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Introduction to BC RSRnet and Evidence- Based Practice. How do I get the best information quickly? Step… Hoens, Alison; Beck, Charlotte Nov 15, 2006

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EBP STEP 1: Asking the question and Acquiring the evidence Alison M. Hoens Clinical Assistant Professor, UBC Clinical Coordinator, PHC Charlotte Beck Librarian, UBC  YEARS SINCE GRADUATION  80  70  60  50  40  30  20  10  0 Series1  0 to 5  6 to 11  35  58  12 to 17  18 to 23  24+  32  37  72  Years since graduation  HIGHEST QUALIFICATION  180  160  140  120  100  80  60  40  20  0 Number  BSc  MSc  PhD  Other  161  32  8  32  PRIMARY ROLE  250  200  150  100  50  0 Number  Clinical  Academic  Research  Administration  205  16  24  40  Primary role  EBP - THE PROCESS Clinical Problem Act Ask Apply Acquire Appraise  EBP - WHAT IS IT? • Evidence-Based Practice: • “The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual pts” ¾ Sackett, 1996 BMJ 312, 71-72.  • “The integration of best research evidence with clinical expertise and patient values” ¾ Sackett, 2000 Evidence-Based Medicine. How to Practice and Teach EBM. 2nd Ed. Churchill Livingtone  EBP • 20,000 biomedical journals worldwide • 6 million articles published per year! • OT: >365 articles published per year • To keep up - 1 article per day • If 1 per week - after 1 year, ~ 6 yrs behind! • PT: >1,400 articles published per year ƒ Paul Stratford, 2003  EBP • What are the barriers to EBP in clinical practice?  BARRIERS TO EBP • Stevenson, T et al. (2005). Influences on Treatment Choices in Stroke Rehabilitation: Survey of Canadian Physiotherapists. Physiotherapy Canada.  • Ranking of importance of factors influencing current practice: • • • • • •  Experience Continuing education (practical) Colleague Influence Continuing Education (theory) Professional Literature * secondary sources Entry Level Training  BARRIERS TO EBP • Mikhail et al, 2005: Physical Therapists’ use of interventions with high evidence of effectiveness in the management of a hypothetical typical patient with acute LBP  • 68% of PTs used interventions with strong or mod evidence of effectiveness • 90% used interventions with limited evidence • 96% used interventions with absence of evidence of effectiveness  BARRIERS TO EBP • Lack of time, computing resources, not enough evidence, lack of access; lack of skills for searching, appraising, and interpreting; lack of incentives (Bennett S. et al, 2003. Australian OT Journal, 50, 13-22.)  • Relevant literature not compiled all in one place (Closs & Lewin, 1998. Br J of Therapy & Rehab, 5, 151155).  • Publication bias, indexing issues, language issues, assessing internal validity, access to electronic databases, access to full text, assessing applicability, drawing conclusions (Maher. C. et al. Phys Ther, 84: 645-654).  BARRIERS TO EBP • I had considerable freedom of clinical choice of therapy: my trouble was that I did not know which to use and when. I would gladly have sacrificed my freedom for a little knowledge. • Sir Archie Cochrane. Effectiveness and Efficiency: Random Reflections on Health Services  BARRIERS TO EBP • “Upon this gifted age, in its dark hour, Rains from the sky a meteoric shower of facts. They lie unquestioned, uncombined. Wisdom enough to leech us of our ill is daily spun, but there exists no loom to weave it into fabric” • Millay’s Sonnets BMJ, 1997  HIERARCHY OF EVIDENCE  GRANDAGE KK, SLAWSON DC, SHAUGHNESSY AF. When less is more: a practical approach to searching for evidence-based answers. 2002 July;90(3):298-304.  