Podiatrists interpretation and use of evidence in MSK practice

Background - The development of podiatric biomechanics could be seen as part of a wider quest for legitimacy by the profession, allowing podiatrists to improve their professional status by claiming a body of knowledge and skills and enabling podiatrists to access a different group of patients. However, podiatric biomechanics theories and effectiveness of functional orthoses have been called into question, as there may be little research evidence to support them. There are many podiatrists who would argue with this statement and point to evidence that functional orthoses are an effective treatment for musculoskeletal conditions. These conflicting views of evidence have not affected the growth of the MSK specialism within podiatry.
Methods - This study was a qualitative study, which explored podiatrists’ beliefs about evidence-based practice in MSK practice, their perceptions of the interpretation of research and other forms of evidence. 17 in-depth interviews were conducted with podiatrists, 9 NHS, 6 private, 2 academics, who treat MSK conditions with functional orthoses. The data was analysed through a hermeneutic approach that using interpretative phenomenological analysis. This is less focused on phenomenological description, more on interpreting the data in a wider social, cultural and theoretical context.
Findings and Discussion - The participants understand the concept of evidence-based practice, as the application of quantitative research evidence to their practice. Research evidence cannot always be easily applied in practice due to the variances in orthotic design, in the causes of MSK conditions and the differences in patients’ lifestyles and preferences. Research evidence does inform their practice but they tend to interpret research evidence according to their own experiences. The participants value their clinical experience, which is formed by testing of orthotic materials and designs and patient responses to them. The evidence that they use could be described as a process of trial and error informed by their patient feedback. A lack of this experience may lead to inexperienced podiatrists’ being unsure about which treatments to give. Patient feedback was seen as the most important form of evidence. However, outcome data was collected only by some of the participants and this was rarely collated and analysed.
Conclusions – The participants may not be undertaking evidence based practice as they define it, as using research evidence in practice. They use their clinical experience more than research evidence in practice. They interpret and use research evidence through their own practical experience. Their experience is formed by a process of trial and error, with orthotic designs, and patient feedback about their treatments. The dependency of podiatric MSK practice on patient evidence rather than research has lead to fears that podiatrists’ claims of legitimacy in MSK practice may be questioned. These fears may be allayed by more comprehensive evaluation of the efficacy of functional orthoses through the collation and analysis of outcome data. There also needs to be a wider debate in podiatry about the definition of evidence in evidence based practice and the types of evidence that are really utilised in practice.