Evidence-Based Practice PDF

Evidence-Based Practice Joosung Kim, PhD, ATC Using Evidence to Make Confident Decisions Evidence-Based Practice (EBP) “Integration of the best research evidence with clinical experience and patient values to make clinical decisions” Sackett et al....

Evidence-Based Practice Joosung Kim, PhD, ATC Using Evidence to Make Confident Decisions Evidence-Based Practice (EBP) “Integration of the best research evidence with clinical experience and patient values to make clinical decisions” Sackett et al. Scientific Evidence EBP Clinical Patient Experience Values EBP is NOT New “As the status of the athletic trainer increases and the true value of his services are fully recognized, it becomes essential that members of the profession recognize the paucity of scientific evidence to support many of its traditional procedures…Today’s demands on an athletic trainer’s time and budget no longer warrant the retention of practices or procedures which fail to survive the critical scrutiny of controlled study.” Simon, JNATA, 1969 Patient Case 22 years old soccer player with chronic low back pain Pain at 7/10 during physical activity and 3/10 at rest Low back stiffness No symptoms distal to the knee Self-reported functional limitations What would your rehabilitation program look like? List your top 3 treatment options Treatment options for LBP Rest Medication NSAIDs, prescription, epidural steroid injection Surgery Modalities TENS, US, heat/ice, laser, traction, etc Soft tissue techniques/manual therapy Stretching, muscle energy technique, myofascial releases, massage, spinal manipulation, etc Exercises Pain reliving positions/exercises mobility/flexibility, strengthening, stability/stabilization, neuromuscular training Alternative medicine Acupuncture, herb, yoga with meditation, etc How successful? How confident are you about your treatment option, leading to a good outcome? How many of you are VERY confident? How many of you are PRETTY confident? How many of you are SOMEWHAT confident? What kinds of evidence support your treatment option? Patient Case 22 years old soccer player with chronic low back pain Pain at 7/10 during physical activity and 3/10 at rest Low back stiffness No symptoms distal to the knee Self-reported functional limitations Subgrouping of patients with LBP  MANIPULATION GROUP (non-radicular LBP) Inclusion Criteria  Recommended Intervention No symptoms distal to the  Manipulation of the lumbopelvic knee region Recent onset of symptoms  Active ROM exercises (50% reduction of self-  Recent onset of symptoms (4 inclusion criteria, the probability of a good outcome after manipulation is 97% STABILIZATION GROUP (non-radicular LBP) Hicks et al. APMR 2005  Inclusion Criteria  Good Outcome  Younger age (50% reduction of self-  Greater general flexibility reported symptoms after 4 (postpartum, average SLR weeks of core stability ROM 91°) training  “Instability catch” or aberrant movements during lumbar flexion/extension ROM  Positive findings for the prone instability test RESULTS If they have >3 inclusion criteria, the probability of a good outcome after stabilization is 80%  SPECIFIC-EXERCISE GROUP (Radicular LBP)  Inclusion Criteria for Extension  Symptoms distal to the buttock  Symptoms centralize with lumbar extension  Symptoms peripheralize with lumbar flexion  Directional preference for extension  Inclusion Criteria for Flexion  Inclusion Criteria for Lateral shift  Older age (>50 y)  Visible frontal plane deviation of  Directional preference for flexion the shoulders relative to the pelvis  Imaging evidence of lumbar  Directional preference for lateral spinal stenosis translation movements of the pelvis RESULTS Preferred direction consistently shows better results but there is no evidence available at this time to calculate the probability of a good outcome after specific-exercise  TRACTION GROUP (Radicular LBP)  Inclusion Criteria  Signs and symptoms of nerve root compression  No movements centralize symptoms RESULTS There is limited evidence to support the use of traction in the treatment of LBP, but the evidence that is available is of low quality  What do you think of the classification approach to treating patients with LBP that could predict good outcomes? Informed clinical decision Improved patient-centered care Development of specific knowledge Does normal population evidence translate to