evidence based practice that hlps in you reasarch and ease you in reaseach practice. in this presentation many things are given which you learn n your research article.

1. Dr Muhammad khan Bugti
DPT,MSPT, MBA
Assistant Professor
BNBWU sukkur

2. Lecture objectives
 Define EBP
 Purpose of EBP
 What is ‘best evidence’
 Discuss how to ask relevant clinical question and its
importance

3. What is EBP?
 The application of clinical decision making for
patient management based on research
evidence, clinical expertise, patient values and
preferences and clinical circumstances
- Dave Sackett
Patient
Concerns
Clinical
Expertise
Best research
evidence
EBM

4. Purpose of Evidence based practice
 To integrate best research evidence with our clinical
expertise and our patient’s unique values and
circumstances
 The concept of EBP makes sure that the patient is
provided quality care because our choices are backed
by sound scientific data
However
There is no pure scientific method that can replace the
influence of experience, intuition and creativity in
clinical judgment

5.  ‘Evidence based practice’ helps in clinical decision
making by integrating the ‘art’ of clinical practice and
the ‘science’ that supports clinical practice
 Therefore, it is the applied evidence to a clinical
scenario or in the context of a patient to support the
process of clinical decision making. We can also call it
EVIDENCE-BASED DECISION MAKING
Purpose Cont….

6. EBP may not be possible when:
 Scientific evidence is incomplete
 Scientific evidence is unavailable
 There is no access to latest literature
 The clinician does not realize the importance of
cognition and metacognition and practices on the
basis of intuition and antedotes

7. Why do we need ‘best evidence’
 Sackett and colleagues mention that
EBP is the conscientious, explicit and
judicious use of current best evidence in
making decisions about the care of the
individual patients.
 Studies that meet validity standards
should be used to determine how the
results of the research apply to the given
clinical situation

8. Component of a good clinical
question - PICO
 The process of EBP starts by asking a relevant clinical
question. Therefore a good and comprehensive
question (relating to the patient issues and
management) is a basis to finding the relevant answer
 P Patient/ problem
 I intervention
 C comparison
 O outcome

9. PICO
 P – the target population? Characteristics of the
patient or the problem being considered
 I – intervention being considered. Prognostic factor or
a diagnostic test
 C – what comparison or control condition is being
considered. (Not relevant for a question of prognosis
or examining one diagnostic test or intervention
 O – outcomes of interest. What measurements will be
relevant to understanding the effectiveness of an
intervention and importance of a prognostic factor or a
diagnostic test accuracy

10. Questions may be related to:
 Patient’s diagnosis, prognosis or intervention
 Clinical guidelines and their validity
 Etiology of patient problem
 Safety and cost effectiveness of care

11. CASE EXAMPLE
 MJ is a 75 yr old woman who suffered a R CVA 2
months back. She is being seen by an occupational,
physical and speech therapist in an inpatient setting.
She walks with a cane – mod assistance and exhibits
poor balance. One of your colleagues suggest that you
consider training the patient on a treadmill with
partial body weight support, but you have not tried
this approach before.

12.  In an elderly patient 2 months post stroke - Patient
 Is partial weight-bearing supported treadmill training -
Intervention
 More effective than traditional gait training with full
weight bearing – Comparison
 For improving walking speed, endurance and balance? -
Outcome

13. Lecture objectives
 In today’s class we will:
 Continue with the process of evidence based practice
 Discuss the PICO further
 Discussion and feedback on PICO assignment

15. The process of EBP
The process of finding evidence to answer clinical queries is a
systematic process. It includes:
1. Formulating a clear clinical question based on patient’s
problem
2. Search the literature for relevant clinical articles/ evidence
3. Evaluate ( critically appraise) the literature for its validity
and usefulness
4. Implement the findings in clinical practice
5. Evaluate the outcome

16. Step 1 – formulating a clear clinical
question
One of the fundamental skills
required for practicing EBM is
the asking of well-built clinical
questions.
To benefit patients and clinicians,
such questions need to be both
directly relevant to patients'
problems and phrased in ways
that direct your search to
relevant and precise answers.
In practice, well-built clinical
questions usually contain four
elements

17.  One of the benefits of careful and thoughtful
question-forming is that the search for evidence is
easier. The well-formed question makes it relatively
straightforward to elicit and combine the appropriate
terms needed to represent your need for information
in the query language of whichever searching service is
available to you.
Once you have formed the question using the PICO
structure, you can think about what type of question it
is you are asking, and therefore what type of research
would provide the best answer

18. Center for Evidence Based Medicine. University of Oxford

19.  PICO
 Who, what and why of the clinical query
 The clearer each element of the question and its
components, easier it is to find relevant articles

20. Scenario for the clinical question
 You run an outpatient group on rheumatoid arthritis and teach
them joint protection and energy conservation . The energy
conservation part seems to be particularly successful. You think
of proposing this to client’s with other conditions experiencing
fatigue such as people with MS or AIDS. You decide to use the
evidence base for using energy conservation education as a way
of decreasing with these client group. You are also interested to
explore whether group or individual sessions are more effective
or whether sessions should focus solely on information or
should include discussion and a self-help focus

21. EVIDENCE BASED PHYSICAL
THERAPY PRACTICE
MM.DD.20XX ADD A FOOTER 21
Evidence-based physical therapist practice is “open and
thoughtful clinical decision making” about physical
therapist management of a patient or client that
integrates the “best available evidence with clinical
judgment” and the patient or client’s preferences and
values, and that further considers the larger social
context in which physical therapy services are provided,
to optimize patient or client outcomes and quality of
life.

