Physical Therapist Assistant

Evidence-based practice is "the conscientious, explicit and judicious use of current best evidence in making  decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research." 

• External evidence - systematic reviews, randomized control trials, best practices, and clinical practice guidelines that support a change in clinical practice
• Internal evidence – clinical expertise -- healthcare provides expertise, quality improvement projects outcome management initiatives
• Patient
  • Preferences – what does the patient really want when given several different options
  • Patient values – quality of care

Evidence-based practice is also a process that begins and ends with the patient. 

Image source: EBP, UC Davis Library

Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ. 1996;312(7023):71-72.

A clinical question needs to be directly relevant to the patient or problem at hand and phrased in such a way as to facilitate the search for an answer. PICO makes this process easier. It is a mnemonic for the important parts of a well-built clinical question. It also helps formulate the search strategy by identifying the key concepts that need to be in the article that can answer the question.

PICO or PICOT:

P= PATIENT / PROBLEM / Population
How would you describe a group of patients similar to yours? What are the most important characteristics of the patient?

I = INTERVENTION
What main intervention, exposure, or prognostic factor are you considering? What do you want to do with this patient?

C = COMPARISON INTERVENTION, CONTROL
What is the main alternative being considered, if any?

O = OUTCOME
What are you trying to accomplish, measure, improve or affect?

The T usually stands for time and can be helpful in making sure you're thinking of the appropriate time frame for your intervention and/or outcomes.

PICO question format:

In a patient with (Problem), how does (Intervention) compare to (Comparison) with regard to (Outcome)?

For a patient with (Problem), how does (Intervention) compare to (Comparison) with regard to (Outcome)?

Examples of PICO questions:

1. Can closed kinetic chain shoulder exercises (intervention) increase the peak torque of shoulder internal- and external rotation (outcome) of a youth baseball player with subacromial impingement syndrome (patient)?

Alternative:

For a youth baseball player with subacromial impingement syndrome (patient), does closed kinetic chain shoulder exercises (intervention) increase the peak torque of shoulder internal- and external rotation (outcome)

2. In adults with low back pain (patient), do spinal stabilization exercises (intervention) reduce pain and increase function (outcome) more effectively than manual therapy (comparison)?

Class Research Requirements:

The assignment involves students thinking of a PICO question with regards to physical agents/modalities in physical therapy (examples are hot packs, ice massage, ultrasound, electrical stimulation, traction, laser, etc). Once the student has their PICO question, they are to perform a search of professional literature and write a paper on the chosen article.

Modalities— some examples include:

• Cryotherapy: cold/ice packs, ice massage, cold baths, vapor coolant sprays.
• Superficial and deep heat (local application): hot packs, paraffin, infrared, fluidotherapy, diathermy, ultrasound
• Systemic heat: large whirlpool, Hubbard thank
• Ultraviolet radiation
• Transcutaneous electrical nerve stimulation (TENS)
• Functional neuromuscular electrical stimulation

Your review should identify the following: a) The problem and its significance (the research question, why it's important to ask this research question, and the hypothesis) b) The type of study conducted and the design of the study c) The results d) The clinical application and significance of the results e) The identified need(s) for further investigation Please submit a screenshot of the database search used to select the article. The typewritten review is to be submitted on Blackboard. Provide the instructor with a hard copy or PDF of the article.

Systematic reviews and meta-analyses are situated at the top of what is known as the “Evidence Pyramid” (see figure below). As you move up the pyramid the amount of available literature on a given topic decreases, but the relevancy and quality of that literature increases. Systematic reviews and meta-analyses are considered to be the highest quality evidence on a research topic because their study design reduces bias and produces more reliable findings. However, you may not always be able to find (or need to find) the highest level of evidence to answer your research question. In the absence of the best evidence, you then need to consider moving down the pyramid.

Source:  

Primary Question Types

• Therapy: how to select treatments to offer our patients that do more good than harm and that are worth the efforts and costs of using them.
• Diagnostic tests: how to select and interpret diagnostic tests, in order to confirm or exclude a diagnosis, based on considering their precision, accuracy, acceptability, expense, safety, etc.
• Prognosis: how to estimate a patient's likely clinical course over time due to factors other than interventions
• Harm / Etiology: how to identify causes for disease (including its iatrogenic forms).

Other Question Types

• Clinical findings: how to properly gather and interpret findings from the history and physical examination.
• Clinical manifestations of disease: knowing how often and when a disease causes its clinical manifestations and how to use this knowledge in classifying our patients' illnesses.
• Differential diagnosis: when considering the possible causes of our patient’s clinical problem, how to select those that are likely, serious and responsive to treatment.
• Prevention: how to reduce the chance of disease by identifying and modifying risk factors and how to diagnose disease early by screening.
• Qualitative: how to empathize with our patients’ situations, appreciate the meaning they find in the experience and >understand how this meaning influences their healing.

From: Sackett, DL. Evidence-based medicine: how to practice and teach EBM.

Note: Meta-analyses and systematic reviews, when available, often provide the best answers to clinical questions.

TYPES OF DESIGN Studies:

Clinical Practice Guidelines (CGP) - The Institute of Medicine (IOM) defines clinical practice guidelines as "statements that include recommendations, intended to optimize patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options."

A Meta-analysis takes a systematic review one step further by combining all the results using accepted statistical methodology.

Systematic Reviews usually focuses on a specific clinical question and conducts an extensive literature search to identify studies with sound methodology. The studies are reviewed, assessed, and the results summarized according to the predetermined criteria of the review question.

Randomized, controlled clinical trials. A prospective, analytical, experimental study using primary data generated in the clinical environment. Individuals similar at the beginning are randomly allocated to two or more groups (treatment and control) and the outcomes of the groups are compared after sufficient follow-up time.

A study that shows the efficacy of a diagnostic test is called a prospective, blind comparison to a gold standard study. This is a controlled trial that looks at patients with varying degrees of an illness and administers both diagnostic tests -- the test under investigation and the "gold standard" test -- to all of the patients in the study.

Cohort studies identify a large population who already has a specific exposure or treatment, follows them over time (prospective), and compares outcomes with another group that has not been affected by the exposure or treatment being studied. Cohort studies are observational and not as reliable as randomized controlled studies, since the two groups may differ in ways other than in the variable under study.

Case control studies are studies in which patients who already have a specific condition or outcome are compared with people who do not. Researchers look back in time (retrospective) to identify possible exposures. They often rely on medical records and patient recall for data collection. These types of studies are often less reliable than randomized controlled trials and cohort studies because showing a statistical relationship does not mean than one factor necessarily caused the other.

Case series and Case reports consist of collections of reports on the treatment of individual patients or a report on a single patient. Because they are reports of cases and use no control groups with which to compare outcomes, they have no statistical validity.

From Duke University Medical Center Library | December 2005