Evidence Based Practice

• PTs will be practicioners of choce in pts health networks and will hold all privileges
• Pts can come straight to the PT
• --no doctor referral needed
• --makes PT primary physicians
• characterized by independent, self-determined, professional judgement and action
• responsibility to exercise judgement within scope of practice and to professionally act on that judgement

implies the use of evidence in clinical decision making rather than unquestioning reliance on knowlege ganed from experts or teachers or familiar practice habits

• Best research evidence
• Patient value
• Clinical experience

• Logical considerations and limited time:
• lack of time to search
• --emphasis on productivity
• lack of access to evidence
• lack of skill to search
• lack of ability to interpret
• --applicability/generalization
• --statistics
• --levels of evidence
• Research Methods:
• difficulty using heirarchy of needs
• applicability to patients
• discrepency between research setting and clinical setting
• clinical question vs. research question

• Access:
• convincing employers of benefits/efficiency of EBP
• join APTA for Hooked on EVidence
• make arrangements with affiliating academic PT programs to have online databass access throug institution
• encourage staff to perform/utilize online search tutorials
• develeop efficient search skills
• Research:
• applicability to patient population
• --learn to write answerable foreground/background questions
• --use specific search terms/stratagies
• --integrate best reaserch evidence with your clinical experience and patients unique values and circumstances
• Statistics:
• start a monthly journal club in clinic, develop CAT library
• encourage researchers to publish "readable" studies
• bring in outside experts to provide training on how to clinically appraise the literature
• online resources
• "clinical parters program" at Chatham Univ.

• Journal:
• Author. Title. Journal Title. Year;volume(issue):pg-pg. doi:#.
• Books:
• Author. Title. Edition#. City, State. Publishers name; copyright year.
• Websites:
• Author (if available). Title. Name of Website. URL. Published [date]. Updated [date]. Accessed [date].

• Pubmed: open- Journals in NCBI Databases
• AMA Manual Style: section 14.10 Names of Journals

• new reference
• choose style (AMA)
• reference type
• fill in fields

export from CINAHL

• grab-it
• bookmarklet
• add to favorites

• heirachries developed to focuse on treatment, diagnostic tests, prognostic indicatiors and economic and decision analyses
• ranking system based on ability to minimize biases

• case report
• case control study
• observational cohort study
• randomized control trial
• double blind method
• systematic review

• a detailed description of the managemnt of a pt that may serve as a basis for future research
• Strengths:
• identify new diseases
• prliminary study
• Weaknesses:
• no control group
• no comparison

• retrospective epdemiologic resarch design used to evaluate the relationship between a potential risk factor and a disease/disorder
• two groups of subjects
• --one has the disease/disorder (the case)
• --control group
• two groups are compared to determine which group has greated proportion of individuals with the risk factor
• Strengths:
• quick and cheap
• convenient
• rare diseases
• Weaknesses:
• based on recall
• confounders
• difference to choose control

• study with controlled manipultions of the subjects is lacking
• ig froups are present, assignment is pre-determined based on naturally occurring subject characteristics or activities
• Strengths:
• observing patients
• prospective
• ethical
• Weaknesses:
• confounders time
• cannot prove causation

• clinical study that uses a randomized process to assign subjects to either an experimental group or control group
• subjects in experimental group receive the intervention/preventative measure
• control group doesn't get manipulation
• BEST ONE

• neither the patient nor physician know whether the patient is receiving the treatment or control
• Strengths:
• controls for bias
• control over exposure
• proves efficacy
• Weaknesses:
• expensive
• time consuming
• ethical issues

• method by which a collection of research is gathered and critically appraised in an effort to reach an unbiased conclusion about the cumulative weight of the evidence on a topic
• an exhaustive literature search to locate all original reports on the topic
• critical appraisal of all the reports
• conclusions are drawn based on a synthesis of studies which meet preset quality criteria
• Strengths:
• summaries study
• validate small studies
• generalizability
• Weakness:
• publication bias
• time consuming
• heterogeneity

• strenth of evidence depends on the quality of the study and design
• heirarchies are tools to facilitate EBPT
• PTs must read and critically appraise the evidence before using it
• best avaialbe evidence must be relevant to the clinical question asked

• systematic review
• randomized control study
• cohort study
• case control study
• case series study
• expert opinion

• an integration of:
• --best evidence from current research
• --patient preferences and values
• --clinical expertise
• evidence is derived from:
• --consistant clinical research with high quality

• ask: formulate an answerable clinical question
• access: track down best evidence
• appraise: critically appraise evidence for its validity
• apply: integrate the results with your clinical expertise
• assess: evaluate the effectiveness of the process

