Best Evidence Topics BETs

Questions in clinical practice n What is the best treatment for…..? n How sure is the diagnosis of……? n What is the prognosis for……..? n Is this likely to be harmful…….? n How does this affect my patient’s life…? n etc.

But….. n Difficult to get ‘quick’ answers due to.. n Time n ‘Know how’ n Resources N.B. ‘quick’ does not mean cheap & nasty

What is a BET ? n Emergency Medicine Department n Manchester Royal Infirmary 1996 n Started from a modified CAT n Can be ‘best available’ evidence rather than ‘highest quality’ –(problem in physiotherapy & EmerMed) n Systematic approach to answering ‘real world’ clinical questions n Pragmatic systematic review n Clinical answers to clinical problems n > 800 BET questions

BET structure n The clinical scenario n The 3 part question n The literature search n The critical appraisal n The summary ( in a table) n The Comment n The ‘clinical bottom line’

Ask the right question n Focus on a real clinical scenario n Pull out the key features from the scenario. n Formulate the 3 part question.

Why develop a 3 part question? n To focus the problem. n To help define & formulate searching.

Clinical scenario A 29 year old patient presents with a 3 month history of supraspinatus tendonitis. You are planning to use some form of electrotherapy but the patient mentions that he had laser for a similar problem in his tendo Achilles that seemed to help. You wonder if this will apply to a tendon in another part of the body.

What is the general question? n Can adult tendonitis be helped by Laser?

What is the patient group? n Adults? n Chronic Tendinitis?

Is there a comparison? n Laser? n Other electrotherapy? n Other therapy? n Nothing or not relevant?

What are the outcomes? n Less pain? n Better function? n Quicker recovery time? n Success rate? n Cost??????

The 3 part question. n IN [adults with chronic tendonitis] n IS [laser beneficial] n AT [decreasing pain and improving function] N.B. Therefore, this is not a systematic review on Laser

What is the patient group? n All Adults? n Chronic Tendinitis? – –Good: Adults with 2 month history of supraspinatus tendonitis – –Not so good: Patients with shoulder pain (too broad. Too much evidence) – –Worse: Manc men aged with a calcified supraspinatus tendon on X- Ray due to repetitive javelin throwing (too narrow.Relevant but no evidence!!)

The Intervention i.e what are we going to do to our patient group? diagnostic questions –Gold standard against new technique n prognostic questions nprognostic questions –Define a factor that may affect the outcome n therapeutic questions ntherapeutic questions –compare treatments?

A diagnostic question n Is MR scanning better than U/S scanning at diagnosis supraspinatus tendonitis? nIs MR scanning better than U/S scanning at diagnosis supraspinatus tendonitis?

A prognostic question n The ‘empty can’ test as a prognostic test in supraspinatus tendonitis ? nThe ‘empty can’ test as a prognostic test in supraspinatus tendonitis ?

A therapeutic question Usually the case for physiotherapy BETs n Laser compared to nothing (or not relevant) n Other electrotherapy? n Other therapy?

What are the outcomes? Often problematic n Clinically relevant nClinically relevant n Patient orientated nPatient orientated n Definable nDefinable n Measurable nMeasurable n May be several for 1 intervention nMay be several for 1 intervention –Less pain? –Better function? n RoM, strength, etc –Quicker recovery time? –Cost?

The 3 part question PAdult chronic tendonitis I1Laser I2Nothing (? Other electrotherapy) OPainDysfunction

Using the 3 part question for searching. A patient group Intervention 1 An outcome Intervention 2 (Not always present or necessary)

Using the 3 part question for searching. Patient group Disease Age Gender Intervention What Action / treatment you are considering Outcome What are you looking to achieve Pain / function Or BP, HR, LA, Life etc in Em.Med

Using the 3 part question for searching. Tendonitis Tendinosis Tendinopathy we want all these papers OR supraspinatus tendonitis OR

Using the 3 part question for searching Laser therapy Low level Laser we want all these papers OR LLLT OR

Using the 3 part question for searching. ALL Tendonitis papers ALL Laser papers we want JUST these papers AND

ALL Tendonitis papers ALL Laser papers JUST these papers NOT

Summary so far.. n Focused questions are answerable questions. n Questions should be based on a clinical scenario. n The 3 part question should be used to help develop a search strategy.

Search Strategy n As comprehensive as possible –Tip: go broad then narrow down n As many databases as possible –Medline –CINAHL –AMED –EMBASE –SPORTDiscus –Cochrane –PEDro n Beware of only using ‘PubMed’ !!

