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Evidence Based Practice (EBP)
in Physiotherapy
What is it?
What it is not?
Why EBP?
How to do?
Saurab Sharma, MPT
Lecturer, Department of Physiotherapy
Kathmandu University School of Medical Sciences
Objective of the session
To explain:
• What is Evidence Based Practice (EBP)?
• What EBP is NOT?
• How to be an Evidence based practitioner?
2
1. What is Evidence based Practice?
3
Brainstorming?
Q. How do you decide what
physiotherapy treatment will you
give for a patient with LBP????
4
Brain-storming
What do you do when you don’t know
the meaning of a word?
5
How to choose which treatment
works?
1. Because we have read about them in books
2. Because we’ve used these before & they have
worked based on our clinical experience
3. Because the research prove that these treatments
work
4. What patients tell you works the best?
6
How to choose which treatment
works?
7
All of These
Which are the components of EBP
Evidence Based Practice (EBP)
What is it?
EBP- components
EBP
• EBP promotes the collection, interpretation &
application of valid evidence in clinical
decision making.
• The evidence could be:
 Patient-reported
 Clinician-observed
 Research-derived
10
EBP: History
• 1970s at McMaster University, Canada
• So, it is called Evidence Based Medicine (EBM)
• Spread to other disciplines
• Started in Physiotherapy in 1990’s
• Started in Nepal in 2010 at KUSMS
Hoffmann T et al. Evidence based practice across the health professionals. 2010
What is “evidence”?
Can be defined as:
“The available facts, circumstances
etc, supporting or otherwise, a belief,
proposition etc or
indication whether or not a thing is true or
valid”
(Thompson D, Concise Oxford Dictionary of Current English, 9th Edition)
12
What is EBM?
“ The conscientious, explicit and judicious
use of current best evidence in making
decisions about the care of individual
patients.”
• Conscientious= based on principles
• Explicit= open/ clear/ unambiguous
• Judicious= sensible/ thoughtful/ fair
(Sackett DL., Rosenberg WMC., Gray JAM, Haynes RB, Richardson WS. 1996.
Evidence based medicine: what it is and what it isn’t. BMJ 312”71 – 2.) 13
2. What is EBP is NOT?
14
What it is NOT?
• Asking seniors/ teachers for clinical doubts
• Reading outdated books
• Using google for finding the answers
• Solely depending on EVIDENCE for clinical
practice (without considering clinical experience
or patient’s preferences or expectations)
15
3. Why Evidence based practice (EBP)?
16
Why do we need EBP?
• Clinical decision-making
• Clinical practice is often 10 years behind research
• Traditional sources of information ie books are no
longer adequate or up-to-date
17
Why do we need EBP?
• Improved quality and efficiency of healthcare
management
• Keeps up to date- Life Long Learning
18
Why research in Physiotherapy?
• Physiotherapy is SCIENTIFIC approach of patient
treatment
• To justify our action/ treatment
19
Why research in Physiotherapy?
• To move from Hit and trial method of treatment to
Evidence based approach
• To standardize the treatment
20
Why research in Physiotherapy?
• To deliver the best quality services to the patients
• Easier and safer Clinical Decision Making
• To understand other health care professional’s
research activities (eg. Evidence Based Medicine)
and communicate with them.
21
Who would want evidence?
• Consumers – best outcomes - EBP
• Clinicians – best clinical practices, ethical
responsibility- EBP
• Management- Evidence Based management
• Policy making- Evidence Based policy
• Funding bodies – accountability and cost
22
Hoffmann T. Evidence based practice across the health professionals. 2010
Usage of PEDro (2010-11)
• One search every 19 seconds
• Maximum utilization- USA (13%), Australia (12%),
Brazil (8%), UK (6%), Spain (6%), Germany (5%)
• Highest usage- Peru (255 times/physiotherapist)
• INDIA – ranks 99 (1.3 times/PT)
23Campos et al. 2013; Physiotherapy
Why EBP in Students?
• To gain updated knowledge
• To identify the most accurate diagnostic tests and
the most effective interventions
• To build strong clinical reasoning based on the
best available evidence
• To defend the answer in viva or exams.
24
25
1st 30%
2nd 29%
3rd 17%
4th 11%
Intern 11%
EBP utilization in Nepal
Subedi K, Maharjan J, Sharma S; 2015- under review
Year of Study
26
Yes – 98 %
No – 2 %
Do You Use Internet As Learning
Source?
