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![Clinical Question
What is it and why do we use it?
A question that is “directly relevant to the problem at hand… [and] phrased to
facilitate searching for a precise answer.”
From: Richardson, WS. Wilson, MC. Nishikawa J. Hayward, RS. The well-built clinical question: a key to
evidence-based decisions. ACP Journal Club. Nov-Dec 1995.
“ 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.”
Centre for Evidence-Based Medicine. (n.d.). Asking focused questions. Centre for Evidence-Based Medicine.
Retrieved from http://www.cebm.net/asking-focused-questions/.](https://image.slidesharecdn.com/physicaltherapy-picoandalternative-180608154706/85/Searching-with-PICO-and-Alternative-question-formulation-framework-Physical-Therapy-24-320.jpg)
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Searching with PICO and Alternative question formulation framework--Physical Therapy
- 1. Searching the literaturein Physical Therapy Jill Boruff, MLIS, AHIP Associate Librarian Liaison to the School of Physical and Occupational Therapy jill.boruff@mcgill.ca
- 2. Objectives 1. Recognize theimportance of question formulation and searching in the EBP cycle 2. Demonstrate how to design a search strategy from a case scenario using a question formulation framework 3. Use MeSH and keywords to search effectively in MEDLINE 4. Locate the library resources available at McGill
- 3. Outline of today’sworkshop 1. How MEDLINE works when searching subject headings and keywords 2. Discussion of the question formulation framework and how to use it in practical situations to search MEDLINE
- 4.
- 5. Discussion 1. Why dowe search? 2. Why do we use subject-specific databases?
- 6. Evidence-Based Practice Cycle Appraising theEvidence Incorporating evidence into decision-making Evaluating the Process Formulating The Clinical Question Searching the Evidence
- 7. Using MEDLINE onOvid
- 8. Find this article! Roll,S. C., & Hardison, M. E. (2017). Effectiveness of occupational therapy interventions for adults with musculoskeletal conditions of the forearm, wrist, and hand: A systematic review. American Journal of Occupational Therapy, 71, 7101180010. https://doi.org/10.5014/ajot.2017.023234
- 10.
- 11. IDEA 1 IDEA 2 IDEA3 Which ideas best represent this article?
- 12. Boolean Logic connectors AND= every reference contains both (or all) of the search terms specified. OR = every reference contains at least one of the search terms
- 13. What are wesearching? IDEA 1 _____________ OR _____________ IDEA 2 _____________ OR _____________ IDEA 3 _____________ OR _____________
- 14.
- 15. No Keywords for CarpalTunnel Syndrome Subject Headings
- 16.
- 17.
- 18. When to searchkeywords Reason Example When the database does not have controlled vocabulary Google, Scopus, Web of Science When subject headings do not fully capture the idea you are searching Yoga/ but you want specifically “hot yoga” or “bikram yoga” When there is more than one name for an idea Transcutaneous Electric Nerve Stimulation/ or tens.mp. When the idea is new and there is not a subject heading for it yet or the subject heading is new Constraint-induced movement therapy
- 19. “controlled vocabulary” Database willsearch descriptor field Should be the focus of the article because the process involves humans Different in each database, but standardized across articles “natural language” Database will search multiple fields May not be the focus of the article Necessary if subject heading does not exist for your term
- 20. Do a searchin MEDLINE Mr. Monty Smith is 43 years old and has a history of Multiple Sclerosis first diagnosed 3 years ago. He had one relapse since diagnosis and walked with a cane post-relapse. He was admitted to hospital 2 years ago with a second relapse. During that admission he developed increased weakness in his legs. It has taken him a long time to recover but he has achieved his goal of walking with a cane. He continues to have good strength in his upper extremities. During the last year, Mr. Smith is struggling to keep up with his usual activities due to generalized fatigue. He is referred to you for a physical therapy program to address his fatigue. You know that exercise therapy can be effective but you wonder if energy conservation might work well with Mr. Smith.
