Greek philosophers emphasized that "knowledge is power." It is clear that having the right information is important. However, the pendulum has swung so much toward knowledge that other aspects of our existence—such as experience and wisdom—have taken a back seat. It is one of the reasons why many business owners and managers complain about graduates who leave school and enter the workforce. Many students have a lot of knowledge, but they don’t know how to apply it; also, the knowledge in itself is not applicable in the "real" world.

Jewish philosophers focused more on wisdom. What is the difference, you ask? Wisdom is the application of the right knowledge for a good cause.

If we want to be wise and not just knowledgeable, we have to take a serious look at how we gather information and how we are going to apply this knowledge. Developing an evidence-based practice is a sign of wisdom; it is not just about the evidence, it is about the practical application of this evidence.

Getting Started
The importance of applying the evidence from research in the clinical setting became clear to me when I read a research article by Chris Powers, PhD, PT, regarding patellofemoral joint dysfunction. In this article, he stated that the existing rationale behind most treatment approaches to this specific problem were controversial. Most of my colleagues and I were of the opinion that patellofemoral pain was the result of abnormal tracking and/or misalignment of the patella. Based on this thinking, we focused on the joint itself and did our patellar-mobilization techniques, taping, strengthening of the vastus medialis oblique and adductors, soft-tissue mobilization, and even bracing. However, after reading the article, I started to change the focus of my treatments toward controlling the pelvis (especially the gluteus medius). We even have abolished some previous treatment techniques we used before. The results have been remarkable, and we have begun objectively measuring this improvement in results. The point is that by taking research into consideration, we have become better care-givers to our patients.

My objective with this article is to help you make your clinic an evidence-based one. We all have our strengths and weaknesses, but there is one area we all should be great in: patient care. Great patient care is the fundamental reason for our profession’s existence. It is the basis of why we do what we do. It is why we should gather evidence and put this evidence into practice. To do this effectively, most of us need to make specific changes in how we are going to develop our clinics.

Pros Versus Cons
There are many reasons why you should make the change to become an evidence-based clinic:
• To improve the quality of care;
• Patient satisfaction;
• Physician satisfaction;
• Our own satisfaction;
• It is a confidence booster because we know we are doing the right thing;
• It can be used as a marketing tool; and
• It helps us become more of an asset for patients and for the profession particularly.

On the other hand, there are several reasons why facilities do not make the change to becoming an evidence-based practice. Many of you are intimidated by the thought that it takes a lot of time to gather information, make conclusions from the information, figure out what equipment to buy, develop a testing regimen, develop a new treatment regimen, train others, and develop an information database. Other reasons for not becoming an evidence-based practice include:
• The thought that PTs are not trained in gathering the right information;
• change is uncomfortable;
• PTs do not understand the value of becoming an evidence-based facility; and
• it costs time and money.

Where does the future of your practice lie? Do you let the pros or the cons determine if your practice will become an evidence-based one?

I am the director of a medium-size rehabilitation center with five PTs, one PT assistant, and one occupational/hand therapist. In the beginning of this year, we decided to discuss what kind of clinic we want to become in the next 10 to 15 years. We concluded that we need to become an evidence-based clinic. The next questions we asked ourselves were: "What does that mean?" and "How do we start?"

What does "evidence-based" mean? An evidence-based practice is a facility where people work according to the fundamental principle of practicing according to proven facts.

Are you overwhelmed by the thought of developing a true evidence-based clinic? Welcome to the club! It is like anything in life that is worthwhile; it is difficult to accomplish. Do you remember when you applied for physical therapy school and you realized how much you had to learn? Do you remember when you started your own clinic?

The good news is that nobody starts out perfect. It is not about perfection; it is about progress—continuous progress. The Japanese culture has a term for this concept: "Kaizen." Kaizen is all about the process of making incremental improvements, no matter how small. First, you need to foster the philosophy of continuous improvement over a long period of time in your practice. Kaizen requires a long-term commitment in all aspects of a program. In our case, it is not only about improving in gathering evidence-based information, but also in acquiring the best technology possible, recruiting the best people, developing the team, doing a better job in marketing, and giving the best patient service.

