1. Evidence-Based Practice
Introduction to the Big Picture

2. What skills do you need? Search a database
Pose good clinical questions
Understand journal article:
Interpret charts and graphs
Know types of research designs
Identify correct statistical test for design
Understand concepts underlying hypothesis testing (like power and effect size)

3. Objectives for Today Learn the 5 EBP steps: 1. Identify the problem
2. Ask a question
3. Find some answers
4. Evaluate the answers
5. Try the best one out

4. The Process of Evidence Based Practice
Yes, you too can be an evidenced based practitioner in just 5 easy steps!

5. Identify the clinical problem1
I want my clients to:
be more functional
have a higher quality of life
have better outcomes faster
transfer skills to home environment
have maintained gains at follow-up
have better adherence to treatment plan

6. She needs an effective treatment that will appeal to her.
Suzy
Post- L CVA
Wants to go home
Difficulty with motor planning (motor apraxia)
Fashion conscious
L inferior parietal lobe
Motor apraxia- difficulty accessing kinesthetic memory patterns so that purposeful movement cannot be achieved because of defective planning and sequencing of movements, although the idea and purpose of the movement is understood
She needs an effective treatment that will appeal to her.

7. Types of problems and their questions1
Assessment/Diagnostic (What is the best assessment to use to identify performance deficits?)
Intervention efficacy (What is the best treatment?)
Intervention cost-effectiveness (Which treatment gives me the most return for my money?)

8. Identify other problems1
Write your problem on the worksheet.
Examples:
My clients don’t like constraint induced therapy, would a modified approach work just as well?
My clients have poor sensory motor skills and have trouble with handwriting.
We send instructions home with the parents but we aren’t sure they understand them.
What kinds of questions do you have about what works in OT?

9. A good problem 1 Focuses on what will work, not why
Focused on an intervention, not a systemic or political problem
Is within your scope of influence
Not too specific, not too broad

10. Patient or Problem Intervention Comparison Intervention Outcomes
Ask a PICO question 2
Patient or Problem Intervention Comparison Intervention Outcomes

11. Good Questions Within OT domain “What” questions, not ‘why’2
Within OT domain
“What” questions, not ‘why’
Just right focus, not too wide, not too narrow
Measurable in some way
Clinically important
Not already answered!

12. Suzy Post- L CVA Wants to go home
Difficulty with motor planning (motor apraxia)
Fashion conscious
In clients who are post L CVA what is the most effective OT treatment for motor apraxia?

13. PICO Examples Write down your PICO2
In children with autism, evidence on vigorous vs. mild exercise, on stereotyped behaviors?
In students with restricted mobility, evidence on environmental supports on ability to engage in play?
In children with hemiplegia, evidence on constraint induced therapy on function?
Write down your PICO

14. In clients who are post L CVA what is the most effective OT treatment for motor apraxia?3
P: stroke, CVA, apraxia, motor planning, hemiparesis
I: occupational therapy, functional training, rehabilitation
O: function, occupational participation, community reintegration, ADL, self care abilities
Examples of key words

15. Some other P I O keywords3
P: cerebral palsy, restricted mobility, ADHD, fine motor deficit, developmental delay, impaired gait/balance
I: sensory integration, gait training, orthotics, NDT, Handwriting without Tears, serial casting, swimming
O: socialization, play participation, fine motor control, academic achievement, mobility, muscle strength
Examples of key words

16. Levels of evidence based on usefulness3
Meta-Analysis
Systematic Review
Critically Appraised Topic, Clinical Guidelines
Critically Appraised Paper
Journal Article, Research
Textbooks, Non-peer Reviewed Literature
Quick, accurate, useful
Cochrane Review
As more evidence is gathered and synthesized the easier it is for clinicians to use it
Not as much

17. What is really evidence?
Research Study
Research that has been analyzed for quality & synthesized to answer clinical questions
Observation of a phenomena in a limited amount of instances (sometimes subjected to statistical tests of significance).
none of this is an exact science
more likely to give credence to a body of research (evidence) than to just one study
don’t believe everything you read

18. Where do we find the evidence?3
Centre for Evidence-based Mental Health  
Cochrane Consumer Network
National Guideline Clearinghouse™ (NGC)  
Centre for Reviews and Dissemination
Trip (tripdatabase.com)
These are free resources for reviews
TRIP turns up everything
Sometimes reviews are found in journal articles!

19. Occupational Therapy AOTA Evidence Exchange
AOTA (aota.org/en/Practice/Researchers.aspx)
AOTA Evidence Exchange
EBP Resource Directory > Systematic Reviews
Everyday Evidence Podcast
OT Seeker (
OT Evidence (
McMaster Occupational Therapy EBR Reviews

20. Where do we find the (free) articles?3
Pub Med (ncbi.nlm.nih.gov/pubmed)
Pub Med Central (pubmedcentral.gov)
Directory of Open Access Journals
Google Scholar (scholar.google.com) (
Pub med has everything, some of it not free
PMC has all free content
DOAJ- easy way to search numerous journals at once

21. PubMed Central 3 Over 1000 open access journals
Over 2000 journals with some access

22. Open Access Directory Open Access: Pediatric Rheumatology
Autism Research
BMC Pediatrics
Articles Journals
PT:
OT:
Rehab:

23. Google Scholar 3 Advanced: by words and where words occur Date Author
Journal
My Library allows you to save searches
Scholar.google.com

24. Critically evaluate the evidence4
Read the article
Fill out a form
Critical Review from McMaster’s University
CAP from AOTA
CASP in the UK
McMasters has free forms and extensive guidelines
CAP has training and examples
Different checklists for different research methods

25. Critically evaluate the evidence4
Study Design
randomization
control for bias
ethical
control group
Sample
size
described
Assessment Properties
Intervention
detailed/replicable
Statistical Analysis
Threats to Validity
internal
external
Standard to all disciplines

26. Make a decision
Given the quality of the evidence, what are the implications for clinical practice?
Bioness- works but pts won’t use because it hurts

27. Implement and evaluate5
Implement
Evaluate
What is the risk?
What is the cost?
Do you need special training?
Getting client consent
Facility support
Choose outcome measures
Keep records of outcomes and adverse events
Do a ROI assessment
return on investment

28. Reasons to Create Evidence
Referrals
Client self-efficacy
Funding for program
Third party payment
Resource allocation
Keep your job !