Evidence Base Practice in Physical Therapy

Mohammed T A, Omar , Ph.D.PTMohammed T A, Omar , Ph.D.PT , ,

Momarar@ksu.edu.saDr.taher_M@yahoo.com

05421154040542115404

Assessment as a Core Part of the Therapy ProcessImpact of Health and Social Care policy on Assessment PracticeDemand for Evidence-Based Practice

•What Is Evidence-Based Medicine?•What Is Evidence-Based Practice?•Implementation of Evidence-Based Practice in geriatric assessment •How Do You Track Down the Best Evidence?•Levels of Evidence and Grades of Recommendations

Lecture outline

Assessment as a Core Part of the Therapy Process

Evaluation of the service provided

Provision of the service

identification of what service needs to be

provided

Needs analysis of the client

identification of the provider of the service

Impact of Health & Social Care policy on Assessment Practice

Cost-Effective Health Care

Clinically Effective Health Care

Health & Social Care policy

Impact of Health & Social Care policy on Assessment Practice

This is forcing rehabilitation professionals to be able to prove the efficacy and efficiency of their interventions that focuses on;Quality, National Standards, Best Value And Evidence-based Practice (EBP), Demonstrate Service Outcomes

Stokes and O’Neill (1999) state that ‘clinical effectiveness, evidence-based practice, outcome measures and clinical audit are the “buzz words” of today’s researcher and practitioner. They are the markers of an aspiration for accountability, productivity and objectivity within the provision of health care’

Evidence-Based Physiotherapy: History

Since the early 1990's, following the rise of EBM (Evidence-based Medicine), the concept of evidence-based practice has been associated with physical therapy.

The first publication on this topic came out of the Department of Epidemiology at the University of Maatricht, Netherlands.

Today, the major study center is the Centre for Evidence-Based Physiotherapy based in the School of Physiotherapy at the University of Sydney, Australia.

Evidence-Based Physiotherapy

Evidence-Based Physical Therapy (EB-PT) has developed from moving toward evidence-based medicine.

The EB-PT has been defined as   "Physiotherapy informed by relevant high quality clinical research"

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Evidence-based practice (EBP) is the integration of the best research evidence, clinical expertise, and the patient’s values and circumstances.

Evidence-Based Practice

This means that EBP ‘requires a combination of art and science’

Why Practice EB-PT Important? The World Confederation of Physical Therapy (WCPT) describes the

rationale for evidence based physiotherapy and asserts that undertaking evidence based physiotherapy helps therapists to:

Improve the care of patients, and communitiesReduce variations in practiceUse evidence from high quality research to inform practice, balancing known benefits and risksChallenge views based on beliefs rather than evidenceMake decision making more transparentIntegrate patient preferences into decision-makingEnsure that knowledge continues to inform practice through life-long learning’

Evidence-Based PracticeEvidence-Based Practice

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Implementation of Evidence-based Practice

strategies that have been suggested for supporting EBP in clinical environments include

Fostering a supportive environment in the workplace for EBPProviding continuing education to develop skills in literature searching, critical appraisaland research methodsCollaborating/participating in research evaluating therapy interventionsParticipating in or establishing a journal clubFocusing on reading research articles that have a rigorous study design or reviews that have been critically appraisedSeeking out evidence-based clinical guidelines.

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Evidence-based practice (EBP) is the integration of the best research evidence, clinical expertise, and the patient’s values and circumstances.

General Introduction: Evidence-Based Practice

This means that EBP ‘requires a combination of art and science’

A process whereby research evidence, clinical knowledge and reasoning are used to make decisions about interventions that are effective for a specific client(s)

Ask: Formulate a clearly-stated, answerable question

Background Questions: ask for general knowledge about a disorder and contain two essential components. These are: A question root (who, what, where, when, how, why, 5W+IH)) A condition, test, treatment, or other health care concernTwo examples of background questions are: What causes fall ? When do complications of CABG usually occur?

EBP uses the PICO model for formulating a clinical question: P= Patient and / or Problem I= Intervention or exposure C= Comparison O= Outcome

Ask: Formulate a clearly-stated, answerable question

Question Type: Categorization is useful for writing the question and statistical analysis

• Therapy(treatment): Evaluates the effects of various treatments or interventions• Harm (not frequently investigate in PT literature): •Evaluates the effects of various treatments or modalities on function, morbidity, mortality• Diagnosis: Evaluates a tool or test’s ability to distinguish among certain conditions• Prognosis: Evaluates the course of a certain condition

Ask: Formulate a clearly-stated, answerable question

An example of a PICO question is:

1-In an older patient with X disorder, is giving Y treatment rather than Z treatment more likely to result in a shorter stay in hospital?

