1. Part 7 appreciate appraise apply
Welcome to the last of the EBP presentations. Today, we’ll look at different ways to access literature and find articles of interest.
Part 7
Brenda Boucher PT, PhD, CHT, OCS, FAAOMPT

2. For all of us, time is currency. It seems to always be in short supply
For all of us, time is currency. It seems to always be in short supply. Taking time to search the literature for evidence relevant to your practice is difficult at best. Knowing that, I want to introduce several options you can use to access literature of interest to you.

3. Information: Pushed Pre-processed Primary
I’ll cover several different ways in which this can be done. Depending on what you want, or what you are looking for, different options offer different advantages. In this presentation, I’ll introduce ways in which information can be “pushed” to you. I’ll also tell how you can access “pre-processed” information, and I’ll discuss how to find primary literature.

4. Pushed Information
Citations representing articles of interest are ed to you.
The first option I mentioned is having information “pushed” to you. This means having citations that represent articles that might be of interest to you, ed directly to you. You simply register with a source that pushes information, indicate what areas of practice are of most interest to you, and state how often you want to receive ed notifications. The service searches the literature and s you a list of citations. How easy is that?. 


5. Pushed Information
Although several search information services exist to “push” information, a particularly good one comes from McMaster University located in Ontario, Canada.

6. J Physiother Speciality Musculoskeletal Relevance 6 News-worthiness 6
Dear Brenda,
New articles: colleagues in your specialty have identified the following article(s) as being of interest:
Article Title Specialty Relevance News-worthiness Kinesio Taping to generate skin convolutions is not better than sham taping for people with chronic non-specific low back pain: a randomised trial.
J Physiother Speciality Musculoskeletal Relevance 6 News-worthiness 6
Mechanical Diagnosis and Therapy has similar effects on pain and disability as `wait and see` and other approaches in people with neck pain: a systematic review.
J Physiother Speciality Chronic Pain Relevance 6 Musculoskeletal 5
Scapular kinematics pre- and post-thoracic thrust manipulation in individuals with and without shoulder impingement symptoms: a randomized controlled study.
JOSPT Speciality Manual Therapy Relevance 6 Musculoskeletal 5
Recommendations for physical therapists on the treatment of lumbopelvic pain during pregnancy: a systematic review.
JOSPT Speciality Manual Therapy Relevance 6 Musculoskeletal 4
Rehab + will send you article citations that are pre-rated for quality by a team of research staff. Each article is rated for clinical relevance and news-worrthiness by at least 3 members of a worldwide panel of practicing clinicians. Here's a sample of an alert I recently received: I set my profile to receive weekly notifications of articles with a rating of 5 or greater pertaining to my selected areas of interest, which include manual therapy, musculoskeletal, sports therapy and chronic pain.
You can see on the slide I was sent 4 citations related to 3 of those specialty areas. Each article was rated a 5 or higher by a panel of 3 practitioners in that specialty area for relevance to practice and news-worthiness. By clicking on the electronic link, I can access the article's abstract via PubMed. I can also click on a link to access the full text article, if available, via PubMed or the publisher's site. I got all this without spending one single minute performing a search myself. And better yet, it was free! The web address for Rehab + is provided for you at the top of this slide.

7. Pre-processed Information
Synopsis or meta-analysis of important articles reviewed by clinical scientists or health professionals
The second option I mentioned to access literature is using a source that provides “pre-processed” information. Consolidated or pre-processed information is available using many different sources, but a few that are commonly used by physical therapists include the Cochrane Database of Systematic Reviews, PEDro, and APTA’s Hooked on Evidence. These sources usually represent the synopsis or meta-analysis of important articles that have been reviewed by health professionals who are experienced in the critical appraisal of literature. Similar to Rehab +, the benefit is that someone trained has done the work for you to search the literature. More so, these sources function to answer important questions related to clinical practice.

8. Important clinical question:
Cochrane Database of Systematic Reviews: systematic reviews of primary research in human health care and health policy.
Important clinical question:
“Does manual therapy help reduce neck pain?”
The Cochrane Database of Systematic Reviews may be considered the leading source for systematic reviews in health care. Cochrane Reviews are systematic reviews of primary research in human health care and health policy, and are recognized as the highest standard in evidence-based health practice. Each systematic review addresses a clearly formulated question. For example, an important clinical question may look this: ”Does manual therapy help reduce neck pain?”  When the key words” manual therapy and neck pain” are entered into a search, all existing primary research on this topic that meets certain pre-determined criteria, and has been assessed using stringent guidelines, is provided by way of a systematic review. Let’s look at an example.