22. Components of Evidence
Based Practice

23. CDM is a complex process which is used to analyze,
synthesize, and interpret relevant information.
Professional judgment is required to achieve effective
outcomes.

24. CLINICAL
REASONING
Specific
Patient
Knowledge
management in
practice
Evidence
based
practice
Finding of
research
Professional
judgment
CONTEN
T
RELEVAN
T
CLIENT
CENTER
ED

25. Patients/clients “ Unique Preference, Concerns,
Expectation”
Individual's expression of desirability or value of one
course of action, outcome, or selection in contrast to
others.

26. Patient
Preference Model
 Traditional Model
Decision about the therapies are made by the
Physiotherapists.
 Contemporary Model
Physical Therapist is able to communicate risk and benefits
of the preferences given by the client using clinical expertise
and high quality research.
a) The physical therapist must be flexible, empathy, and
honest in communication
b) In the contemporary model, physical therapist
encourages client in decision making.

27. “ Practice knowledge is knowledge arising from
professional practice and experience”

28. MM.DD.20XX
Reproduced from Evidence-Based Healthcare: A Practical Guide for Therapists, Tracy Bury & Judy Mead, Page 10,
Copyright 1999 by Elsevier. Reprintedith permission from Elsevier. 28

29. CASE SCENARIO
• 24 Year old male k/c of DM, HTN admitted
with c/o
-Fever 104
-Vomiting
-ALOC
Currently Intubated and sedated on CMV with
450 ml Tidal Volume
On Inotropic support
CXRAY Showing : Lt Lung Collapsed
Trop I 1.04
Patient is on DNR code and family wants CPR
if condition deteriorates
How will you describe the role of evidence
in your clinical decision making?

30. CASE SCENARIO
• 60 Year old female k/c of 2nd POD of
Total Knee Arthroplasty,
As per the need and demand of the
patient, High Chair is suggested for sitting,
one of the Pt’s attendant had previously
undergone same treatment but didn’t used
high chair.
What will be your physical therapy
management in this case scenario?

31. TERMINOLOGIES TO RECALL
The purposeful use of various physical therapy procedures
and techniques, in collaboration with patient/ client and
when, appropriate, other care providers, in order to effect a
change in patient/client’s condition
Intervention
Comprises knowledge of or skill of some thing or some event
gained through involvement in or exposure to that thing or
event
Experiences
Prediction of the natural course of a disease or condition or
its development based on previously identified risk factors.
Also predicted optimal level of improvement through
intervention and the amount of time required to achieve that
level
Prognosis
A process that integrates and evaluates the data obtained
during a patient/ client examination often resulting in a
classification that guides prognosis, the plan of care and
subsequent intervention
Diagnosis
The cause, set of causes, or manner of causation of a disease Harm or

32. PT PATIENT/CLIENT MANAGEMENT
PROCESS
MM.DD.20XX
Reprinted from Guide to Physical Therapist Practice 3.0 (http://guidetoptpractice.apta.org), with permission of the
American Physical Therapy Association. Copyright © 2006 American Physical Therapy Association. All rights
reserved.
32

33.  The first step is a professional commitment as best
one can, under given environment and resource
constraint.
 Second is to consider the questions that arise
during the daily management of a patient problem.
 These questions direct the search for evidence

34. Background questions reflects a desire to understand
the nature of a patient/clients problem or need.
These questions focus on the natural evolution of a
condition and its medical or surgical management
rather on physical therapy component.

35.  What are the side effects of steroid treatment for
asthma?
 How long will it take for a total knee arthroplasty
incision to heel?
 What are the sign and symptoms of an exacerbation
of multiple sclerosis?
 Will it be possible to play baseball again after elbow

36. Foreground questions are the heart of evidence-based
physical therapist practice. These questions help clinicians
to make decisions about the specific physical therapy
management of the problem or issue.

37.  Will the Neer’s test help me detect rotator cuff
impingement in a 35-years-old male tennis player
with shoulder pain?
 Is a manual muscle test a reliable and valid measure
of quadriceps strength in a 42-years-old woman
with multiple sclerosis?
 Is lower extremity muscle strength a predictor of
fall risk in a 76-year-old woman with diabetes?
 Is PNF an effective treatment technique for
restoring core trunk stability in a 7 year old child
with right hemi-paresis due to stroke

38.  Diagnostic test
 Clinical measures
 Interventions
 Outcome measures
 Prognosis

39. It is a process by which PT labels and classify a
patient/client’s problem or need
Test used during PT examination provide the objective
data for the diagnostic process.
Test
Accurate and
Persuasive
information
Risk and
cost

40. Clinical Measures are used to quantify patient’s
impairment in body functions and structures as well as
Activity Limitations and Participation Restriction.