Subedi K, Maharjan J, Sharma S; 2015- under review
27
No. of students
61%
31%
45%
32%
9%
How Did You learn about
E-learning?
Subedi K, Maharjan J, Sharma S; 2015- under review
WHICH ALL E-LEARNING SITES ARE
YOU AWARE OF?
28
94%
83%
52%
59%
33%
41%
14%
28%
42%
10%
9%
5%
EBP utilization by students in
Nepal
Subedi K, Maharjan J, Sharma S; 2015- under review
29
91%
30%
6%
74%
5%
Awareness of social sites as
E-learning source
Subedi K, Maharjan J, Sharma S; 2015- under review
30
5%
11%
33%
40%
10%
How often you use E-learning for
regular learning?
Subedi K, Maharjan J, Sharma S; 2015- under review
31
24%
65%
10%
0%
1%
Does internet help in your
E-learning?
Subedi K, Maharjan J, Sharma S; 2015- under review
32
83%
33%
41%
52%
10%
8%
What Are Your Barriers to
E-learning?
Subedi K, Maharjan J, Sharma S; 2015- under review
3. How to do EBP?
33
5 steps to EBP
1. Convert a clinical problem into answerable
clinical question
2. Find the best evidence (literature search)
3. Critically appraise evidence for validity, impact
and applicability
4. Apply results to clinical practice
5. Evaluate the effectiveness and efficacy 34
(Hoffmann T. Evidence based practice across the health professionals. 2010)
Step 1. Convert a clinical problem
into a searchable question
• Patient or population (P)
• Intervention (I)
• Comparison (C)
• Outcome (O)
= PICO
35
How to ask a clinical question?
• Patient or population (P)- adult, children,
pregnant women, elderly?
• Intervention (I)- Cryotherapy
• Comparison (C)- Ice vs Ultrasound
• Outcome (O)- Pain, functional ability, muscle
strength, range of motion etc.
36
Step 2 –Search for the best evidence
• Recent evidences
• Internet – try to find articles which have
already been through an appraisal process
eg. Cochrane, PEDro
• Some databases: PubMed/ Medline,
Scopus, Embase, CINAHL, proquest
37
Step 3 – Critically appraise the
evidence
• Level of Evidence - SACKETT, NHMRC, Oxford,
GRADE
• Quality scoring- PEDro scale
• Adopt standard guidelines or checklists-
PRISMA, CONSORT, STROBE checklists
(http://equator-network.org)
38
Step 3 – Critically appraise the
evidence
• Validity- is the evidence trustworthy?
• Impact-
– Look at the results
– Clinical importance of study
– Significant effect on the outcome
• Applicability- are the results clinically important?
39
Hierarchy of Evidence
40
Experimental
studies
Meta-analysis &
Systematic reviews
Randomised Controlled Trials
(RCT)
Observational
Studies
Cohort
Case-control
Cross-sectional
Case-series
Case-report
Expert opinion
Step 4 : Apply the Results to Clinical
practice
Use the results of your literature search
• to frame your treatment protocols;
• to generate future research questions and
• to determine the cost-effectiveness of treatments
41
Step 5 : Evaluate
• Evaluate the effectiveness and efficacy with which
steps 1-4 were carried out
• Think about ways to improve
• Evaluate the efficacy of the intervention on
outcomes
42
Steps in EBP
43
5 A’s
What is optimal evidence?
 Best available
 Current/latest
 Valid and reliable
 Relevant
 Applicable
 Cost-effective
44
Summary
1. What is EBP?
2. What it isn’t?
3. Why EBP?
4. How to do EBP?
45
Thank You!!!!