9. On the Cochrane Database of Systematic Reviews, I entered manual therapy and neck pain and retrieved this window: Mobilisation and manipulation for neck pain, electrotherapy for neck pain, acupuncture, conservative measures, manual therapy and exercise for neck pain. Each review represents consolidated, pre-processed analyses of all studies that met the minimal criteria for inclusion. It also includes a bottom line recommendation called “Authors; conclusion”. The abstract of each review provides a summary statement of the authors analysis of the studies included in the review, as well as detailed information about the critical appraisal of each study. However, original articles are not included. If a clinician is interested in reading the original articles, he or she will need to access those articles via an alternate database.
There is a caveat worth noting. In the field of physical therapy, there still exists a lack of high quality studies with adequate homogeneity to render strong recommendations, and as such, the final review statement of many Cochrane systematic reviews reads like this: Authors' conclusions: The current literature does not support or refute the effectiveness of treatment. “X”. Large, well conducted RCTs are needed to determine the effectiveness and efficacy for individuals with this particular disorder.
Authors' conclusions: The current literature does not support or refute the effectiveness of treatment. “X”. Large, well conducted RCTs are needed to determine the effectiveness and efficacy for individuals with this particular disorder.

10. Physiotherapy Evidence Database (PEDro): database of randomized controlled trials, systematic reviews, and clinical practice guidelines in physiotherapy
PEDro is another source of consolidated, pre-processed information. PEDro is short for: Physiotherapy Evidence Database. It is a free database of over 28,000 randomised trials, systematic reviews, and clinical practice guidelines in physiotherapy. For each trial, review or guideline, PEDro provides citation details, the abstract, and a link to the full text, where possible. All trials on PEDro are independently assessed for quality. These quality ratings are used to quickly guide users to trials that are more likely to be valid and to contain sufficient information to guide clinical practice. PEDro is produced by the Centre for Evidence-Based Physiotherapy at The George Institute for Global Health.

11. In PEDro, you can perform a simple search on your topic of interest, which will produce a list of all clinical trials, systematic reviews and practice guidelines related to the topic. It will also give you a rating for each item. Let’s do simple search on PEDro to see what we can find on the topic of manual therapy and neck pain. A simple search yields a total of 144 items, consisting of practice guidelines and systematic reviews, which are not rated, as well as clinical trials, which are rated on a scale of The clinical trials in this list, range in ratings from as high as 9/10 to as low as 2/10. Needless to say, 144 items is a lot to go through. Let’s do an advanced search and see what we get. An advanced search

12. Hooked on Evidence: database of extractions of articles related to physical therapy interventions
Another source for consolidated, pre-processed evidence is APTA’s Hooked on Evidence. Hooked on Evidence contains many thousand extractions of articles related to physical therapy interventions, which have been entered into a database. The database does not contain articles on diagnostic and prognostic tests or outcome measures, and this may be considered a limitation of this this particular service. Articles for extraction are selected by volunteer contributors and are not peer reviewed. They are checked by staff for accuracy of entered information, and then edited for format. Hooked on Evidence provides a critical appraisal of an article, as well as a link to the PEDro score, if available, and a link to the PubMed abstract, if available. A helpful tool provided by Hooked on Evidence, however, is a link to a page listing other databases and resources, and their associated links, to assist clinicians in their search for literature.

13. Primary Information
Independent search to find primary literature related to topic of interest
The third option I mentioned to find literature is the process of accessing primary literature. This means performing an independent search to find primary literature related to a topic of interest. A clinician may know the name of an article, the author of an article, or the journal in which an article was published, and wish to access the original study. OR, a clinician may not have any of that information, but wants to find one or more articles that address a particular question, condition, diagnosis or intervention. Many databases and search engines exist to help with that process. Some of the more commonly used in physical therapy include PubMed, Medline, and CINAHL.

14. PubMed: database representing articles and biomedical literature, including Medline citations and abstractss
PubMed is a particularly useful source that contains links to full text articles at participating publishing websites. PubMed contains over 23 million records representing articles and biomedical literature. Most of these are MEDLINE citations, so anything that can be found on MEDLINE, can be found using PubMed. PubMed provides access to MEDLINE citations and author’s abstracts from more than 5,600 biomedical journals published in the US and other countries. Let’s see how PubMed works.

16. Congratulations! appreciate appraise apply
OK. Believe it or not, we have completed our journey towards understanding Evidence based practice. The job that lies ahead is to use this information to make informed and better decisions with patient care. Remember, asking is the answer. I hope this series of presentations has given you an appreciation for the usefulness of Evidence Based Practice, and that you’ve gained skills to critically appraise literature that is designed to inform clinical practice. Now go out, apply all that you have learned, and make your practice even better.