Search Strategy n Medline, CINAHL, AMED, SPORTDiscus, EMBASE: [{(exp tendonitis OR tendinosis.mp OR tendinopathy.mp)} OR “supraspinatus tendonitis”.mp] AND [(low level laser.mp OR low level laser therapy.mp OR laser therapy.mp OR therapeutic laser.mp). LIMIT to human AND English language. n In addition the Cochrane database and PEDro database were also searched

Search Strategy RESULTS n 5 papers including 1 systematic review were found. A further paper was also found in conference proceedings via a personal communication making a total of 7 papers. n Of the 6, one was a commentary on the systematic review. The conference proceedings paper was laser therapy to shoulder trigger points, not tendonitis and so was considered irrelevant. All the papers found predated the systematic review so this is presented in the table only

Summarise the papers n CRITICAL APPRAISAL IS KEY –BETs is not a short cut to proper CAT!! n What are the key points? n If someone read this would they know what was done in appraisal? n Describe the exact numbers & p values n Concentrate on the issue at hand –IS it relevant to 3 part Question? n List any weaknesses in papers

Search Strategy

Comments n What does the evidence tell us? n Is it applicable to my 3 part question? n Is it applicable to my clinical practice? n Have the authors missed something? n Is further research needed?

Comments n “The systematic review is the most recent paper concerning low level laser therapy on tendinopathy and seems to favour its use over placebo in decreasing the pain associated with tendonitis. It comments that the use of laser therapy is dependent on power density and dose applied and the pooled mean effects will alter when studies do not meet optimal irradiation doses.”

The Clinical Bottom Line One sentence statementOne sentence statement n The next patient you see today… n What are you going to do? n Has the BET given you enough evidence to change your practice?

The Clinical Bottom Line “Laser therapy is superior to placebo in reducing pain of chronic tendinopathy by about 32%.”

Your turn!!! nAnAnAnA 30 year old female patient presents with a 7 day history of patellar tendonitis. You think of treating her with oral NSAIDs. However, recently you have seen some information about NSAIDs in a gel form. This seems an appealing alternative and you wonder if there is any evidence of its efficacy. nQnQnQnQuestions –P–P–P–Patient group ? –T–T–T–Treatment / interventions ? –O–O–O–Outcome ?

The 3 part question n IN [Adults with acute tendonitis] n n IS [topical or oral NSAIDs] n BETTER AT [reducing pain and improving function]

Using the 3 part question for searching. Patient group Adults tendonitis Intervention 1 Oral NSAIDs Outcome Pain / function Intervention 2 Topical NSAIDs (gel)

PAdultTendonitis I1 Oral NSAIDs I2 Topical NSAIDs OPainFunction

Your turn again!!! n A middle aged lady is receiving physiotherapy for her OA knee. She mentions that her husband has heard that Glucosamine tablets are great for arthritis and is thinking of buying some from a health-food shop. She asks what you think about them. Before imparting wise words, you decide to check the evidence first. n Questions –Patient group ? –Treatment / interventions ? –Outcome ?

The 3 part question n IN [adults with OA knee] n DO [glucosamine tablets] n n IMPROVE [pain and function]

Using the 3 part question for searching. Patient group Adults OA knee Intervention 1 Glucosamine tablets Outcome Pain / function

PAdultOA I1 Glucosamine tablets I2(none) OPainFunction

And again…! n A 65 year old lady has had a total knee replacement for osteoarthritis. She has had an uneventful post op recovery and, as per protocol, has an appointment for outpatient physiotherapy. With the pressure on appointments you wonder whether instruction on a home exercise programme will be just as effective as outpatient physiotherapy at improving function and range of knee flexion.

3 PART QUESTION: n IN [Adults following TKR] n IS [a home exercise programme better than an outpatient programme] n AT IMPROVING [RoM and function]

Using the 3 part question for searching. Patient group Adults Post TKR Intervention 1 Outpatient physio Outcome RoM / function Intervention 2 Home physio

PAdult Post TKR I1 Outpatient physiotherapy I2 Home physiotherapy ORoMFunction

What next? n Don’t keep it yourself n Get it on the web

You decide to do a BET Find a scenario Formulate a 3 part QGet it checked Do a searchGet it checked Get the papers Critically Appraise Complete the BET One week 1-12 weeks GET IT CHECKED

Summary n The BET is the best way to put all your work together n The BET can be used to change practice n The BET can improve journal clubs