What about when there is no evidence? Clinicians Creating Evidence to Drive Practice

Patient concern Clinical expertise Best research evidence Improved patient outcomes Evidence Based Medicine

Practicing EBM – the 5 A’s Ask a clinical question Acquire the best evidence Appraise the evidence Apply the evidence Step 1 Assess your performa nce Step 2 Step 3 Step 4 Step 5

Levels of evidence Quality

What are the barriers to quality research? Study design IRB Sufficient numbers Subject recruitment Subject retention Control vs treatment group Random allocation Equality of groups Data collection Normalizing data Relevance of the data Clinical significance DON’T forget…

Measurement - outcomes What were the outcomes? Primary Secondary Were they appropriate? How were the results reported? Were they significant? Methods: Outcomes and Results

Which outcome measures do you use? ew=Shared ew=Shared

How often are you seeking out research? PICO CAT Lit review Clinical Queries BMJ VOLUME DECEMBER 1995

JASPA* (Journal associated score of personal angst) J: Are you ambivalent about renewing your JOURNAL subscriptions? A: Do you feel ANGER towards prolific authors? S: Do you ever use journals to help you SLEEP? P: Are you surrounded by PILES of PERIODICALS? A: Do you feel ANXIOUS when journals arrive? YOUR SCORE? (0 TO 5) * Modified from: BMJ 1995;311: (?liar) 1-3 (normal range) >3 (sick; at risk for polythenia gravis and related conditions)

The story of the continuing education course

What about anecdotal evidence?

Why don’t you find out for yourself?

Action research- clinicians answering their questions

Action research- Background Began in Education A method for teachers to investigate ways to enhance their teaching Cyclical process of Developing a plan Implementing procedures Collecting data Analyzing results Modifying the plan

Action research vs. clinical practice Action Research Recognize a need Developing a plan Implementing procedures Collecting data Analyzing results Modifying the plan Clinical practice Evaluate Develop and plan of care Implement interventions Collect data Analyze results of care Modify the treatment care plan

Please discuss- At your table, discuss with others: 1. A clinical question you have or have had 2. A method of answering that question 3. a method of assessing the outcome 4. What you will do with the information once you have it

I feel like an active warm-up may be better than heat and ES I’m going to try warming my knee patients up on a bike instead of heat/ES Patients are excited that they could possibly reduce pain at home with their own recumbent bike Patients like it. Are there improved outcomes? Let me check my outcome questionaires and visits/patient I do seem to be getting better results in fewer visits. Maybe I should market that!

Clinicians Patients and clients Health Care Facilities Health

Components of action research Key ConceptExample Action research is participatoryYou find an area in your practice that you feel could be better. Action research is socially responsive and takes place in context People start asking you more about a new fad (crossfit). You want to figure out if it is beneficial to your patients. Action research helps clinicians examine the everyday, taken-for-granted ways in which they carry out professional practice You commonly use handouts for home exercises. You wonder if compliance would be better with videos Knowledge gained can liberate clinicians, patients, and systems and enhance treatment, practice and policy making. It turns out that your efforts in preventing injuries at the local high school has produced increased referrals to your clinic.

A Practical (recent) Example Observation Dr. K volunteers his time at the local high school coaching soccer. The girls coach came to him yesterday worried about her team because she has had 5 girls on her varsity team next year who have torn their ACL. They may not be able to play next school season.

Act Dr. K collects some data The girls season starts with games prior to the first day of school Schools cannot hold tryouts until the last week of July providing only a week of practice before games begin He surveys the girls about their summer activity levels and training schedules, outside of soccer He investigates which positions these girls play, with the suspicion that they are forwards and defenders, making their running more sporadic and high velocity He investigates what type of warm up is utilized and what conditioning/training is implemented

Plan change Dr. K finds various injury prevention programs that have had good success in reducing ACL injury rates FIFA- PEP JUMP SPORTSMETRICS

Implementation Dr. K teaches the team and coach to implement the FIFA 11+ program He also collaborates with the high school athletic trainer to check in on proper form and implementation of the program at each practice and game

Collect data Dr. K tracks injuries that season to see if there are fewer ACL injuries Dr. K performs pre-season testing of drop jump performance of both the JV and Varsity teams He again performs post-season Drop jump assessment to observe quality of movement in each girl He develops a rating scale (or finds one) to determine who is at greater risk due to landing mechanics. He advises those at greater risk to come into the clinic for further training to decrease their risk

Assess Dr. K assesses if the program implementation has improved the health of his clients with fewer ACL injuries as well as reduced risk of ACL tear. He modifies the program as needed He now approaches the various club teams that these girls play on in the spring to continue the program in the off season.

Why should I do Action Research?

You’re already doing it

The goal is to improve how you are doing things

You patients will appreciate you for advancing their care

You will be more productive

You will stand out in your field

You may be the new guru of the latest technique