- 21. Discussion 1. What didyou find? 2. Did everyone find the same information? Is this important?
- 22. http://www.flickr.com/photos/32595 872@N02/4195880838/ Formulating the clinical questionand how to use it http://www.flickr.com/photos/32595872 @N02/4195880838/
- 23. Evidence-Based Practice Cycle Appraising theEvidence Incorporating evidence into decision-making Evaluating the Process Formulating The Clinical Question Searching the Evidence Start here!
- 24. Clinical Question What isit and why do we use it? A question that is “directly relevant to the problem at hand… [and] phrased to facilitate searching for a precise answer.” From: Richardson, WS. Wilson, MC. Nishikawa J. Hayward, RS. The well-built clinical question: a key to evidence-based decisions. ACP Journal Club. Nov-Dec 1995. “ 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.” Centre for Evidence-Based Medicine. (n.d.). Asking focused questions. Centre for Evidence-Based Medicine. Retrieved from http://www.cebm.net/asking-focused-questions/.
- 25. Clinical Question • Directlyrelevant to the patient’s problem: Mother comes with her child with autism in your office There is a specific issue you would like to address • Phrased to facilitate searching for a relevant and precise answer: “Is occupational therapy effective in treating children with autism?” “Does sensory integration improve social behaviour in children with autism?”
- 26.
- 27. Best evidence foryour question Question Best Evidence Therapy •Systematic reviews / meta-analyses •Randomized controlled trials Diagnosis •Diagnostic validation studies •Prospective studies / blind comparison to a gold standard Prevention •Systematic reviews / meta-analyses •Randomized controlled trials •Cohort studies, case control studies Prognosis •Inception cohort studies •Case control studies •Case series Cost-effectiveness •Economic analyses For more information: http://guides.mclibrary.duke.edu/c.php?g=158201&p=1036068
- 28. A framework forsearch question Elements Answer Patient or Population Intervention Comparison Outcome Type of question Answerable clinical question
- 29. A framework forsearch question Elements Answer Problem Population Patient stakeholder Professional stakeholder Type of question Answerable clinical question Elements Answer Intervention Context Outcome measure Time
- 30. Mrs. Holiday isa 65 year old female who is living with the effects of a stroke that happened two years ago. Her recovery has allowed her to get back to work and return to leisure activities, albeit in a modified manner. Her stroke was in her left middle cerebral artery and was considered moderate. She is consulting you, the physical therapist, because for the last two months she is having difficulty completing her weekly hikes due to difficulty controlling her right leg during the walks. You have determined one of the main contributing factors to this problem is the presence of spasticity in the right leg. You know that transcutaneous electric nerve stimulation is used to address this problem, but you wonder if a combined therapy modality might be more effective for Mrs. Holiday in order to improve her ability to control the right leg during walks?
- 31. Elements Answer Patient orPopulation Intervention Comparison Outcome Type of question Answerable clinical question: Mrs. Holiday is a 65 year old female who is living with the effects of a stroke that happened two years ago. Her recovery has allowed her to get back to work and return to leisure activities, albeit in a modified manner. Her stroke was in her left middle cerebral artery and was considered moderate. She is consulting you, the physical therapist, because for the last two months she is having difficulty completing her weekly hikes due to difficulty controlling her right leg during the walks. You have determined one of the main contributing factors to this problem is the presence of spasticity in the right leg. You know that transcutaneous electric nerve stimulation is used to address this problem, but you wonder if a combined therapy modality might be more effective for Mrs. Holiday in order to improve her ability to control the right leg during walks? 65 year old female stroke survivor with spasticity in right leg Combined therapy modality Transcutaneous electric nerve stimulation Improved motor function Therapy In stroke survivors with lower limb spasticity, is a combined therapy modality more effective than transcutaneous electric nerve stimulation alone to improve motor function?