a specific population? Improved standing in the sports medicine community Type of Evidence Anecdotal Classroom Scientific Objectivity Applicability Levels of Evidence Systematic Review and Meta Analysis A comprehensive review of all relevant scientific studies on a particular interest What is good? More reliable than individual studies Exhaustive review of literature Inexpensive to conduct studies Less human sources required No IRB required What is not so good? Time-consuming Not easy to synthesize studies Example of Systematic Review Does the regular wearing of a knee brace improve knee function and stability after ACL reconstruction? Real Example of Systematic Review Hughes L, Paton B, Rosenblatt B, et al Blood flow restriction training in clinical musculoskeletal rehabilitation: a systematic review and meta-analysis British Journal of Sports Medicine 2017;51:1003-1011. Real Example of Systematic Review Results Twenty studies were eligible, including ACL reconstruction (n=3), knee osteoarthritis (n=3), older adults at risk of sarcopenia (n=13) and patients with sporadic inclusion body myositis (n=1). Randomized Controlled Trial A study design that randomly assigns participants into an experimental group or a control group. What is good? Randomization will control bias Reliable evidence What is not so good? Time and Money Management of participants and study Real Example of Randomized Controlled Trial VS.  Patient Satisfaction Ankle Function Semi-Rigid Brace Taping This study shows that treatment of acute lateral ankle sprain with a semi-rigid brace leads to less complications and higher patient satisfaction than treatment with tape. In line with previous studies, there is no difference regarding functional outcome and pain. Therefore, using a semi- rigid brace should be considered for the treatment of acute ankle sprains. Case Report An article that describes and interprets an individual case, often written in the form of a detailed story. What is good? Quick delivery of new diseases or trends Knowledge of rare disease Initiation of awareness What is not so good? Lack of generalizability Not so systematic approach Hard to determine the effect Example of Case Report Athletic trainer had observed three cases of turf toe injuries over 4 seasons on a collegiate football team. All three cases were different in terms of severity. The sports medicine team applied specific approaches to each athlete Nonoperative treatment for stable injuries (the plantar plate is not completely disrupted) Surgical intervention and plantar-plate repair for unstable injuries (the plantar plate and sesamoid apparatus ruptured) Surgical intervention was determined based on Stress and instability testing. All three athletes successfully returned to participation. Sports medicine team realized there is a lack of detailed approach for these patients. The group detailed the diagnosis and treatment for these cases and published their cases in the JAT. Another Example of Case Report Role of Evidence in Clinical Decision-Making Process Not limited to identifying the best treatment for an individual patient case Useful in other areas of clinical practice Prevention, diagnosis, and prognosis Ottawa Ankle Rules In the early 1990’s only 15% of patients with foot/ankle injuries in emergency departments had fractures Nearly everyone got x-rays to rule out fractures 85% of x-rays came back negative Can we reduce the number of false (-) X-rays? Ottawa Ankle Rules Bachman et al, Brit Med J, 2003  Improved practice with OAR? Before Ottawa Ankle Rules: 85% of x-rays were (-) With original Ottawa Ankle Rules: 63% of x-rays were (-) With modified Ottawa Ankle Rules: 49% of x-rays were (-) 99% of patients with fracture identified as needing an x-ray Prevalence of (-) x-rays reduced by 36% Cost savings! Less wait times in emergency department! Less unnecessary radiation exposure to patients! All that matters to patients!! EBP=Standard of Care? Help practitioners to develop a new philosophy that integrates all sources of evidence to improve patient care Required for third party reimbursement Not new in the health care fields EBP CEU mandatory 5 Steps in Practicing EBP 1. Define a clinically relevant question 2. Search for the best evidence 3. Critically appraise the evidence 4. Apply the evidence Ask 5. Evaluate the outcomes of your application Assess Acquire Apply Appraise