Evidence-based practice (EBP) is a fundamental component of healthcare. The primary goal of EBP is to empower the clinician to make informed decisions. It has evolved over time when considering the concept’s name, definition and scope. Evidence-based practice is a movement that started in the 1990s and initially related solely to the medical profession (Djulbegovic & Guyatt 2017). In 1991, Gordon H. Guyatt introduced the term evidence-based medicine (EBM) (Guyatt 1991). The EBM Working Group, led by Gordon H. Guyatt, resided with McMaster University in Canada (Herbert 2011). It was felt that clinicians were not using research evidence during practice, relying more on their own beliefs regarding care, even when research showed that new developments could improve patients’ lives if implemented (Herbert 2011). The process outlined for EBM included sourcing research evidence, critically appraising the evidence and synthesising the information retrieved to inform patient care (Djulbegovic & Guyatt 2017; Guyatt 1991). The focus was on the importance of the research evidence, with less emphasis placed on the clinician’s intuition and clinical experience when making clinical decisions regarding practice (Guyatt et al., 1992). Because of the escalation of published research literature at that time, being efficient in finding and evaluating the literature was an essential clinical skill for clinicians to acquire to practice EBM (Guyatt 1991; Guyatt et al. 1992). A skill still crucial in today’s practice.

A change occurred, narrowing the gap between research evidence and clinical expertise in the understanding of EBM. In 1997, David Sackett highlighted that using external evidence (research literature) alone to assist with clinical decision-making was insufficient to support EBM (Sackett 1997). David Sackett was one of the founders of EBP (Moseley et al. 2020). He stressed that the clinician’s experience, expertise and, therefore, practice knowledge, in addition to research evidence and being cognisant of the patient’s concerns, values and beliefs, are necessary during clinical practice when implementing EBM (Sacket 1997). He introduced the concept of a ‘good doctor’, indicating that such a practitioner implement EBM with the above-mentioned multifaceted components (Sackett 1997).

Similarly to Sackett (1997), Kleiner et al. (2023), in a recent integrative review, highlight what constitutes good practice in physiotherapy by outlining what patients and physiotherapists alike consider a ‘good’ physiotherapist to be. The authors state that such an individual should be responsive to patients, caring, demonstrate ethical qualities, be an effective communicator and be competent. Competence is further unpacked as being knowledgeable, having clinical experience, being reflective, being confident, being curious, being able to clinically reason and having practical skills that ensure good patient outcomes (Kleiner et al. 2023). All attributes necessary to aid in following the steps of EBP and practice evidence-based physiotherapy.

The Sicilian Statement on EBP was published in 2005, following the International Conference of Evidence-Based Health Care Teachers and Developers in September 2003. This statement was constructed following a review of the literature on evidence-based healthcare and incorporating the views of conference delegates. This statement proposed a name change from EBM to EBP (Dawes et al. 2005). This name change occurred as other healthcare professions embraced the EBP approach. In addition, the benefits of the entire healthcare team following an evidence-based paradigm during clinical practice were recognised (Dawes et al. 2005). Since then, more research evidence is available outlining the benefits of EBP. In a recent scoping review of 636 articles, Connor et al. (2023) mapped the outcome of EBP programmes implemented in healthcare settings across healthcare disciplines. The authors found that such programmes can potentially improve patient outcomes, healthcare return on investments made and optimise patient satisfaction (Connor et al. 2023).

The definition of EBP as supported in the Sicilian Statement was:

This definition of EBP embraced the earlier sentiments stated by Sackett (1997) but added the importance of the healthcare context and resource availability in the context of care as additional factors to consider when implementing EBP (see Figure 1).

In October 2001, member organisations of World Physiotherapy (then the World Confederation for Physical Therapy) gathered in London to discuss the status of EBP in the profession (Stewart 2003). Furthermore, to get buy-in from regions to ensure that EBP would become the norm and part of the specific culture of practice in all regions as we advance (Stewart 2003). Twenty years have passed since this meeting, with noteworthy developments in clinical practice, teaching and learning and research synthesis.

This commentary aims to answer the following question:

What is EBP and its current state in clinical physiotherapy?

Literature on the steps and process of EBP, the opinions of physiotherapists towards EBP, how physiotherapists implemented evidence-based physiotherapy during clinical practice and the known barriers and facilitators are discussed in order to make recommendations for future developments.