- 32. Elements Answer Problem Population Patient stakeholder Professionalstakeholder Type of question Answerable clinical question Elements Answer Intervention Context Outcome measure Time Mrs. Holiday is a 65 year old female who is living with the effects of a stroke that happened two years ago. Her recovery has allowed her to get back to work and return to leisure activities, albeit in a modified manner. Her stroke was in her left middle cerebral artery and was considered moderate. She is consulting you, the physical therapist, because for the last two months she is having difficulty completing her weekly hikes due to difficulty controlling her right leg during the walks. You have determined one of the main contributing factors to this problem is the presence of spasticity in the right leg. You know that transcutaneous electric nerve stimulation is used to address this problem, but you wonder if a combined therapy modality might be more effective for Mrs. Holiday in order to improve her ability to control the right leg during walks? Spasticity in right leg TENS, combined modality therapy Improved motor function In stroke survivors with lower limb spasticity, is a combined therapy modality more effective than transcutaneous electric nerve stimulation alone to improve motor function? Therapy 65 year old female Leisure activities Stroke 2 years agoPhysical Therapist
- 33. What are wesearching? IDEA 1 Stroke/ IDEA 2 Muscle Spasticity/ IDEA 3 Transcutaneous Electric Nerve Stimulation/ IDEA 4 Combined modality therapy/ AND
- 34. Evidence-Based Practice Cycle Appraising theEvidence Incorporating evidence into decision-making Evaluating the Process Formulating The Clinical Question Searching the Evidence Move to the next step
- 36. Back to ourfirst search Mr. Monty Smith is 43 years old and has a history of Multiple Sclerosis first diagnosed 3 years ago. He had one relapse since diagnosis and walked with a cane post-relapse. He was admitted to hospital 2 years ago with a second relapse. During that admission he developed increased weakness in his legs. It has taken him a long time to recover but he has achieved his goal of walking with a cane. He continues to have good strength in his upper extremities. During the last year, Mr. Smith is struggling to keep up with his usual activities due to generalized fatigue. He is referred to you for a physical therapy program to address his fatigue. You know that exercise therapy can be effective but you wonder if energy conservation might work well with Mr. Smith.
- 37. Elements Answer Patient orPopulation Intervention Comparison Outcome Type of question Answerable clinical question: Mr. Monty Smith is 43 years old and has a history of Multiple Sclerosis first diagnosed 3 years ago. He had one relapse since diagnosis and walked with a cane post-relapse. He was admitted to hospital 2 years ago with a second relapse. During that admission he developed increased weakness in his legs. It has taken him a long time to recover but he has achieved his goal of walking with a cane. He continues to have good strength in his upper extremities. During the last year, Mr. Smith is struggling to keep up with his usual activities due to generalized fatigue. He is referred to you for a physical therapy program to address his fatigue. You know that exercise therapy can be effective but you wonder if energy conservation might work well with Mr. Smith. Adult male with multiple sclerosis-related fatigue post second relapse Energy conservation Exercise Therapy Reduced fatigue Therapy In patients with multiple sclerosis-related fatigue, is energy conservation more effective than exercise therapy in reducing fatigue?
