Evidence Base Practice in Physical Therapy Mohammed T A, Omar , Ph.D.PT, Momarar@ksu.edu.sa Dr.taher_M@yahoo.com 0542115404

Lecture outline Assessment as a Core Part of the Therapy Process Impact of Health and Social Care policy on Assessment Practice Demand 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

Assessment as a Core Part of the Therapy Process Needs analysis of the client identification of what service needs to be provided Evaluation of the service provided Assessment is the first step in the health care process and provides the foundation for effective treatment. Assessment occurs again at the end of the health care process in the form of evaluation. It is also necessary to undertake a re-assessment at several stages during stage four of the process, service provision, because without thorough and accurate assessment the intervention selected may prove inappropriate and/or ineffective. Provision of the service identification of the provider of the service

Impact of Health & Social Care policy on Assessment Practice Cost-Effective Health Care Clinically Effective Health Care The practice of EB-PT really comes from making the "cost effectiveness of physiotherapeutic intervention in comparison with other ... treatment, or no treatment at all" make clinical sense. Another reason for the existence of EB-PT, is because it is "the best strategy clinicians can use to cope with uncertainty of modern clinical practice, and to meet the ethical imperative of providing the best possible care for our patients”. Every individual providing an physical therapy service has a responsibility to maintain and improve effectiveness and efficiency through the use of outcomes measures and audit. Physical therapists should employ a range of quality activities including: evidence-based practice, adherence to national and professional standards and guidelines, risk-management, continuing professional development and listening to the views of those who use the service.

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’ The practice of EB-PT really comes from making the "cost effectiveness of physiotherapeutic intervention in comparison with other ... treatment, or no treatment at all" make clinical sense. Another reason for the existence of EB-PT, is because it is "the best strategy clinicians can use to cope with uncertainty of modern clinical practice, and to meet the ethical imperative of providing the best possible care for our patients”. Every individual providing an physical therapy service has a responsibility to maintain and improve effectiveness and efficiency through the use of outcomes measures and audit. Physical therapists should employ a range of quality activities including: evidence-based practice, adherence to national and professional standards and guidelines, risk-management, continuing professional development and listening to the views of those who use the service. measuring service outcomes is important in facilitating mutual goal setting, increasing the focus of therapy on the client, monitoring client progress, as well as demonstrating that therapy is valuable

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"

Evidence-Based Practice Evidence-based practice (EBP) is the integration of the best research evidence, clinical expertise, and the patient’s values and circumstances. Best Research Evidence: valid and clinically relevant research with a focus on patient-centered clinical research Clinical Expertise: use of clinical skills and experiences Patient’s Values and Circumstances: the patient’s unique preferences, concerns, and expectations in his or her setting 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 communities Reduce variations in practice Use evidence from high quality research to inform practice, balancing known benefits and risks Challenge views based on beliefs rather than evidence Make decision making more transparent Integrate patient preferences into decision-making Ensure that knowledge continues to inform practice through life-long learning’ EBP is important for patient, physiotherapists and profession and founders of physiotherapy services

Evidence-Based Practice Opinion-based Based on opinions among experts Implicit Individual preferences & interpretations Authority based (static and non-critically accepted Evidence-based High quality clinical research Patient preferences (client’s beliefs and values). Practice knowledge (clinical experience). Evidence alone is never sufficient to make a clinical decision” Consider risks and benefits, costs, inconvenience, alternative treatment strategies, patient preferences/values & circumstances. “EBM posits a hierarchy of evidence to guide clinical decision making” Not all research is equal in terms of relevance and statistical support, however, that does not mean lower level evidence is not worthwhile.  

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 EBP Providing continuing education to develop skills in literature searching, critical appraisal and research methods Collaborating/participating in research evaluating therapy interventions Participating in or establishing a journal club Focusing on reading research articles that have a rigorous study design or reviews that have been critically appraised Seeking out evidence-based clinical guidelines. In busy clinical settings, implementing EBP may be difficult. There are many potential barrier to the full implementation of EBP, including lack of time, lack of access to literature and lack of skills in finding and interpreting research.

General Introduction: Evidence-Based Practice Evidence-based practice (EBP) is the integration of the best research evidence, clinical expertise, and the patient’s values and circumstances. A process whereby research evidence, clinical knowledge and reasoning are used to make decisions about interventions that are effective for a specific client(s) EBP is not about conducting research it is about USING RESEARCH research Evidence: valid and clinically relevant research with a focus on patient-centered clinical research Clinical Expertise: use of clinical skills and experiences Patient’s Values and Circumstances: the patient’s unique preferences, concerns, and expectations in his or her setting This means that EBP ‘requires a combination of art and science’

Form answerable questions to address any gaps in our knowledge. Ask: Analyze what we know and what we do not know, in relation to improving our clinical practice. Form answerable questions to address any gaps in our knowledge. Acquired: Search for and find the best research evidence to address our questions. Appraise: the information, based on its validity, impact or size of effect, and applicability. Apply: Integrate information gathered from the best research evidence with clinical expertise and the patient’s values and circumstances Analysis: the effectiveness of any intervention taken based on steps 1-4, and the effectiveness and efficiency of the process

