Evidence-Based Practice PDF Fall 2024

 EVIDENCE-BASED PRACTICE GWU - PT 8351 Professional Issues in Physical Therapy Health Care Management I David Scalzitti, PT, PhD Fall 2024  SESSION OBJECTIVES Evaluate the role of research evidence in phys...

 EVIDENCE-BASED PRACTICE GWU - PT 8351 Professional Issues in Physical Therapy Health Care Management I David Scalzitti, PT, PhD Fall 2024  SESSION OBJECTIVES Evaluate the role of research evidence in physical therapy practice. Define evidence-based practice. Discuss the components of evidence-based practice. Identify the steps of evidence-based practice.  October 11, 2029 By JMortonPhoto.com & OtoGodfrey.com, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=44599363 COMPLETE: Worksheet with one question related to your future practice. https://goo.gl/forms/RgeV0HqACjFaQwNy2  What Is Evidence-Based Practice? The conscientious, explicit and judicious use of current best evidence in making decisions about the care of patients The integration of best research evidence with our clinical expertise and our patient’s unique values and circumstances. Straus SE, et al. Evidence-Based Medicine: How to Practice and Teach EBM, 5th edition. Churchill Livingstone. 2019.  Evidence Based Physical Therapy “…the integration of best available scientific evidence with clinical expertise and a patient’s unique values and circumstances. …these three sources of evidence form a foundation on which you and your patients will work together to determine the best course of physical therapy care in any given circumstance.” Fetters and Tilson, second edition, page 2 Evidence based practice Portney LG. Foundations of Clinical Research. Fourth edition. Patient Values and Circumstances The unique preferences, concerns and expectations each patient brings to a clinical encounter… …and the patient’s clinical state and the clinical setting. Straus SE, et al. Evidence-Based Medicine: How to Practice and Teach EBM, 5th edition. Churchill Livingstone. 2019.  Clinical Expertise The ability to use clinical skills and past experience. Straus SE, et al. Evidence-Based Medicine: How to Practice and Teach EBM, 5th edition. Churchill Livingstone. 2019.  Evidence Best research evidence means clinically relevant research. Especially patient-centered clinical research related to diagnosis, prognosis, and intervention. Straus SE, et al. Evidence-Based Medicine: How to Practice and Teach EBM, 5th edition. Churchill Livingstone. 2019.  Choosing Wisely for PT 1. Don’t use (superficial or deep) heat to obtain clinically important long term outcomes in musculoskeletal conditions. 2. Don’t prescribe underdosed strength training programs for older adults. 3. Don’t recommend bed rest following diagnosis of acute DVT after the initiation of anticoagulant therapy unless significant medical concerns are present. 4. Don’t use CPM machines for the postoperative management of patients following uncomplicated total knee replacement. 5. Don’t use whirlpool for wound management. https://www.choosingwisely.org/societies/american-physical-therapy-association/ Phys Ther 2015;95:9-24  From the Publishers of Consult Guys White Coat or No White Coat? COPYRIGHT © 2019, ALL RIGHTS RESERVED Whatever you wear, cleanse your hands! Research Agenda for Physical Therapy. Stevens-Lapsley J, Hicks GE, Zimney K, Slaven EJ, Manal TJ, Jeffries LM. Research Agenda for Physical Therapy From the American Physical Therapy Association. Phys Ther. 2023;103(10):pzad126. doi:10.1093/ptj/pzad126  Clinical Research … involves human subjects and answers questions about diagnosis, intervention, prevention, and prognosis in relation to disease or injury. – Fetters & Tilson, Evidence Based Physical Therapy 2nd ed, p 3. … is a structured process of investigating facts and theories and of exploring connections, with the purpose of improving individual and public health. It proceeds in a systematic way to examine clinical or societal conditions and outcomes, and to generate evidence for decision making. – Portney, Foundations of Clinical Research 4th ed, p 2.  Clinical Research - NIH A research study in which one or more human participants are prospectively assigned to one or more interventions (which may include placebo or other control) to evaluate the effects of those interventions on health-related biomedical or behavioral outcomes. ART SCIENCE  Scientific Method A systematic, empirical, and controlled critical examination of hypothetical propositions about the associations among natural phenomena From Portney, Foundations of Clinical Research 4th edition  The Research Process Identify the Research Question Design the Study Implement the Study Analyze Data Disseminate Findings  Structure of Published Research Dissertation Research Paper I. Statement of the problem Introduction and Purpose (includes II. Review of literature a brief review of literature) III. Methods