Understanding the process and steps related to EBP is essential to facilitate optimal communication between parties. In addition, reviewing the steps highlights how the components of EBP – the clinician’s experience and expertise, the use of research evidence and the patient’s preferences – are integral to EBP. Literature also suggests that inefficient application of the process and steps of EBP are still apparent in healthcare today (Connor et al. 2023). Lastly, a lack of knowledge and training on EBP are barriers to EBP during physiotherapy clinical practice, as demonstrated in recent literature from Africa and the Middle East (Alshehri et al. 2017; ShahAli et al., 2023; Silumesii, Damba & Magapatona 2024).

During the early phase of EBM, which later changed to EBP, a distinct five-step process was outlined (Dawes et al. 2005; Dusin, Melanson & Mische-Lawson 2023; Herbert 2011; Hoffmann, Bennett & Del Mar 2023; Sackett 1997). Table 1 contains these five steps, which are labelled accordingly. A seven-step process was later proposed as an alternative, where step zero is cultivating a spirit of enquiry, and the last step relates to disseminating the EBP results (Melnyk et al. 2010).

Clinical decision-making remains complex, relying on the clinician’s ability to collect, evaluate, interpret and synthesise information from many sources. It includes clinical reasoning and problem-solving which require the clinician to use research evidence, information from patient assessment, known practice knowledge (clinician experience and expertise) and patient preferences to inform decisions (Abdu et al. 2024; Dawes et al. 2005; Herbert 2011; Sackett 1997). Thoughtful assessment, using appropriate standardised outcome measures consistently to gather evidence, and being reflective during clinical practice are components of EBP (Abdu et al. 2024). All of these aspects are integral to the steps of EBP.

The practice has moved away from the viewpoint that the clinician makes the decisions for the patient to be more inclusive and consider patient preferences (Herbert 2011; Hoffmann et al. 2023; Welding & Smith 2013; World Physiotherapy 2023). Therefore, shared decision-making is the focus, making use of clinicians’ ‘soft skills’ during practice: communication, attitude, etiquette, situational awareness, empathy, active listening, respect and building rapport with the patient, which are essential (Metgud & D’Silva 2021; Ogden et al. 2021). In addition, it includes assessment of patient-reported outcomes using patient-reported outcome measures during patient evaluation, if applicable (Weldring & Smith 2013). Therefore, placing the patient central to the process of EBP as depicted in Figure 1.

The World Physiotherapy’s definition of EBP encapsulates this newer contemporary model of practice: ‘Evidence should be integrated with clinical experience, taking into consideration beliefs, values and the cultural context of the local environment, as well as patient/client preferences’ (World Physiotherapy 2023:1). Implementation of EBP during clinical care is influenced by several factors, one of which could be the opinions of the end-user.

Considering the importance of EBP in healthcare, it is vital to assess clinicians’ implementation of EBP during clinical practice. Tools are available to allow researchers to assess this construct. Fernández-Dominquez et al. (2014) conducted a systematic review, collated the tools used in research studies to evaluate EBP in clinical physiotherapy and reviewed the reliability and validity of the respective tools. The authors identified 24 instruments in the review but concluded that they all had shortcomings in relation to the constructs included to evaluate EBP in clinical physiotherapy (Fernández-Domiquez et al. 2014). Balzer et al. (2023), in a more recent systematic review, indicated that the Evidence-Based Practice Inventory (EBPI), Evidence-Based Practice Confidence (EPIC) scale and Health Sciences-Evidence-Based Practice (HS-EBP) questionnaire are tools available with sufficient content validity, reliability and internal consistency to assess EBP in healthcare practitioners, including physiotherapy. Therefore, the ability to assess EBP during clinical physiotherapy with standardised tools has improved.

Physiotherapists’ beliefs and confidence regarding the ability to conduct EBP activities influence clinical practice implementation. Literature from an Australian study, including in part information collected with the EPIC scale, suggests that allied health professionals, for example, physiotherapists, occupational therapists, among others, with no formal postgraduate qualifications begin to lose confidence related to EBP activities within the first 5 years of clinical practice (Klaic, McDermott & Haines 2019b). This involves using research evidence to inform clinical decision-making (Klaic et al. 2019b). Specifically, activities involving critical analysis of published studies (Klaic et al. 2019b). The authors suggest that this loss of confidence may be because of early-career clinicians’ limited opportunities to practise these skills during clinical practice. In addition, there may be a lack of support and guidance from senior colleagues who have lost their confidence in conducting EBP activities (Klaic et al. 2019b). In a second qualitative study, the authors noted that the lack of practice and implementation of EBP steps during clinical practice leads to a degradation of these skills (Klaic, McDermott & Haines 2019a). This then, in turn, results in efficiencies when clinicians search for research evidence, and the process is then deemed too time-consuming (Klaic et al., 2019a). Not using research evidence during clinical practice is concerning, as this could imply that patients do not receive evidence-based care.

