1. Introduction to Evidence-Based Athletic Training Practice MATA 2015 Mark Weber, PhD, ATC, PT, SCS

2. Objectives Following the presentation the participant will be able to: – define evidence-based practice and discuss it’s 3 components. – develop a clinical question based on the PICO(T) process – identify search strategies for answering clinical questions – identify levels of evidence based on the CEBM scale – interpret the results of the PEDro and QUADAS internal validity scales

3. Disclosures No commercial interest in this presentation. No personal gain But my alma mater is the reigning national champions!

4. Importance Steves and Hootman "......Athletic trainers need to embrace the critical-thinking skills............. [EBP] provides an important next step in the growth of the athletic training profession." --- JAT 2004 Welch et. al. "...... (EBP) in athletic training is a necessary step …… advancement of athletic trainers (ATs) as health care professionals.......... most ATs still are not practicing in an evidence- based manner." ---- JAT 2014

5. Disconnect AT’s valued the concept of EBP BUT Demonstrated low knowledge of EBP Low to moderate confidence in their EBP knowledge Hankemeier et al. (JAT 2013)

6. BOC EBP Foundational vs Clinical

7. Evidence-Based Practice Athlete’s preferences Athletic Trainer’s expertise Best available evidence Resources

8. EBP Steps Assess - Clinical scenario Ask - Develop PICO(T) Acquire - Search based on PICO(T) Appraise - Review Results Apply – Integrate Assess II Athlete outcome Self-assess

9. Clinician Component Clinical expertise/skills include: – background knowledge – clinical interpretation skill – psychomotor skills – ask relevant clinical questions – find and interpret answers to clinical questions Practice Self-assessment

10. PICO(T) P = population, patient, or problem I = intervention or diagnostic test of interest C = comparison or control O = patient relevant outcome(s) (T) = time frame

11. Example PICO(T) Clinical Scenario - What special tests should I use to assess an athlete with suspected ACL injury? P = ACL injury I = Lachman C = Anterior Drawer O = diagnostic accuracy

12. PICO(T) Based Search Strategy Google?, Bing?, Yahoo?

13. (P) (I) (C)

14. ACLAnt. Drawer Lachman (P) (I) (C)

16. Shortcut

17. Results

20. Pooled results from the meta-analysis Lachman is much more sensitive than anterior drawer or pivot shift – SnNout – a negative Lachman rules it out…sort of (Sn = 85 ok, not great) All three are similar in specificity – SpPin – a positive Lachman, anterior drawer, or pivot shift rules it in Clinician self-assessment

21. Tips from the Field Frame your questions in the PICO(T) format – (P) and (I) are required – (C) and (O) are recommended, not required – (T) optional When possible, filter with meta-analysis or systematic review Avoid Google, Bing, Yahoo, etc….

22. Examples from Steves and Hootman JAT 2004;39(1):83–87

23. Not a Meta-analysis or Systematic Review? Internal validity is key – The degree to which a change in outcome can be attributed to the intervention rather than to extraneous factors – “Believability” or “Truth” – Control of bias Alphabet soup to the rescue – CEBM – PEDro – QUADAS

24. Centre of Evidence-Based Medicine CEBM - http://www.cebm.net/

25. CEBM – Levels of Evidence Level of Evidence Intervention Studies Diagnostic Studies ISystematic Review/Meta- analysis IIRCTCohort with consistently applied standards IIINon-randomized Clinical Trial Cohort without consistently applied standards IVCase-Control or Case SeriesCase-Control VCase Study, Expert Opinion, or Mechanism-Based Reasoning Level I = highest evidence (lowest potential for bias) Level V = lowest evidence (greatest potential for bias)

26. Intervention Studies – CEBM, Bias, Results

27. PEDro Designed to measure internal validity of rehabilitation RCTs 0 to 10 scale – 10 = highest internal validity (lowest potential bias) – 0 = lowest internal validity (highest potential for bias) PEDro - http://www.pedro.org.au/http://www.pedro.org.au/

28. www.pedro.org.au

29. PEDro Simple Search How is patellar tendinopathy treated?

30. Search Results

31. Scrolling Further Down

32. Detailed PEDro Results

33. Article

34. Advanced PEDro Search

35. PEDro Strengths – Focus on rehab interventions – Scores the internal validity – Provides links – Simple Search – Advanced Search Weakness – Only interventions, no diagnostic studies – Does not contain all studies

36. Internal Validity in Diagnostic Testing QUADAS – QUality Assessment of Diagnostic Accuracy Studies http://www.bris.ac.uk/quadas/ QUADAS has 14 point scale – Higher score – less bias – Lower score more bias QUADAS 2 has a 7 item scale Does not have an article database like PEDro Is used by Cochrane Systematic Reviews

37. Clinical Utility Clinical skill – guides clinical decision making Rehab – shotgun approach wastes time, money and may increase risk Diagnosis – tests with poor diagnostic accuracy waste time, money, and increase risk Practice thinking in PICO(T) terms

38. Clinical Utility Identified barriers – Time – Role strain – Knowledge – Gap between clinical and educational settings – Lack of mentors Manspeaker et al. JAT 2011 McCarty JAT 2013

39. Addressing Time Issue PICO(T) Know where to search (PEDro, PubMed, CINAHL, Cochrane Datebase) Look for applicable systematic reviews / meta- analyses Practice! – Were you successful on your first Lachman?

40. Questions? mweber@umc.edu