• relect of desire to understand the nature of the problem or need
• most often focuse on the medical aspects rather than PT issues
• aquestions asked by pts, students and new grads
• experienced professionals will ask these questions when presented with new situations
• general knowledge - who, what, when, where, why

• questions are central to EBPT allowing clinicians to make decisions about specific clinical management issues
• questions can involve diagnostic tests, clinical measures, prognostic factors, interventions, clinical prediction rules, and outcomes
• question about different factors are worded differently
• PICO
• specific knowledge

• P: patient, population, or problem
• I: intervention, exposure, test
• C: comparison intervention (if relevant)
• O: outcomes

• treatment/intervention
• diagnosis/assessment
• prognosis
• --increase risk?
• etiology/harm
• meaning/process
• --experience certain conditions?

• thearpy
• prevention (best)
• etiology/harm (best)

• prevention (2nd best)
• prognosis (best)
• etilogy/harm (2nd best)

• prevention (3rd best)
• prognosis (2nd best)
• etiology/harm (3rd best)

Diagnosis

cast analysis

• 1. search once concept at a time
• 2. combine similar concepts with OR
• 3. combine different concepts with AND
• 4. revise/apply limits
• 5. add to folder/selected list
• 6. find full text
• 7. manage results - print, email, save
• 8. manage search history

• AND:
• decrease results
• used to indicate both terms be present
• OR:
• increase results
• used to indicate the either term may be present
• NOT:
• used to determine that one term not be present
• nesting:
• order of operations
• items in ( ) combine first
• always combine OR before AND terms

used to combine terms using Boolean Operators to create complex searches

• balancing recall and precision = effective search
• keyword:
• broad search
• high recall + low relevance
• subject:
• narrow search
• low recall + high relevance
• comprehensive search:
• subject + keyword
• high recall + mixed high and low relevance

search for terms in the title, abstract

• searches for all words from the root word
• * - ovid
• $ - CINAHL

• fielded search
• apply more limits - age range, years of publication, gender

• broaden terms
• truncation
• additional synonyms for terms
• what other disciplines research this topic

• Medline
• CINAHL - nursing/allied health
• Conchrane - collection of 6 data bases
• --cochrane systematic review
• --other reviews
• --clinical trials
• --methods studies
• --technology studies/assessments
• --economic evaluations
• freely available resources
• PEDro
• --australian EBP tool
• --focuses on PT
• --only use AND or OR, not both
• --automatic truncation
• National Guidlines Clearinghouse
• PubMed
• TRIP
• --(turning research into practice)
• --filters results by evidence based medical heirarchy

• hopital library
• public library
• local college/univ. library
• google scholar

• characterized by informe, shared decision making development of pt knowledge, skills needed, self-management, and preventative behaviors
• a rejection of the traditional model in which providers make choices for pts based on knowledge and understanding of health related issues

• promote the rights of pts to make decisions about the health care
• include principles that promot EBP
• promotes:
• --autonomy - pts rights to make decisions
• --beneficience - make decisions in the pts best interest
• --malficience - avoid harm

• requires formal conversation between PTs and pts concerning services to be accepted
• shared decision supports an active partnership between the patient and PT in all decisions

• Hippocratic Oath: do no harm
• Declaration of Helsinki: standard medical care/treatment; research
• Belmont Report: respect for persons, beneficience, justice
• Nuremburg Code
• NBAC: bioethics advisory (stem cells, right of human subjects)

• Risks:
• probability and magnitude of a harm
• unanticipated problems
• Benefits:
• direct
• secondary
• monitoring

• an abstract
• mental images of an observable phenomenon described in words
• --age, strength

• a non-observable abstraction created for a specific purpose that is define by observable measures
• --satisfaction
• --quality of life

• an organized set of relationships among concepts and construcs that is proposed to explain relationships
• aka: conceptula framework/theoretical framework
• grand theory
• --Piagets Theory of Cognitive Development

• summarizes and critiques prior studies to clarify what is known about the research topic
• may be focused on studies related to research question
• may indicate need for furture research
• may include limitations of prior research to establish a rationale for the current study
• should be evaluated
• --age of prior studies reviewed
• --logical sequence of info
• --articles relate to research question

• a statement of what is being researched
• not too broad to answer, but not too small as to be insignificant

• predict no difference or relationship between variable will de demonstrated
• results may be due to chance
• preferred style in many scholarly publications

• predictions that state the expected relationship
• any observed difference is not due to chance
• may be nondirectional or directional