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 concern Two examples of background questions are: What causes fall ? When do complications of CABG usually occur? Foreground Questions Ask for specific knowledge used to inform clinical decisions or actions. Often what researches use when investigating a particular treatment, prognosis, outcome measure. 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 The cause of a condition Diagnosis and assessments Prevention of conditions Prognosis of conditions (people with KOA undergoing total knee replacement, what improvement in walking capacity will be achieved after 6 weeks ? Treatment outcomes Client concerns Economic evaluation

Ask: Formulate a clearly-stated, answerable question 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? 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? Canadian Occupational Performance Measure (COPM) 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 Develop search strategies before you start, including: Databases you will use Key terms to search under Set limits of your search (time language) Evidence from more experienced colleagues: 1. How can you be sure that the information they give you is reliable? 2. Where have they obtained their opinions from? 3. Is their knowledge up to date? Evidence from textbooks: Sometimes textbooks are written in such a way that it is unclear how the authors reached their conclusions. Sometimes the opinions that are expressed in textbooks may be out of date before the book is even published, or be inconsistent with current best evidence. Often more useful for answering general background questions

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: Cochrane Database of Systematic Reviews TRIP database (Turning Research into Practice) PEDro (Physiotherapy Evidence resource) Current clinical trials at www.clinicaltrials.gov. Medline/PubMed (www.ncbi.nlm.nih.gov/entrez/query.fcgi) Medline Plus(www.nlm.nih.gov/medlineplus/healthtopics.html), Ovid (www.ovid.com), which provides a searchable database of medical, scientific, and academic research information. CINAHL PHYSIOTHERAPY EVIDENCE DATABASE (PEDro) PEDro is an initiative of the Centre for Evidence-Based Physiotherapy (CEBP). It has been developed to give rapid access to bibliographic details and abstracts of randomised controlled trials, systematic reviews and evidence-based clinical practice guidelines in physiotherapy. Most trials on the database have been rated for quality to help therapists quickly discriminate between trials that are likely to be valid and interpretable and those that are not. The PEDro site has been supported by a number of organisations, including the Australian Physiotherapy Association, the School of Physiotherapy at the University of Sydney, the Cochrane Collaboration and New South Wales’ Department of Health. The site can be found at: http://www.pedro.fhs.usyd.edu. au/index.html (accessed 26.10.05). It also contains two useful tutorials: Part I: Are the findings of this trial likely to be valid? Part II: Is the therapy clinically useful?

Randomized controlled clinical trials Appraise : Obtain the Evidence with Searches analysis Met- Systematic review Randomized controlled clinical trials Cohort studies Case control studies Case serious /case report Animal research Case control studies are studies in which patients who already have a specific condition are compared with people who do not have the condition. The researcher looks back to Identify factors or exposures that might be associated with the illness. Rely on medical records and patient recall for data collection. Is less reliable than randomized controlled trials and cohort studies Case Studies/Case report: 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. Cohort studies take a large population who are already taking a particular treatment or have an exposure, follow them forward over time, and then compare them for outcomes with a similar group that has not been affected by the treatment or exposure being studied. Cohort studies are observational and not as reliable as randomized controlled studies. Randomized Controlled Trials (RCT) A RCT are carefully planned projects that introduce a treatment or exposure to study its effect on real patients. A RCT include methodologies that reduce the potential for bias (randomization and blinding) and that allow for comparison between intervention groups and control groups (no intervention). A RCT is an experiment and can provide sound evidence of cause and effect. Meta-analyses: will thoroughly examine a number of valid studies on a topic and combine the results using accepted statistical methodology to report the result as if it were one large study. Systematic Review: usually focus on a clinical topic and answer a specific question. An extensive literature search is conducted to identify studies with sound methodology. The studies are reviewed, assessed, and the results summarized according to the predetermined criteria of the review question. A RCT randomly assigns the exposures and then follows patients forward to an outcome.

Appraise: Levels Of Evidence And Grades Of Recommendations Description Level s systematic 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 I one properly designed RCT of appropriate size Level II well-designed trials without randomization single group pre- and post-cohort, time series or matched control studies Level III well-designed non-experimental studies from more than one centre or research group Level IV opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees Level V

Appraise: Levels Of Evidence And Grades Of Recommendations Evaluation criteria are : Credibility (Internal Validity) Transferability (External Validity)/Applicability Dependability (Reliability( 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? What is the question? What is the purpose of the research? Did the research design allow the question to be answered? What were the results? Were the researchers interpretations valid? Are the results relevant and useable in practice?

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 outcomes Cost effectiveness Client satisfaction Therapist satisfaction

Appraise : Evaluate performance After the intervention has been completed, evaluate your performance. Was my question answerable? Was my question stated explicitly enough to help me in my search for the evidence? Did I search the right sources for the evidence or was there somewhere else I should have looked? Did I manage to find sound evidence quickly and efficiently? Did I appraise the evidence effectively? Do I need to improve my critical appraisal skills Were you pleased with your decision? Did the use of evidence-based practice help? Did the patient benefit from the intervention? Did you find a way of more effectively locating the information? 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.