Condon et al. (2016), in a scoping review of 25 studies, collated evidence that evaluated whether physiotherapists can undertake the steps of EBP during clinical practice. Studies from Africa, the Middle East, the Far East and South America on the topic of interest were not available for inclusion in the review. The authors found that asking the question (step 1), acquiring the evidence (step 2) and appraising the evidence (step 3) were steps of the EBP process mostly utilised by physiotherapists (Table 1). Step 4 – applying the findings to practice and step 5 – evaluating the outcome, require improvement. This indicates that shared decision-making, including patient preferences, clinical reasoning and evaluation of the impact of EBP, still has room for improvement during clinical physiotherapy. Findings in the scoping review indicated that physiotherapists tended to prefer using colleagues as evidence sources (Condon et al. 2016). Physiotherapists believed that feedback from their colleagues was informed by their experience and, therefore, more relevant to the specific clinical question and context of practice (Condon et al. 2016). Gleadhill et al. (2022) also found that colleagues’ treatment choices and input influenced physiotherapists’ decision-making regarding EBP. The creation of networks and their influence on EBP during physiotherapy practice are evident.

The creation of research evidence, for example, randomised controlled trials (RCTs) and synthesis of research evidence, for example, systematic reviews (SRs) and clinical practice guidelines (CPGs) as part of EBP and to inform evidence-based physiotherapy, has significantly increased over time (Moseley et al. 2002, 2020). In 2002, a substantial body of high-level evidence (RCTs, n = 2376 and SRs, n = 332) was available for clinicians to use to inform the process of EBP on the Physiotherapy Evidence Database (PEDro) (Moseley et al., 2002) (Figure 2). As of August 2019, 34 619 RCTs, 9004 SRs and 686 CPGs are available to clinicians (Moseley et al. 2020) (Figure 2). Disseminating the outcomes of interventions, as outlined by Melnyk et al. (2010), is a key step in the EBP process.

Literature suggests that undergraduate curricula in some regions need to be updated to include the teaching and learning of EBP to students. Evidence-based practice involves lifelong learning and the need to upskill oneself when gaps in clinical and research skills are identified. Findings from this article indicate that participation in postgraduate training and attaining additional qualifications optimises the implementation of EBP during clinical practice. The creation and participation in continual professional development, such as workshops, short courses, diplomas, or additional postgraduate degrees (MSc and PhD), create future opportunities for clinicians and academics to optimise EBP.

Over the last 20 years, strides have been made in creating outcome measures in all spheres of physiotherapy practice, for example, intensive care versus outpatients and urban versus rural. In addition, the psychometric properties of such tools are available for review to assess their applicability for practice. Regular reflective practice is needed to ensure a range of outcome measures are implemented during practice to improve the clinical execution of EBP and provide proof of the evidence of physiotherapy treatment implemented. This includes patient-reported outcomes with patient-reported outcome measures.

Further research is needed in cross-cultural adaptation and validating existing outcome measures into languages other than English to increase the utility of these tools across regions. In the absence of an existing tool relevant to a specific outcome, which is culturally sensitive within the context of care, a collaboration between clinicians and researchers is needed to create and test such a tool.

The availability of time during clinical practice, support at the workplace and resources influence the implementation of EBP. Addressing these organisational factors is warranted to optimise evidence-based patient care.

The presence of large language models, such as, ChatGPT, Claude AI and Perplexity AI, among others, are here to stay, and they have the potential to positively and negative influence education, research and clinical practice. How to implement and what is acceptable use during EBP requires discussion and further research.

A culture of EBP in clinical physiotherapy is in existence upon reflection of published literature from different regions of the world, and one can therefore say that the aim of the World Physiotherapy meeting held in London in 2001 has been achieved. Patients have the right to quality, evidence-based patient care to optimise their rehabilitation. When physiotherapists undertake the steps of EBP to implement research evidence into clinical practice, it has the potential to optimise patient outcomes, impact funding of services rendered and enhance patient satisfaction through shared decision-making. Improvements can still occur with regards to the method and quality of EBP conducted, as highlighted in this article.