41. “Interventions are the techniques and procedures PT use to produce a
change in the patient/client ”
 Focus:
 Benefit or Risk of a treatment technique.
 Goal:
 To identify which treatment approaches will provide the desired
effect
 Consider the patient/client’s preferences and values.
 Minimize costs
 Expedite the treatment process

42. “A process of making predictions about
the future health status of
patient/client.”

43. FOREGROUND QUESTIONS
SIMPLE
FOREGROUND QUESTIONS
COMPARITIVE
DIAGNOSTIC
TEST
Will chest X-ray help me
detect pneumonia in a 25
year old patient with
dyspnea and productive
cough?
Is chest X-ray more reliable
than chest CT in detecting
pneumonia in a 25 year old
patient with dyspnea and
productive cough?
CLINICAL
MEASURES
Is BOD POD a reliable and
valid measure to quantify
the amount of fat in tissue?
Is BOD POD more reliable
and valid than skin fold
thickness test for
quantifying amount of fat
in tissues?
PROGNOSTIC
FACTORS
Is lower extremity muscle
weakness a predictor of fall
risk in a 76-year-old woman
with diabetes?
Which is a stronger
predictor of fall risk, lower
extremity muscle weakness
or loss of proprioception,
in a 76-year-old woman
with diabetes?

44. INTERVENTION Is Mulligan technique an
effective treatment
technique for restoring
ROM in a 45 year old
adult with cervical
spondylosis?
Is Mulligan technique more
effective than Maitland
technique for restoring ROM
in a 45 year old adult with
cervical spondylosis?
OUTCOME
MEASURES
Does participation in
a cardiac
rehabilitation
program increase
the chance that a 58-
years-old man will
return to work
following a MI
Does participation in a
cardiac rehabilitation
program increase the
chance of return to work
more than home
walking program in a 58-
years-old man following
a MI

45.  Patients
 Physiotherapists and the profession
 Funders of physiotherapy services

46.  Practice that involves high quality research is more safe and relevant
for patients than a practice which is only of assumptions, thoughts,
poor experience and lack of knowledge.
 Physiotherapy will produce the best possible clinical outcomes when
it is evidence based.
 Now a days patients are increasingly demanding information about
their disease or clinical problems and the options available for
treatment.

47.  Physiotherapists assert that they are professionals.
 One of the unique characteristic of a professional is
Trustworthiness, in a sense that they are expected to be
good, consider the patient’s interests and have high
ethical standards.
 A prerequisite is that the profession must be aware of
what the evidence says.
 A practitioner that does not know whether the evidence
indicates that the interventions they offer are effective
may have a questionable claim to being ‘professional’.
 physiotherapists act as a autonomous or semi

48.  Identify a clinical question
 Search for the most appropriate evidence
 Critically appraise this evidence
 Incorporate the evidence into a strategy for action
 Evaluate the effects of any decisions and action taken
Thomson et al., 2005

49.  Know-how in finding, appraising, and applying evidence
 Information Resources on tap
 Lack of Time

50. We usually break questions about the effects of
intervention into four parts (Sackett et al 2000)
 Patient/ problem/ population
 Intervention or management strategy
 Comparative intervention
 outcome

51. Patient Intervention Comparisonintervention outcome
Adult with acute low back
pain
Bed rest Advice to stay active Pain and disability
In patients with acute low back pain, does bed rest or advice
to stay active produce greater reductions in pain and
disability?’

52. Exerci
se

53. What are background & Foreground
Questions?????
 What is Myasthenia Gravis?
 Does the use of cell phones increase the
incidence of brain cancer?
 What are the symptoms of bacteremia?
 What are the causes of surgical wound
infection following hip replacement?
 How can we prevent falls in the elderly?
 What cooling methods are used to treat
heatstroke?

54.  What is Myasthenia Gravis? B
 Does the use of cell phones increase the incidence
of brain cancer? F
 What are the symptoms of bacteremia? B
 What are the causes of surgical wound infection
following hip replacement? F
 How can we prevent falls in the elderly? B
 What cooling methods are used to treat
heatstroke? B
 What factors influence parents' decisions

55. Examples of PICO
1. In ventilated patients ,(head-of-bed
elevation of 45 degrees compared to 20
degrees reduce incidence of ventilated
associated pneumonia
2. In hospitalized children, does the Wong-
Baker Pain FACES Rating Scale compared to
the Child Medical Fear Scale) more
effectively evaluate the child's level of pain?

56. 1. In ventilated patients (P), head-of-bed
elevation of 45 degrees (I) compared to 20
degrees (C) reduce incidence of ventilated
associated pnemonia (O)
2. In hospitalized children,(P) does the Wong-
Baker Pain FACES Rating Scale (I) compared
to the Child Medical Fear Scale (C) more
effectively evaluate the child's level of pain
(O)?
3. In non-ambulatory patients, (P) does