46
saurabsharma1@gmail.com
Kathmandu University
School of Medical Sciences

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Evidence based practice (EBP) in physiotherapy

  • 1. Evidence Based Practice (EBP) in Physiotherapy What is it? What it is not? Why EBP? How to do? Saurab Sharma, MPT Lecturer, Department of Physiotherapy Kathmandu University School of Medical Sciences
  • 2. Objective of the session To explain: • What is Evidence Based Practice (EBP)? • What EBP is NOT? • How to be an Evidence based practitioner? 2
  • 3. 1. What is Evidence based Practice? 3
  • 4. Brainstorming? Q. How do you decide what physiotherapy treatment will you give for a patient with LBP???? 4
  • 5. Brain-storming What do you do when you don’t know the meaning of a word? 5
  • 6. How to choose which treatment works? 1. Because we have read about them in books 2. Because we’ve used these before & they have worked based on our clinical experience 3. Because the research prove that these treatments work 4. What patients tell you works the best? 6
  • 7. How to choose which treatment works? 7 All of These Which are the components of EBP
  • 8. Evidence Based Practice (EBP) What is it?
  • 10. EBP • EBP promotes the collection, interpretation & application of valid evidence in clinical decision making. • The evidence could be:  Patient-reported  Clinician-observed  Research-derived 10
  • 11. EBP: History • 1970s at McMaster University, Canada • So, it is called Evidence Based Medicine (EBM) • Spread to other disciplines • Started in Physiotherapy in 1990’s • Started in Nepal in 2010 at KUSMS Hoffmann T et al. Evidence based practice across the health professionals. 2010
  • 12. What is “evidence”? Can be defined as: “The available facts, circumstances etc, supporting or otherwise, a belief, proposition etc or indication whether or not a thing is true or valid” (Thompson D, Concise Oxford Dictionary of Current English, 9th Edition) 12
  • 13. What is EBM? “ The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” • Conscientious= based on principles • Explicit= open/ clear/ unambiguous • Judicious= sensible/ thoughtful/ fair (Sackett DL., Rosenberg WMC., Gray JAM, Haynes RB, Richardson WS. 1996. Evidence based medicine: what it is and what it isn’t. BMJ 312”71 – 2.) 13
  • 14. 2. What is EBP is NOT? 14
  • 15. What it is NOT? • Asking seniors/ teachers for clinical doubts • Reading outdated books • Using google for finding the answers • Solely depending on EVIDENCE for clinical practice (without considering clinical experience or patient’s preferences or expectations) 15
  • 16. 3. Why Evidence based practice (EBP)? 16
  • 17. Why do we need EBP? • Clinical decision-making • Clinical practice is often 10 years behind research • Traditional sources of information ie books are no longer adequate or up-to-date 17
  • 18. Why do we need EBP? • Improved quality and efficiency of healthcare management • Keeps up to date- Life Long Learning 18
  • 19. Why research in Physiotherapy? • Physiotherapy is SCIENTIFIC approach of patient treatment • To justify our action/ treatment 19
  • 20. Why research in Physiotherapy? • To move from Hit and trial method of treatment to Evidence based approach • To standardize the treatment 20
  • 21. Why research in Physiotherapy? • To deliver the best quality services to the patients • Easier and safer Clinical Decision Making • To understand other health care professional’s research activities (eg. Evidence Based Medicine) and communicate with them. 21
  • 22. Who would want evidence? • Consumers – best outcomes - EBP • Clinicians – best clinical practices, ethical responsibility- EBP • Management- Evidence Based management • Policy making- Evidence Based policy • Funding bodies – accountability and cost 22 Hoffmann T. Evidence based practice across the health professionals. 2010
  • 23. Usage of PEDro (2010-11) • One search every 19 seconds • Maximum utilization- USA (13%), Australia (12%), Brazil (8%), UK (6%), Spain (6%), Germany (5%) • Highest usage- Peru (255 times/physiotherapist) • INDIA – ranks 99 (1.3 times/PT) 23Campos et al. 2013; Physiotherapy
  • 24. Why EBP in Students? • To gain updated knowledge • To identify the most accurate diagnostic tests and the most effective interventions • To build strong clinical reasoning based on the best available evidence • To defend the answer in viva or exams. 24
  • 25. 25 1st 30% 2nd 29% 3rd 17% 4th 11% Intern 11% EBP utilization in Nepal Subedi K, Maharjan J, Sharma S; 2015- under review Year of Study