- 38. Mr. Monty Smithis 43 years old and has a history of Multiple Sclerosis first diagnosed 3 years ago. He had one relapse since diagnosis and walked with a cane post-relapse. He was admitted to hospital 2 years ago with a second relapse. During that admission he developed increased weakness in his legs. It has taken him a long time to recover but he has achieved his goal of walking with a cane. He continues to have good strength in his upper extremities. During the last year, Mr. Smith is struggling to keep up with his usual activities due to generalized fatigue. He is referred to you for a physical therapy program to address his fatigue. You know that exercise therapy can be effective but you wonder if energy conservation might work well with Mr. Smith. Elements Answer Problem Population Patient stakeholder Professional stakeholder Type of question Answerable clinical question Elements Answer Intervention Context Outcome measure Time Fatigue In patients with multiple sclerosis-related fatigue, is energy conservation more effective than exercise therapy in reducing fatigue? Therapy Adult male w/ multiple sclerosis Physical Therapist Exercise therapy General activities Reduced fatigue Post second relapse
- 39. What are wesearching? IDEA 1 Multiple sclerosis/ IDEA 2 Exp exercise therapy/ IDEA 3 Energy methabolism/ or Energy conservation.mp IDEA 4 Fatigue/ AND
- 41. When is thisframework useful? • To identify your clinical question • To select the best resource(s) or study design to answer your question • To focus your search on the most important elements
- 42. Database Subject areasPublication types included Dates covered Controlled vocabulary Medline / PubMed Biomedicine and health care Journal articles, editorials 1946 to present Yes EMBASE Biomedicine, rehabilitation, pharmacology Journal articles, editorials, conferences 1947 to present Yes CINAHL Nursing and allied health Journal articles, editorials, trade magazines 1937 to present Yes PsycInfo Psychological, social, behavioral, and mental health Journals articles, books, book chapters 1806 to present Yes Database comparison
- 43. Reviewing what welearned
- 44. Reviewing what welearned 1. The importance of question formulation and searching in the EBP cycle 2. Using the question formulation framework to refine your question and focus your search 3. Designing a search strategy from a case scenario: • use subject headings and keywords according to your needs • choosing the type of study you are looking for
- 45. Need Help? Osler Libraryof the History of Medicine • Located in the McIntyre Medical Building • Reserve materials, holds, and ILL pick-up available • Study space Schulich Library of Physicial Sciences, Life Sciences, and Engineering • Located on lower campus • Library service hours with librarian on duty: Monday to Friday, Sunday • Non-reserve materials for Life Sciences • Extended hours for study • My office!
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Editor's Notes
- #2 Introduce yourself;
- #3 State the objectives of this lesson; State your expectations for students' participation and the importance of searching for their academic and professional practices.
- #4 Content broken up into two parts: technical and practical
- #5 First we will look at how the database works http://www.redorbit.com/media/uploads/2013/06/KidMathShapes_062513-617x416.jpg
- #6 Question 1: (to look for evidence to support our practices) Question 2: (focused on our specific needs; they contain the most updated knowledge) Discussion about database search Ask them the first question and have a whole-class discussion. Then move on to the second question. Let at least 3 students talk.
- #7 Cycle of "decision making" Present the cycle of literature search. Emphasize the importance of a good search for a good practice—but don’t spend much time here as we spend more time on it later.
- #8 Finding MEDLINE/OVID database Navigate here from PT/OT subject guide Point out that they need to be on Advanced search, MEDLINE, “map term to subject heading” While still in Ovid, tell them that you will show them how to find an article by title. Have them click on the “title” button. Then tell them that you will put up the title on the next slide.
- #9 Give them some time to find the article. Then go back to ovid and find it yourself to show them how to click on the title to see the full record.
- #10 Tell them that they should see something like this with all this info
- #11 And we will focus on these three parts (cut down so that you can see better!) Emphasize that Subject headings search the Subject heading field (and that they will learn how to do that in a moment) And keywords search the title and abstract field, not the full text.
- #12 Ask them to read the abstract and give 3 ideas that are representative of that article If possible, write the 3 ideas in the PPT presentation (bubbles). Discuss different ways of describing each idea Now, to find an article, what do we do?
- #13 Explain the role of AND/OR logic connectors Emphasize that they fundamentally work in our favor to find the best type of evidence (OR expands our search, AND filters our search).