ASK • The Clinical Question • Covell, DG et al. Ann Intern Med, 103(4), 596-9, 1985 • - 40% background, 45% foreground, 15% nonmedical  ASK • BACKGROUND • General knowledge • What, where, when, why, how • Best answered with general reference  • FOREGROUND • Very specific re patient care • All clinical questions eg. Therapy, harm, prognosis • Defines search strategy  ASK  FOREGROUND  BACKGROUND  Experience  ASK • Foreground Questions • • • • •  PICO P - Patient/Problem I - Intervention C - Comparison O - Outcome  ASK • Why PICO? • Improves retrieval • Cabell, J Gen Intern Med 16(12), 838-44, 2001: One simple education session markedly increased resident searching activity  Pop’n  Interv’n Compare Outcome  ACQUIRE • Example: • Question - Is TENS effective in the management of Chronic Low Back Pain in Adults? • P - adults (18-65), chronic (>6 months) LBP • I - TENS • C - no TENS, sham TENS • O - pain, ROM, function, RTW  ASK • Group activity • Divide into groups • OT ¾ Seating, dysphagia etc  • PT ¾ Orthopaedics, neuro etc  • Each group develop a PICO statement for a clinical issue for which you would like to do a literature search  ACQUIRE • Best resource depends on type of question • Background vs foreground  • Efficiency: • Clinicians ideal ~2 minutes • Medline: can take ~ 30 minutes  HIERARCHY OF EVIDENCE  GRANDAGE KK, SLAWSON DC, SHAUGHNESSY AF. When less is more: a practical approach to searching for evidence-based answers. 2002 July;90(3):298-304.  ACQUIRE • Background Questions: • Textbooks • Review Articles • EBM textbooks: online eg. Clinical Evidence • MD Consult  ACQUIRE • Foreground Questions • Pre-appraised • PEDro, OT seeker • ACP Journal Club • Cochrane • DARE • EBM Reviews - Cochrane, DARE, ACP • Databases with filters  ACQUIRE • Other Databases - not preappraised • MEDLINE • PubMed • EMBASE • CINAHL • SUMsearch  ACQUIRE • Search engines • • • •  Google Google Scholar Dogpile *PABC Physioengine http://weblogs.elearning.ubc.ca/physio  ACQUIRE APPRAISAL CRITERIA • Author • Scholarly or peer reviewed • Accuracy • Currency • Objectivity • Coverage • Purpose  ACQUIRE DATABASE TOOLS • Using the computer’s language • Manipulating the results • Getting alerts  ACQUIRE • 1. PICO - decide on all concepts • 2. Build one concept at a time • 3. Combine with OR (Boolean operator *gathers) • 4. Combine concepts to find relationships with AND (Boolean operator *refining, cutting down) • 5. Consider ‘Limits’  ACQUIRE Building the search strategy • Identify concepts from PICO • Decide on words • 2 methods: keywords or classification  ACQUIRE • KEYWORDS • • • • • •  Character recognition Not conceptual Computers Get what you put in Need to think! Eg. Stroke • Not strokes • Not CVA • Not CVAs  • Use truncation / wildcards  • CLASSIFICATION Filing system Conceptual Human Beings Preferred term Thesaurus MESH (Medical Subject Headings) • Eg. Cerebrovascular accident • • • • •  Truncation/Wildcards • Different symbols – often * or $ • Saves on typing e.g communic$ for communicate, communication, communicative etc. • Includes plurals e.g Child* for children • But use with care – child* also includes childBIRTH! • Variant spellings included with wildcard e.g. p*ediatrics will include paediatrics  ACQUIRE Building the search strategy: 1. Search one concept at a time 2. Combine with OR (Boolean operator *gathers like concepts) 3. Combine concepts to find relationships with AND (Boolean operator *refining, cutting down)  ACQUIRE • Boolean Operators • AND • OR • NOT  BOOLEAN LOGIC:  AND  BOOLEAN LOGIC:  OR  ACQUIRE • Group Activity • Meet with your groups that you developed your PICO question • Add to your PICO question using Boolean operators and keywords/MESH terms  ACQUIRE HIERARCHY OF EVIDENCE • • • • • • •  Meta-analysis Systematic reviews Clinical Practice Guidelines Randomized Controlled Trials Cohort Studies Case-controlled Studies Case studies Cormack (2002)  ACQUIRE METAANALYSIS VS SYSTEMATIC REVIEW •  META ANALYSIS • Locate clinical trials • Criteria: RCT • Rank: Methodological Score • Similar outcome measures • Variable Rx protocols • Pool results • Statistical analysis • ?Significant effect • Houghton, 2004 Electrotherapy Update, CPA Teleconference, May 2004  •  SYSTEMATIC REVIEWS • Locate clinical trials • Criteria: RCT • Rank: Methodological score • Variable outcomes • Organized based on Rx protocols • Blinded reviewers (+/- or ?) • No statistics (#/+/-)  ACQUIRE • • • •  Randomized Controlled Trial Cohort study Case control study Case study  ACQUIRE Building the search strategy Contd. • LIMITS • • • •  Study design *hierarchy Language eg. english Age groupings Year of publication  ACQUIRE • Group Activity • Meet with your groups that you developed your PICO question • Add your PICO question using limits  ACQUIRE SUMSearch • Search for:TENS AND CHRONIC BACK PAIN • •  Reviews/Editorials Selected journals at PubMed  • •  Practice Guidelines (some guidelines are systematic reviews) National Guideline Clearinghouse™ 3 documents.  • • •  Systematic reviews (what is so good about systematic reviews?) 2 documents. DARE (includes Cochrane abstracts) PubMed (possible systematic reviews) 15 documents.  • •  Original research PubMed (2 searches)  0 documents.  41 documents.  ACQUIRE •  PEDro: TENS and Chronic Back Pain  • •  Author/Association: Melzack R, Vetere P, Finch L Title: Transcutaneous electrical nerve stimulation for low back pain. A comparison of TENS and massage for pain and range of motion. Source: Physical Therapy 1983 Apr;63(4):489-93 Method: clinical trial Method Score: 7/10 [Eligibility criteria: No; Random allocation: Yes; Concealed allocation: Yes; Baseline comparability: Yes; Blind assessors: Yes; Blind subjects: No; Blind therapists: No; Adequate follow-up: Yes; Intention-to-treat analysis: No; Between-group comparisons: Yes; Point estimates and variability: Yes. Note: Eligibility criteria item does not contribute to total score] *This score has been confirmed*  • • •  ACQUIRE •  ACP Journal Club Evidence-Based Medicine: TENS and Chronic Back Pain  • • • •  -----------------------------------------------------------------------Volume 2 Jul-Aug 1997 p 107 -----------------------------------------------------------------------Review: Transcutaneous electrical nerve stimulation reduces pain and improves range of movement in chronic low-back pain Objective: To evaluate the effectiveness of transcutaneous electrical nerve stimulation (TENS) in reducing pain and improving range of movement in patients with chronic low-back pain.  •  •  Data sources: English-language studies were identified by searching EMBASE (1985 to September 1995), MEDLINE (1966 to October 1996), CISCOM, and AMED (from the start of the database to January 1995) using the terms TENS, ALTENS, TNS, transcutaneous electrical neurostimulation, electroacupuncture, peripheral conditioning stimulation, percutaneous neural stimulation, microamperage electrical stimulation, cranial electrotherapy stimulation, and transabdominal neurostimulation. Additional studies were identified by scanning the bibliographies of retrieved articles, searching books and abstracts from pain conferences, and contacting experts.  ACQUIRE •  Study selection: Studies were selected if they were randomised controlled trials comparing TENS or acupuncture-like transcutaneous electrical nerve stimulation (ALTENS) with placebo in patients with low-back pain of >= 8 weeks of duration.  •  Data extraction: Data were extracted on pain reduction, range of movement, functional status, return to work, and side effects.  •  Main results: 68 studies were identified; 6 (4 evaluating TENS and 2 evaluating ALTENS) met the selection criteria and involved 288 patients. More patients receiving TENS or ALTENS had reduced pain than those receiving placebo {P = 0.005}* (Table). More patients receiving ALTENS had improvement in range of movement than those receiving placebo {P = 0.001}* (Table). Insufficient data were available on TENS treatment alone to evaluate range of movement, functional status, and return to work. Insufficient data were available on ALTENS treatment alone to evaluate functional status and return to work. The use of TENS or ALTENS was relatively free from side effects.  •  Conclusion: TENS and ALTENS reduce pain, and ALTENS improves range of movement in patients with chronic low-back pain. ------------------------------------------------------------------------  •  ACQUIRE •  Commentary  •  Given the socioeconomic importance of low-back pain, it is a matter of urgency to find a treatment that really works. TENS or ALTENS is often used for this condition, but their effectiveness remains uncertain. This methodologically rigorous systematic review by Gadsby and Flowerdew suggests that TENS or ALTENS is superior to placebo in relieving pain and restoring function. Although this result looks straightforward at first glance, its practical implications are probably not. One concern is that the effect size is not large and therefore may seem unconvincing to clinicians. This fact is compounded by the paucity of studies included in the final analysis. Even these few studies do not contain homogeneous groups of patients: Many of those included could be classified as having failed back surgery syndromes, and most had nonspecific low-back pain (which in itself is hardly a well-defined disease entity). … may be of limited use to those who routinely treat patients with low-back pain. The authors do not comment on some of the discrepancies between their findings and the results of other systematic reviews on the subject, thus leaving the reader uncertain as to whether this intervention actually works.  •  Edzard Ernst, MD, PhD University of Exete  ACQUIRE •  PUBMED - CHRONIC BACK PAIN AND TENS  •  Limits: All Adult: 19+ years, English, Human  •  1: Yokoyama M, Sun X, Oku S, Taga N, Sato K, Mizobuchi S, Takahashi T, Morita K. Related Articles, Links Comparison of percutaneous electrical nerve stimulation with transcutaneous electrical nerve stimulation for long-term pain relief in patients with chronic low back pain. Anesth Analg. 2004 Jun;98(6):1552-6, table of contents. 4: Rakel B, Barr JO. Related Articles, Links Physical modalities in chronic pain management. Nurs Clin North Am. 2003 Sep;38(3):477-94. Review. PMID: 14567204 [PubMed - indexed for MEDLINE] 6: Tsukayama H, Yamashita H, Amagai H, Tanno Y. Randomised controlled trial comparing the effectiveness of electroacupuncture and TENS for low back pain: a preliminary study for a pragmatic trial. Acupunct Med. 2002 Dec;20(4):175-80.  •  • • • • • • • •  ACQUIRE • • •  MESH - CHRONIC BACK PAIN  • •  1: Back Pain Links Acute or chronic pain located in the posterior regions of the THORAX; LUMBOSACRAL REGION; or the adjacent regions. Year introduced: 1993  •  • •  •  Suggestions: Lower back pains; Lower back pain; Back pain, lower; Back pains, lower; Back pains, low; Low back pains; Back pain, low; Pain, lower back; Pains, lower back; Chromosome painting; more...  2: Low Back Pain Links Acute or chronic pain in the lumbar or sacral regions, which may be associated with musculo-ligamentous SPRAINS AND STRAINS; INTERVERTEBRAL DISK DISPLACEMENT; and other conditions. Year introduced: 1993  ACQUIRE •  COCHRANE REVIEWS: CHRONIC BACK PAIN AND TENS  •  Schonstein, E. Kenny, DT. Keating, J. Koes, BW. Work conditioning, work hardening and functional restoration for workers with back and neck pain. [Systematic Review] Cochrane Back Group Cochrane Database of Systematic Reviews. 3, 2004.  •  2. Carroll, D. Moore, RA. McQuay, HJ. Fairman, F. Tramer, M. Leijon, G. Transcutaneous electrical nerve stimulation (TENS) for chronic pain. [Systematic Review] Cochrane Pain, Palliative Care and Supportive Care Group Cochrane Database of Systematic Reviews. 3, 2004.  ACQUIRE • Setting up alerts  ACQUIRE GETTING FULLTEXT • Pubmed • Google Scholar • CINAHL with fulltext • Hospital Library services  FAMILIARITY/CONFIDENCE WITH USING SEARCH TECHNIQUES 70  60  50  40 Keywords vs MESH Terms Boolean Operators Limits  30  Setting up alerts 20  10  0 Not at all  Limited Average Above average LEVEL OF FAMILIARITY/CONFIDENCE  Very  vs Se co n da ry  so ur c Bl es Ra nd ind in o g Co mi nt zat Co am ion in -i a nt er tion ve n Re tio lia n bi lit Sa Va y m pl lid e ity si ze Po ca w e l c Ra ul r a nd Ca ti om se on C iz ed oh stu Co ort dy s Sy nt ro tud st y em lle at d tr ic ia Re l M et a- vie an w al Co ys nf id p- is Re enc va lu e la e in tiv t e e U rv Fa Ri se al s U i l k of Re -s se R M gr afe at of c Sy Ma ess nu io io s st m n em ter be E Cr qu r at it ic at io Re ica n vi l R ew ev U se Ch iew of e PE ck li D ro st sc al e  Pr im ar y  FAMILIARITY/CONFIDENCE WITH TERMS  9  8  7  6  5  4  3  2  1  0  TERM  THE BOTTOM LINE …………..  Ahoens@providencehealth.bc.ca  


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