After making this long-term commitment, we need to develop a plan of action and then implement it. Last, we need to evaluate the results of the implementation to determine if we are progressing to perfection. The most efficient Japanese car companies in the world are based on the Kaizen principle of continuous improvement. Use the concept of Kaizen in becoming an evidence-based clinic, and see where you will be in 2, 5, and 10 years from now.

Components of an Evidence-Based Practice
Let us review the different components of developing this project of becoming an evidence-based practice. They are: research, technology, programs, and personnel.

Research
Research is an important ingredient to our success as professionals. Therapists in our clinic are able to assess the reliability of the different research projects. During our weekly staff meeting, we spend some time discussing a research article and its application in patient care. One of the most difficult things is not to waste any time finding the right information. It is important to understand that, as practitioners, we do not have to do the research ourselves—it is already done by others who are specialized in this area. Our task is to assess what is applicable in practice and to integrate the research findings in daily examinations and treatments. Some great sites of "predigested" research are www.hookedonevidence.com and www.evidenceinmotion.com.

Technology
Objective measurements are honest measurements. The Guide to Physical Therapist Practice by the American Physical Therapy Association states that a measurement is said to be reliable when it is consistent time after time, with as little variation as possible. To be able to do these measurements, you need to purchase the right technology. It can be as simple as a tape measure or a gonio-meter, or as complex as a computerized 3D digital camera system. Start out simple, and work your way into more complex technology.

Programs Within the Clinic
The question is, what do you want to accomplish? Do you just want to have a system of gathering applicable information, discussing this information, and applying it into practice? Or, do you want to start your own evaluation program to see how much faster your patients will be healed due to the evidence-based treatment and how much it saved the insurance companies?

Not only will your treatments be better, but now you will also be able to measure the results and put them into a database. This data can be analyzed and be used as a marketing tool for referral sources and insurance companies. You may even want to start your own research project at a later stage. As you can see, there are different reasons to start a program. First, you need to know why you would like to start these programs.

Teams
I believe that one individual cannot know everything; thus, the best way to maximize our efforts is to create teams. My advice is to start developing a working relationship with other colleagues who are familiar with research, or contact a local university and talk to the director or professor of biomechanics. Share your idea with them, and ask for advice. Draw them in by asking for their ideas and opinions. You are going to get valuable information in, for example, how to set up a program, what equipment to buy, and how to create a database.

Also, try to develop teams in your clinic. Perhaps two people can do the research; another two can look into the technology; and you, as the director, can make the connections outside the clinic. Meet at least once per week for 30 or 60 minutes. Do this for 3 to 4 months, and your program will get started and you’ll be on your way. It will not be perfect in the beginning, but that is fine as long as you work according to the Kaizen concept.

Physical therapy is a combination of hard facts, intuition, common sense, and experience. Because our profession has relied a lot on the latter three, we are now rightfully focused on the first. However, we have to be careful not to become like the Greek philosophers, for whom knowledge was the beginning and the end. We have to be wise and value also our intuition, our common sense, and our experience as trained professionals.

Andre van Commenee, PT, has been a physical therapist since 1984. He has worked for the Olympic Games, the World Cup soccer tournament, the World Championships in Track and Field, and at five European Cup Finals in track and field. In 2006, he became the director of rehabilitation at Congress Physical Therapy and Rehabilitation, Pasadena, Calif.

Recommended Reading
American Physical Therapy Association. Guide to Physical Therapist Practice. 2nd ed. Alexandria, Va: American Physical Therapy Association; 2001.

Collins J. Good to Great: Why Some Companies Make the Leap ... and Others Don’t. New York, NY: HarperCollins Publishers Inc; 2001.

Liker J. The Toyota Way: 14 Management Principles From The World's Greatest Manufacturer. New York, NY: The McGraw-Hill Companies; 2004.

Powers CM. The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther. 2003;11:639–646.