Evidence-based Back Pain Management (EBM in general)


Published on

A generic introductory presentation on using evidence-based medicine (EBM) principles to answer clinical questions. Back pain was used as an example to introduce the concept. The presentation does not address the treatment of back pain. The presentation was given in May 2010.

Published in: Health & Medicine

Evidence-based Back Pain Management (EBM in general)

  1. 1. Evidence-Based Back Pain Management Sohail Bajammal, MBChB, MSc, FRCS(C), PhD(c) Assistant Professor of Orthopaedics May 30, 2010
  2. 2. What got me into EBM…. <ul><li>What is a double blind study? </li></ul><ul><li>Two orthopaedic surgeons </li></ul><ul><li>reading an ECG </li></ul>
  3. 3. Double blind in orthopaedics?
  4. 4. EBM is not new……. <ul><li>“ ثم نرقى في البحث والمقاييس على التدريج والترتيب مع انتقاد المقدمات والتحفظ في النتائج ونجعل غرضنا في جميع ما نستقرئه ونتصفحه استعمال العدل لا اتباع الهوى ونتحرى في سائر ما نميزه وننتقده طلب الحق لا الميل مع الآراء” </li></ul>الحسن بن الهيثم
  5. 5. I will tell you NOTHING about back pain management
  6. 6. I will show you how YOU can FIND EVERYTHING about back pain management
  7. 7. Objectives <ul><li>What is EBM? </li></ul><ul><li>How to ask an answerable question? </li></ul><ul><li>How to search for an answer? </li></ul><ul><li>How to assess the quality of the evidence? </li></ul>
  8. 8. GCC EBHC
  9. 9. National & Gulf Center for EBHP
  10. 10. Statistically speaking… <ul><li>An hour presentation is </li></ul><ul><li>shorter than 5 days workshop (p<0.05) </li></ul>
  11. 11. What is EBM? Haynes et al. BMJ 2002;324:1350 Clinical Circumstances Research Evidence Patients’ Preferences Clinical Expertise
  12. 12. 5As of EBM
  13. 13. Is this a good question? <ul><li>What is the best treatment of acute back pain? </li></ul>
  14. 14. Asking a good question (PICO)! <ul><li>P opulation </li></ul><ul><li>I ntervention </li></ul><ul><li>C ontrol </li></ul><ul><li>O utcome </li></ul>
  15. 15. Is this a good question? <ul><li>In adult patients younger than 50 years old with acute low back pain, does bedrest reduce the risk of recurrence of pain within one year compared with physiotherapy? </li></ul><ul><li>P: Adult patients <50yr with acute LBP </li></ul><ul><li>I: Bedrest </li></ul><ul><li>C: Physiotherapy </li></ul><ul><li>O: Recurrence of pain within one year </li></ul>
  16. 17. How would you search for answers? <ul><li>Ask the audience </li></ul><ul><li>Ask a friend </li></ul><ul><li>Flip through a textbook </li></ul><ul><li>Google it up! </li></ul>
  17. 18. What’s wrong with textbooks? <ul><li>Excellent for the principles & basic knowledge </li></ul><ul><li>Usually single authored chapters </li></ul><ul><li>Likely biased, author’s opinion </li></ul><ul><li>Not peer-reviewed </li></ul><ul><li>Outdated (at least 4 years) </li></ul>
  18. 19. What’s wrong with googling?
  19. 20. What’s wrong with googling? <ul><li>Reliability & credibility of source </li></ul><ul><li>Google Scholar is good </li></ul>
  20. 21. So what to do?
  21. 22. 5S Hierarchy of Evidence Haynes RB. Evid Based Med 2006;11:162-164 RCTs, Cohort, Case control, Case series Expert Opinion: Classical Textbooks
  22. 23. Primary Sources <ul><li>Original articles </li></ul><ul><li>Through databases: MEDLINE, EMBASE </li></ul><ul><li>Using: PubMed, OVID </li></ul><ul><li>You have to retrieve and appraise the articles </li></ul><ul><li>Strength (pyramid) of evidence </li></ul>
  23. 24. Pyramid of Evidence http://library.downstate.edu/EBM2/2100.htm 
