1. EBP in practice…

2. 43-year-old woman with 1-3 migraine headaches per week.43-year-old woman with 1-3 migraine headaches per week. Otherwise healthy.Otherwise healthy. Stress is a significant trigger for her headaches,Stress is a significant trigger for her headaches, Imitrex aborts her headaches most of the time, but she dislikes taking it because of the side-effects and cost.Imitrex aborts her headaches most of the time, but she dislikes taking it because of the side-effects and cost. She prefers “alternative” approachesShe prefers “alternative” approaches Has heard that acupuncture can help migraines.Has heard that acupuncture can help migraines.

3. The patient asks: Should she pursue treatment with us or try an “alternative” approach such as acupuncture?Should she pursue treatment with us or try an “alternative” approach such as acupuncture? What do we think would be the most effective treatment for her?What do we think would be the most effective treatment for her?

4. The 5-step process: 1.Convert information needs into a clear question. 2.Search for the best evidence in the literature. 3.Critically appraise the evidence. 4.Integrate with a patient’s needs, preferences, circumstances, and values. 5.Evaluate the outcome.

6. Background Questions What are the most effective treatments for chronic migraine headache?What are the most effective treatments for chronic migraine headache? PharmacologicalPharmacological Non-pharmacologicalNon-pharmacological Is acupuncture an effective treatment for migraine headache?Is acupuncture an effective treatment for migraine headache? Are there any significant risks associated with acupuncture?Are there any significant risks associated with acupuncture?

7. P = I = C = O = Foreground Questions In middle aged women with migraine headaches is there any evidence that acupuncture compared to sham treatment, biofeedback, relaxation training, and cognitive-behavioral therapy reduces the frequency, intensity, and/or duration of migraines?

8. Background vs. Foreground Questions: Where to look Background questions  EB e-textbooks [UpToDate, Clinical Evidence] EB guidelines, systematic reviews, ESTs Foreground questions  if not found at a higher level, search MEDLINE / PsycINFO search

10. UptoDate and Clinical Evidence for background informationUptoDate and Clinical Evidence for background information Two evidence-based guidelinesTwo evidence-based guidelines AAN (pharmacological and non) AAN (pharmacological and non) Headache Consortium (behavioral and physical treatments) Headache Consortium (behavioral and physical treatments)

12. Acupuncture for idiopathic headache

13. Conclusion from Cochrane Systematic Review: Existing evidence supports the value of acupuncture for the treatment of idiopathic headaches… There is insufficient evidence to assess … whether it is as effective as other headache treatments.” No significant risks.

14. What did we find? Clinical Evidence and UptoDate, e-textbooks: Evidence-based up to date background information on migraineEvidence-based up to date background information on migraine Recent evidence-based guidelines on HA management: American Academy of NeurologyAmerican Academy of Neurology Headache Consortium (behavioral and physical treatments)Headache Consortium (behavioral and physical treatments) Systematic reviews: From the Cochrane Library:From the Cochrane Library: “Acupuncture for idiopathic headache”“Acupuncture for idiopathic headache” Two reviews on “Is acupuncture safe?”Two reviews on “Is acupuncture safe?” Specific EBP search tools in Medline and PsycINFO (MeSH terms/ filters/ clinical queries in PubMED ) SUMMARIES SYNTHESES Individual articles

15. What did we know thus far? Acupuncture > sham or no txAcupuncture > sham or no tx ? Compared to other txs? Compared to other txs Relatively safeRelatively safe Relaxation, CBT, and BFTRelaxation, CBT, and BFT ….have all been shown to reduce migraine headaches between 40-60%.

16. Foreground questions: In middle aged women with migraine, is CBT more effective than biofeedback in reducing frequency, duration or intensity of migraine headaches?In middle aged women with migraine, is CBT more effective than biofeedback in reducing frequency, duration or intensity of migraine headaches? Or…In middle aged women with migraine, is acupuncture more effective than CBT in reducing frequency, duration or intensity of migraine headaches?Or…In middle aged women with migraine, is acupuncture more effective than CBT in reducing frequency, duration or intensity of migraine headaches?

17. Medline and PsycINFO

18. PsycINFO and PubMed: Important search concepts Why not just type in keywords?Why not just type in keywords? TruncationTruncation AlertsAlerts

19. Why not just type keywords? Keywords look for that exact word in the article. Acupuncture……………Acupressure Behavior……………….. Behaviour Tension headache………Muscle contraction headache Depression………………Major depressive disorder dysthymia

20. Controlled Vocabulary Librarians “tag” each article with labels based on the concepts in the article. These labels are standardized. This allows the user to retrieve information that uses different terminology for the same concept. Medline: MeSH terms

21. Truncation Keywords look for that exact word in the article. Acupuncture……………Acupressure (acup$) Behavior……………….. Behaviour (behav*) Tension headache………Muscle contraction headache Depression………………Major depressive disorder dysthymia

22. How to do a Medline/ PsycINFO EBP search: 1. 1.Select terms from the controlled vocabulary list 2. 2.Search each term individually 3. 3.Use AND / OR to combine the sets. 4. 4.Limit to Humans and English 5. 5.Limit to EBM reviews.

23. …and we set up Alerts

24. Alerts Individual journals and databases Medline and PsycINFO: save your search automatic email Partner with your medical librarian Ask people in your own field…

25. EBP begins and ends with the patient Formulate Questions Find the best evidence Appraise the evidence Apply the Evidence Assess the impact

26. Best research evidence Patient Characteristics, Values, and Context Clinical Expertise CD Relaxation, BFT, CBT: A Behavioral therapy + Med : B Acupuncture: some evidence but inconclusive More evidence for acupuncture than other “alternative” treatments Acupuncture is low risk

27. Best research evidence Patient Characteristics, Values, and Context Clinical Expertise CD Prefers “alternative” treatments Concerned about cost No co-morbid conditions Similar to pts in studies Behavioral treatments feasible Insight into the link between stress and headaches Cost of acupuncture unknown at time of assessment Not needle-phobic

28. Best research evidence Patient Characteristics, Values, and Context Clinical Expertise CD Assess the patient accurately Communicate with the patient Integrate the research and clinical evidence Ability to deliver the txs of choice?

29. Step 4: Applying the evidence Clinical intervention that involves the patientClinical intervention that involves the patient Clinical decision is made jointlyClinical decision is made jointly

30. The Clinical Decision: Begin treatment with BFT and relaxation training “Alternative” treatment Affordable, feasible Incorporate CBT Monitor outcome Reconsider acupuncture therapy

31. Questions and Discussion….