  • 26. 26 Yes – 98 % No – 2 % Do You Use Internet As Learning Source? Subedi K, Maharjan J, Sharma S; 2015- under review
  • 27. 27 No. of students 61% 31% 45% 32% 9% How Did You learn about E-learning? Subedi K, Maharjan J, Sharma S; 2015- under review
  • 28. WHICH ALL E-LEARNING SITES ARE YOU AWARE OF? 28 94% 83% 52% 59% 33% 41% 14% 28% 42% 10% 9% 5% EBP utilization by students in Nepal Subedi K, Maharjan J, Sharma S; 2015- under review
  • 29. 29 91% 30% 6% 74% 5% Awareness of social sites as E-learning source Subedi K, Maharjan J, Sharma S; 2015- under review
  • 30. 30 5% 11% 33% 40% 10% How often you use E-learning for regular learning? Subedi K, Maharjan J, Sharma S; 2015- under review
  • 31. 31 24% 65% 10% 0% 1% Does internet help in your E-learning? Subedi K, Maharjan J, Sharma S; 2015- under review
  • 32. 32 83% 33% 41% 52% 10% 8% What Are Your Barriers to E-learning? Subedi K, Maharjan J, Sharma S; 2015- under review
  • 33. 3. How to do EBP? 33
  • 34. 5 steps to EBP 1. Convert a clinical problem into answerable clinical question 2. Find the best evidence (literature search) 3. Critically appraise evidence for validity, impact and applicability 4. Apply results to clinical practice 5. Evaluate the effectiveness and efficacy 34 (Hoffmann T. Evidence based practice across the health professionals. 2010)
  • 35. Step 1. Convert a clinical problem into a searchable question • Patient or population (P) • Intervention (I) • Comparison (C) • Outcome (O) = PICO 35
  • 36. How to ask a clinical question? • Patient or population (P)- adult, children, pregnant women, elderly? • Intervention (I)- Cryotherapy • Comparison (C)- Ice vs Ultrasound • Outcome (O)- Pain, functional ability, muscle strength, range of motion etc. 36
  • 37. Step 2 –Search for the best evidence • Recent evidences • Internet – try to find articles which have already been through an appraisal process eg. Cochrane, PEDro • Some databases: PubMed/ Medline, Scopus, Embase, CINAHL, proquest 37
  • 38. Step 3 – Critically appraise the evidence • Level of Evidence - SACKETT, NHMRC, Oxford, GRADE • Quality scoring- PEDro scale • Adopt standard guidelines or checklists- PRISMA, CONSORT, STROBE checklists (http://equator-network.org) 38
  • 39. Step 3 – Critically appraise the evidence • Validity- is the evidence trustworthy? • Impact- – Look at the results – Clinical importance of study – Significant effect on the outcome • Applicability- are the results clinically important? 39
  • 40. Hierarchy of Evidence 40 Experimental studies Meta-analysis & Systematic reviews Randomised Controlled Trials (RCT) Observational Studies Cohort Case-control Cross-sectional Case-series Case-report Expert opinion
  • 41. Step 4 : Apply the Results to Clinical practice Use the results of your literature search • to frame your treatment protocols; • to generate future research questions and • to determine the cost-effectiveness of treatments 41
  • 42. Step 5 : Evaluate • Evaluate the effectiveness and efficacy with which steps 1-4 were carried out • Think about ways to improve • Evaluate the efficacy of the intervention on outcomes 42
  • 44. What is optimal evidence?  Best available  Current/latest  Valid and reliable  Relevant  Applicable  Cost-effective 44
  • 45. Summary 1. What is EBP? 2. What it isn’t? 3. Why EBP? 4. How to do EBP? 45

Editor's Notes

  1. Is treatment a personal opinion or a factual evidence? Research eliminates the subjective elements and makes decision making process more easier.
  2. Is treatment a personal opinion or a factual evidence? Research eliminates the subjective elements and makes decision making process more easier.
  3. Is treatment a personal opinion or a factual evidence? Research eliminates the subjective elements and makes decision making process more easier.
  4. Started in new medical school – medicine of 3 years (where all content can’t be taught, students need to be directed how to find evidence?)
  5. Proposition- plan, proposal
  6. These evidences are either obsolete, or inadequate or not valid …
  7. Universal truths do not change, but facts in medicine and physiotherapy can change, management and diagnosis can get more advanced. Treatments become obsolete etc…
  8. Break the question down into its component parts Identify the client group or problem Intervention(s), Diagnosis, Prognosis Client’s experience and concerns Outcome(s) of interest
  9. Will be elaborated on next class on searching for evidence
  10. Collect tools- sackett, NHMRC, PEDro- further reading