  24. 27. MeSH (Medical Subject Headings)
  25. 29. It is a “strategy” Acute Low Back Pain OR &quot;Low Back Pain&quot;[Mesh] AND Low Back Ache Low Backache OR OR AND Treatment Management Therapy OR OR OR Surgery
  26. 30. PubMed Tutorials
  27. 35. Critical Appraisal
  28. 38. It’s time consuming
  29. 39. Secondary Sources Systematic Reviews
  30. 40. Syntheses <ul><li>The authors have done the work for you </li></ul><ul><li>Hopefully : </li></ul><ul><ul><li>They asked a good question </li></ul></ul><ul><ul><li>They searched the literature systematically (keywords & MeSH) </li></ul></ul><ul><ul><li>They identified the studies and assessed their quality </li></ul></ul><ul><li>This is called Systematic Review </li></ul><ul><li>If they did statistical combination of results, this is called Meta-analysis </li></ul>
  31. 41. How to search for “Syntheses”? <ul><li>Same databases: MEDLINE, EMBASE </li></ul><ul><li>Cochrane Library </li></ul>
  32. 42. PubMed
  33. 44. Cochrane Library
  34. 48. Are all syntheses good? <ul><li>You still have to appraise the quality of these systematic reviews and meta-analyses </li></ul><ul><li>It’s time consuming </li></ul>
  35. 49. Appraisal
  36. 51. So what’s next? Critically-Appraised Journal Articles & Abstracts Evidence-Based Guidelines & Textbooks
  37. 52. Synopses <ul><li>Physicians with training in research methodology: </li></ul><ul><ul><li>Read the articles </li></ul></ul><ul><ul><li>Assess their quality </li></ul></ul><ul><ul><li>Summarize them for you </li></ul></ul><ul><li>Many journals: </li></ul><ul><ul><li>JBJS(A) Evidence-Based Orthopaedics Section </li></ul></ul><ul><ul><li>ACP Journal Club </li></ul></ul><ul><ul><li>Database of Abstracts of Reviews of Effects (DARE) </li></ul></ul>
  38. 55. Summaries <ul><li>Evidence-based guidelines and textbooks </li></ul><ul><li>Examples: </li></ul><ul><ul><li>UptoDate </li></ul></ul><ul><ul><li>Clinical Evidence </li></ul></ul><ul><ul><li>National Guideline Clearinghouse </li></ul></ul>
  39. 56. http://clinicalevidence.bmj.com/
  40. 57. http://www.guideline.gov/
  41. 64. Systems <ul><li>This is the ultimate goal </li></ul><ul><li>Computerized decision support </li></ul><ul><li>Too sophisticated for us to think about now </li></ul>
  42. 65. All what we’ve talked about Research Evidence
  43. 66. To practice EBM, we need all the four Clinical Circumstances Research Evidence Patients’ Preferences Clinical Expertise
  44. 67. We need….. <ul><li>To apply the evidence as it applies to our local hospitals </li></ul><ul><li>To involve the patients actively in the decision making </li></ul><ul><li>To have our own studies: </li></ul><ul><ul><li>Different social, cultural, ethnic, and economical backgrounds </li></ul></ul>
  45. 68. http://www.andrews-clinic-natural-therapies.co.uk/documents/54.html
  46. 69. Resources
  47. 70. http://eapps.ngha.med.sa/ebm/
  48. 71. http://ebmjeddah.info/
  49. 72. Information Overflow
  50. 73. MDLinx.com
  51. 74. http://plus.mcmaster.ca/EvidenceUpdates/
  52. 75. This presentation is available online <ul><li>www.uqu.edu.sa/ssbajammal </li></ul><ul><li>المحاضرات </li></ul>
  53. 76. Summary <ul><li>EBM is not only research evidence </li></ul><ul><li>5As of EBM: Ask, Acquire, Appraise, Apply, Act </li></ul><ul><li>Always ask a PICO question </li></ul><ul><li>Search: </li></ul><ul><ul><li>Summaries  Synopses  Syntheses  Studies </li></ul></ul><ul><ul><li>Keywords & MeSH headings </li></ul></ul><ul><ul><li>Use Clinical Queries </li></ul></ul><ul><li>Appraise </li></ul>[email_address]