Journal Translational Myology - Basic Applied Myology 2013; 23 (4): 217-220 
- 220 - 
 
absence of innervation in humans. Proc Natl 
Acad Sci USA. 2007;104(49):19339–19344. 
[3] Braddom RL. Handbook of Physical Medicine 
and Rehabilitation. Saunders; 2004. 
[4] Brandstätter S. Rückenleiden: Gesund werden. 
Gesund bleiben 2. Holzhausen Verlag GmbH; 
2009. 
[5] Bringezu G, Schreiner O. Die Therapieform 
manuelle Lymphdrainage: ein aktuelles 
Lehrbuch einer erfolgreichen Behandlungs-
methode. 3. Aufl. Ebert; 1997. 
[6] El Dib RP, Atallah AN, Andriolo RB. Mapping 
the Cochrane evidence for decision making in 
health care. J Eval Clin Pract. 2007;13(4):689–
692. 
[7] Epstein RA. Influence of pharmaceutical 
funding on the conclusions of meta-analyses. 
BMJ. 2007;335(7631):1167. 
[8] Gutmann E. The denervated muscle. Pub. 
House of the Czechoslovak Academy of 
Sciences; 1962. 
[9] Guyatt G CJ. Evidence-based medicine: A new 
approach to teaching the practice of medicine. 
JAMA. 1992;268(17):2420–2425. 
[10] Jantsch H, Schuhfried F. Niederfrequente 
Ströme zur Diagnostik und Therapie. 2. Aufl. 
Maudrich; 1981. 
[11] Kern H. Funktionelle Elektrostimulation 
paraplegischer Patienten. Österr Z Phys Med. 
1995;5(1 Suppl):1-79. 
[12] Kern H, Boncompagni S, Rossini K, Mayr W, 
Fanò G, Zanin ME, et al. Long-term 
denervation in humans causes degeneration of 
both contractile and excitation-contraction 
coupling apparatus, which is reversible by 
functional electrical stimulation (FES): a role 
for myofiber regeneration? J Neuropathol Exp 
Neurol. 2004;63(9):919–931. 
[13] Kern H, Carraro U, Adami N, Biral D, Hofer C, 
Forstner C, et al. Home-based functional 
electrical stimulation rescues permanently 
denervated muscles in paraplegic patients with 
complete lower motor neuron lesion. 
Neurorehabil Neural Repair. 2010;24(8):709–
721. 
[14] Kovács R. Electrotherapy and Light Therapy: 
With Essentials of Hydrotherapy and 
Mechanotherapy. 6. Aufl. Lea & Febiger; 1949. 
[15] Kowarschik J. Die Diathermie. 7. Aufl. 
Springer Verlag; 1930. 
[16] Kowarschik J. Physikalische Therapie. 2. Aufl. 
Springer; 1957. 
[17] Lange U, Berg W, Engel MJ, Fetaj S, Lichti G, 
Reuss-Borst M, et al. Evidenz zur 
Physikalischen Medizin in der Rheumatologie. 
Aktuelle Rheumatologie. 2009;34(05):299–302. 
[18] Licht S. Stroke and its rehabilitation. E. Licht; 
1975. 
[19] Mennell JB. Physical Treatment by Movement, 
Manipulation and Massage: With 288 
Illustrations, Some in Colour. 5. Aufl. 
Churchill; 1945. 
[20] National Guideline Clearinghouse (NGC). 
Practicing Chiropractors’ Committee on 
Radiology Protocols (PCCRP) for 
biomechanical assessment of spinal subluxation 
in chiropractic clinicalpractice. Available at:  
http://www.guideline.gov/content.aspx?id=1457
6 [Accessed 20th Aug. 2013] 
[21] Rogoff JB, Licht SH. Manipulation, traction, 
and massage. 2. Aufl. Williams & Wilkins; 
1980. 
[22] Rusk HA. Rehabilitation Medicine. 4. Aufl. C. 
V. Mosby; 1977. 
[23] Sackett DL, Rosenberg WMC, Gray JAM, 
Haynes RB, Richardson WS. Evidence based 
medicine: what it is and what it isn't. BMJ. 
1996. 312(7023):71-72. 
[24] The Evidence-based Medicine Triad. Available 
at: http://www.cochrane.org/about-us/evidence-
based-health-care [Accessed 11th Nov. 2013] 
[25] Turner EH, Matthews AM, Linardatos E, Tell 
RA, Rosenthal R. Selective Publication of 
Antidepressant Trials and Its Influence on 
Apparent Efficacy. New England Journal of 
Medicine. 2008;358(3):252–260. 
[26] Watson T. Electrotherapy: Evidence-based 
Practice. 12. Aufl. Churchill Livingstone; 2008. 
[27] Weßling H. Theorie der klinischen Evidenz: 
Versuch einer Kritik der Evidenzbasierten 
Medizin. LIT Verlag Münster. 2011. 
[28] Wichert, Peter. Evidenzbasierte Medizin 
(EbM): Begriff entideologisieren. Dtsch 
Arztebl. 3. Juni 2005;102(22):A1569–570. 
[29] Wildbacher Ingrid, Brandstätter Silvia, Kruzic 
Nives, Gerner Gabriele, Kiesl Ute. 
Österreichischer Muster-Leistungskatalog 
Physikalische Medizin – empirische 
Grundlagen zur Wirksamkeit der Inhalte. GMS 
Health Technology Assessment. 2013;9:1–14. 
[30] Zuiderent-Jerak T, Forland F, Macbeth F. 
Guidelines should reflect all knowledge, not just 
clinical trials. BMJ. 2012;345:e6702. 
 


Evidence based medicine in physical medicine and rehabilitation (English version)

Directory of Open Access Journals

MUCC (Crossref)

http://www.pagepressjournals.org/index.php/bam/article/download/bam.2013.4.217/3920

Evidence based medicine in physical medicine and rehabilitation (English version)

Abstract

Similar works

Full text

Available Versions

Crossref

Directory of Open Access Journals

MUCC (Crossref)

Crossref