Methods IV. Results Results V. Discussion Discussion Cited literature References  Steps of Evidence-Based Practice Formulate a clear clinical question from a patient’s problem Search the literature for relevant clinical articles Critically appraise the evidence for its validity and its usefulness Implement useful findings in clinical practice Evaluate our performance  Knowledge-to-Action Li LC, van der Wees PJ. PHYS THER 2015;95:486-491 © 2015 American Physical Therapy Association  Quiz EBP is …. “Applying sensitivity in practice is like using evidence in practice, however. Until we integrate the concepts of evidence and sensitive practice into every course, they will be viewed as optional—as adornments to practice rather than the heart of practice. The person who could most powerfully illustrate the importance of sensitive practice—and of evidence-based practice—is the same person who's teaching the manual therapy techniques or the therapeutic exercise techniques or the wheelchair transfers. The more we link these issues to application in practice, the more real they are, and the more likely they are to be applied.” Rothstein JM. In Conference on Toward sensitive practice: issues for physical therapists working with survivors of childhood sexual abuse. Phys Ther. 1999; 79(3):262-268.  SUMMARY Evaluate the role of research evidence in physical therapy practice. Define evidence-based practice. Discuss the components of evidence-based practice. Identify the steps of evidence-based practice.  CLINICAL QUESTIONS GWU - PT 8351 Professional Issues in Physical Therapy Health Care Management I David Scalzitti, PT, PhD Fall 2024  KEY POINTS Formulate clinical questions related to the patient, intervention, comparison, and outcome (PICO). Distinguish between foreground and background questions. Formulate clinical questions in the context of the patient’s goals. Utilize the ICF framework in formulating clinical questions. Formulate PICO questions for physical therapist intervention, diagnosis, and prognosis.  Steps of Evidence-Based Practice Formulate a clear clinical question from a patient’s problem Search the literature for relevant clinical articles Critically appraise the evidence for its validity and its usefulness Implement useful findings in clinical practice Evaluate our performance Case 1: Chronic Stiff Shoulder Patient With Chronic Stiff Shoulder A 55-year-old woman reports a 6-month history of shoulder pain and stiffness. Currently her pain is 3-4 out of 10 with no pain at rest. She has pain at the end of her available range of motion for her shoulder. She has difficulty dressing, reaching over her head, and performing other household chores because of her stiffness. She has difficulty reaching behind her back and placing her hand behind her head. Her pain is localized to her shoulder and does not radiate down the arm. She has difficulty sleeping only when attempting to lie on the involved side. Passive range of motion of the involved side is as follows: flexion=120°, abduction=110°, external rotation with her arm at her side=20°, external rotation with the arm at 90° of abduction=40° and internal rotation at 90° of abduction=10°. She only has pain after restriction to passive motion with a firm end-feel. Isometric resisted testing does not increase her pain. Cervicothoracic extension is limited. What are your questions?  Background Questions Usually for general knowledge Usually includes a question root e.g., who, what, where, when, why, how Usually related to the clinical condition Examples What is adhesive capsulitis? What is the mechanism of ACL injuries? Who is more likely to be diagnosed with RA? How do you measure shoulder range of motion?  Foreground Questions Usually ask for specific knowledge e.g. does this work? Related to diagnosis, prognosis, and treatment for a particular patient  Where Clinical Questions Arise Diagnosis Evaluation Prognosis Outcomes Examination Intervention  PICO Clinical Question The Patient or problem being addressed The Intervention, or diagnostic test, or prognostic factor A Comparison intervention, ? or diagnostic test, or prognostic factor The clinical Outcome or outcome of interest  Questions Related to Intervention Which interventions are better than others? – Which interventions are better than no treatment? – Which new interventions are as good as existing interventions? Which interventions are harmful? ?  Sample Intervention Question P: For children with cerebral palsy... I: …does strength training… C: …compared to no training… O: …improve gait? ??  Intervention Practice P: For persons with … I: …does … C: …compared to … O: …improve …? ICF model  Sample DIAGNOSIS Question P: For persons with acute knee injuries… I: …is the anterior drawer test… C: …compared to the reference standard… O: …ACCURATE to detect the presence of anterior cruciate ligament tears? ??  