In older adult with rheumatoid arthritis is educational program about joint protection effective in reducing joint pain and improving function?

What evidence is there for the validity and relevance of the Barthel Index vs. the COPM as an assessment of performance for older adults who have a physical disability?

Are self management strategies more effective than medical care alone for improving health status, quality of life and function amongst adults with coronary heart disease?

Acquire: Obtain the Evidence with Searches

Where to find the research evidence, once the foreground question is developed?

•More experienced colleagues •Textbooks • Internet/World Wide Web• Specific Journal Subscriptions• Internet Sources for Medical Information

Acquire: Obtain the Evidence with Searches

Internet/World Wide Web

There are many Web-based sources from which to obtain clinical research. A few evidence-based sites are:

1. Cochrane Database of Systematic Reviews 2. TRIP database (Turning Research into Practice)3. PEDro (Physiotherapy Evidence resource)4. Current clinical trials at www.clinicaltrials.gov. 5. Medline/PubMed (www.ncbi.nlm.nih.gov/entrez/query.fcgi) 6. Medline Plus(www.nlm.nih.gov/medlineplus/healthtopics.html), 7. Ovid (www.ovid.com), which provides a searchable database of

medical, scientific, and academic research information. 8. CINAHL

Appraise : Obtain the Evidence with Searches

Appraise: Levels Of Evidence And Grades Of Recommendations

Level sDescription

Level Isystematic review of multiple well-designed randomized controlled trials (RCTs); the term meta-analysis is used to describe quantitative approaches to synthesizing evidence from multiple RCTs

Level IIone properly designed RCT of appropriate size

Level IIIwell-designed trials without randomization single group pre- and post-cohort, time series or matched control studies

Level IVwell-designed non-experimental studies from more than one centre or research group

Level Vopinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees

Appraise: Levels Of Evidence And Grades Of Recommendations

Evaluation criteria are : 1. Credibility (Internal Validity) 2. Transferability (External Validity)/Applicability 3. Dependability (Reliability(4. Conformability (Objectivity(

There are three basic questions that need to be answered for every type of study: 1-Are the results of the study valid? 2-What are the results? 3-Will the results help in caring for my patient?

Apply: Into clinical Practice

The next step is to consider your own clinical experience and judgment and that of your colleagues. Now combine the research evidence, your clinical expertise, and the individual patient’s situation and formulate your answer as to how to best perform (or, in some instances, not perform) the intervention for your patient.

Remember The fact that an article or research study has been published does not necessarily mean that it is valid or reliable, or applicable to your clinical practice.

Appraise : Evaluate performance

Ask yourself: Did you ask an answerable clinical question? Did you find the best external evidence? Did you critically appraise the evidence and evaluate it for its

validity and potential usefulness? Did you integrate critical appraisal of the best available external

evidence from systematic research with individual clinical expertise in personal daily clinical practice?

Appraise : Evaluate performance

After the intervention has been completed, evaluate your performance, consider:

The client’s outcomesCost effectivenessClient satisfactionTherapist satisfaction

Appraise : Evaluate performance

After the intervention has been completed, evaluate your performance.

1. Was my question answerable? 2. Was my question stated explicitly enough to help me in my search for the

evidence? 3. Did I search the right sources for the evidence or was there somewhere

else I should have looked? 4. Did I manage to find sound evidence quickly and efficiently? 4. Did I appraise the evidence effectively? 5. Do I need to improve my critical appraisal skills6. Were you pleased with your decision? 7. Did the use of evidence-based practice help? 8. Did the patient benefit from the intervention? 9. Did you find a way of more effectively locating the information? 10. You may even want to start your own database of effective

interventions!

Use of EBP in Geriatric Physical Therapy

Concerns selection of ◦ Appropriate tests & measures / examination procedures◦ Interventions◦ Methods of assessing patient outcomes

Provide objective information Are appropriate for the patient population Are based on quality evidence

◦Reliability, validity, sensitivity, specificity

Evidence based practice is all about having a questioning approach to your work. It is not a 'one off'. It is a continuous process to both provide the best quality care for your patients and develop you as a therapist , personally and professionally.