Diagnosis Practice P: For persons with … I: …is … C: …compared to … O: …ACCURATE to …?  Sample PROGNOSIS Question P: For older adults… I: …does the Berg Balance Test… O: …PREDICT falling in the next 12 months? ??  PROGNOSIS Practice P: For persons with … I: …does … C: …compared to … O: … PREDICT …?  Chronic Stiff Shoulder Background Question: Foreground questions (PICO): Intervention Diagnosis P P I I C C O O  Patient Problem 22 year old full time college student and works as a part time waitress. Locates pain across low back, right > left. Occasional numbness right thigh in distribution of lateral femoral cutaneous nerve. Onset 4 weeks ago after a motor vehicle accident. Has stopped jogging since accident. X-rays - negative for fracture. Medications: Advil (as needed); birth control. Previous medical history: arthroscopic knee surgery 2 years ago. Smokes half-pack of cigarettes per day.  Too Many Questions? Most important to the patients well-being? Most feasible to answer in time allowed? Most interesting? Most likely to recur?  SUMMARY Distinguish background and foreground questions. Create clinical questions using PICO for physical therapist diagnosis, prognosis, and intervention. Consideration of patient’s goals and ICF framework in developing clinical questions.  Before next week, read one of these articles van den Bekerom MP, Struijs PA, Blankevoort L, Welling L, van Dijk CN, Kerkhoffs GM. What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults? J Athl Train. 2012;47(4):435-43. – doi: 10.4085/1062-6050-47.4.14 – PMID: 22889660 – PMCID: PMC3396304 Bundgaard H, Bundgaard JS, Raaschou-Pedersen DET, et al. Effectiveness of adding a mask recommendation to other public health measures to prevent SARS-CoV-2 infection in Danish mask wearers: a randomized controlled trial. Ann Intern Med. 2021;174(3):335-343. – PMID: 33205991 Schachter CL, Stalker CA, Teram E. Toward sensitive practice: issues for physical therapists working with survivors of childhood sexual abuse. Phys Ther. 1999;79(3):248-61. – PMID: 10078769  Next Time SEARCHING FOR EVIDENCE PREP: READ the rest of Chapter 2 in Fetters and Tilson (from page 18 to the end of the chapter) ASSIGNMENT: to be submitted via Blackboard – WRITE A DIAGNOSIS CLINICAL QUESTION FOR CASE 2 – WRITE A PROGNOSIS CLINICAL QUESTION FOR CASE 2 – WRITE AN INTERVENTION CLINICAL QUESTION FOR CASE 2 – FORMAT CITATION IN AMA and APA STYLE PMID: 26654252 CASE 2: PERSON WITH PLANTAR FASCIITIS  Person with Plantar Fasciitis A 45-year-old who works as an operating room nurse reports a 3-month history of insidious onset left heel pain. The pain is worse upon first weight bearing in the morning, after prolonged sitting, and at the end of the workday. She denies numbness or tingling. She does not complain of pain in other joints. The patient’s goal is to be able to walk 2 miles after work as part of a weight loss program. Body Functions and Structures – Body mass index: 31.2 kg/m2. – Lower quarter screen: No significant findings in the lumbar spine, hip, or knee. – Palpation: Tenderness at medial calcaneal tuberosity. – Range of motion: Limited dorsiflexion. – Pain: 8/10 upon first weight bearing in the morning as assessed with a verbal rating scale. – Windlass test: Positive. – Dorsiflexion-eversion test: Negative. Activities and Participation – Foot and Ankle Ability Measure (FAAM) ADL subscale score: 73%. FAAM sports subscale score: 53%. OVERVIEW OF REFERENCE STYLES  AMA vs APA Articles in Reference List AMA Author(s). Article title. Journal Name. Year;Volume(Issue No.): pp-pp. APA Authors, A.A.. (Publication Year). Article title. Journal Name, Volume(Issue No.), pp-pp.  AMA vs APA Books in Reference List Online Citations  AMA vs APA In-text Citations AMA = Superscripts Examples: …physical therapy is effective.1 According to Scalzitti et al2… APA = Author’s name and year Examples: …physical therapy is effective (Jette 2016). According to Kendall (1993)…  Additional GW Resources For assistance with formatting of references AMA manual of style http://www.amamanualofstyle.com/ For assistance with keeping track of references RefWorks http://www.refworks.com/  APA Resources http://www.bibme.org/citation-guide/apa/ American Psychological Association. (2020). Publication Manual of the American Psychological Association, 7th Edition. Washington, D.C.: American Psychological Association. PRACTICE  ANSWERS AMA Goldstein MS, Scalzitti DA, Bohmert JA, et al. Vitalizing practice through research and research through practice: the outcomes of a conference to enhance the delivery of care. Phys Ther. 2011;91(8):1275-84. APA Goldstein, M.S., Scalzitti, D.A., Bohmert, J.A., et al. (2011). Vitalizing practice through research and research through practice: the outcomes of a conference to enhance the delivery of care. Phys Ther, 91(8), 1275-84. THANK YOU! ANY QUESTIONS? [email protected]