- #14 Show them how to connect the different ideas to find articles in the database
- #15 The following examples will show you why subject headings are important and why we use them Tie back to the ideas you put into the bubbles on slide 17 Then go to Ovid and search Carpal Tunnel Syndrome. Point out “explode” and “focus”. Will explain explode in next example. “Focus” gives you articles where the subject heading is the main idea, but not recommended to use especially with PT questions. Will see why in example. Explain that subheadings narrow your search even more, again, not a useful tool for PT questions. Then move back to powerpoint
- #16 Importance of subject headings: No key word for Carpal Tunnel syndrome Focus: If you used FOCUS on Carpal Tunnel, you wouldn’t have gotten this article Go back to Ovid, search Upper extremity. Use it to explain explode Then come back to powerpoint
- #17 Explode: Must explode upper extremity, easy way to get all parts; keyword would need to search each word Go back to Ovid, search Splints; Show that it doesn’t explode
- #18 Importance of subject headings: If you searched “splint” or “splints” as keyword, you would not have gotten this article. Subject heading allows you to get all of the spellings or ways of writing an idea
- #19 examples of when keywords are useful. Need to be able to use both SH and keywords
- #20 Summarize the ideas that you already discussed (don’t spend long here)
- #21 Ask them to search Medline to find articles to help this patient.
- #22 Discuss their findings Let at least 3 students share their findings, so that we can see diversity of results. Discuss why they found different information and whether this is important.
- #23 http://www.flickr.com/photos/32595872@N02/4195880838/ Now we are moving to the second part of the the workshop: practical. Looking at how to formulate a question and how to use this question.
- #24 Importance of clinical question Go back to the cycle and explain to find the best evidence to answer our question, we need to better formulate questions to search! Start with the question!
- #25 What is a clinical question and why do we use it? Focus on the importance of clinical questions for their own professional practice. It is not a theoretical exercise; it is rather a very practical issue.
- #26 The clinical question has two parts, here are examples of those two parts Emphasize that phrasing it precisely will enhance the chances of getting relevant information.
- #27 Explain that the “evidence” is in a pyramid, with the best, but less available, evidence is at the top of the pyramid. All of these study designs are in Medline, but we have to search through them to find them.
- #28 There are different types of questions and best evidence to answer these questions. Link to resource for refresher on this idea.
- #29 Introduce a framework for clinical question Explain each element
- #30 Introduce a framework for clinical question. Ask them whether they are familiar with it, and whether they use it during their studies. Also, explain each element with the help of the students, if possible. Patient/family stakeholder: spouse, parent of a child, caregiver and how it impacts them Professional Stakeholder: Is this a referral from another professional? Do you need to consider referral to another professional (social worker? OT?) Context: Live alone? Want to get back to work? Time: Any time factors
- #31 Read the scenario
- #32 Find each element in the example – use the framework to identify the main parts of the question. As the students to ID the element before you reveal it.
- #33 Find each element in the example As the students identify the elements in this framework, write them either on the slides or on the board.
- #34 Connect back to ideas, and how using the framework helps you find these ideas.
- #35 Now time to search, since we have the question
- #36 Verify if all students found the same article Mention that we don’t always search on outcome Demonstrate the search in Ovid. Discuss: we were lucky to find a review. What if we didn’t find one? We would need to expand our search. Ask them possible ways to expand the search, and how it would look like in the database search. If time allows, let them do a new search and discuss the results. Here they could add keywords or just search tens AND stroke AND spasticity separately from combined modality therapy AND stroke AND spaticity and do the comparison themselves. What if we had a lot of results? Then use limits. Most useful for question formulation is AGE (only for pediatrics or elderly) or publication type (RCT or SysRev)
- #37 Discuss the PICO elements in the scenario Emphasize the idea that the example contains much information that are not relevant for the PICO framework.
- #38 Have them tell you the elements. Mention that there is lots of information in this scenario and the framework helps you ID it. and have them do the search by themselves. Leave this slide up for them to do the search.
- #39 Mention l Show the framework elements and have them do the search by themselves. Lots of information in the scenario; framework helps you find the elements. Discuss the results, and check which elements they used to their search.
- #40 (I don’t usually show this slide, but we’ll see if it is useful this time)
- #41 Discuss how you did the search using this slide (I don’t go back into the database here unless someone has a specific question). Emphasize how I searched the keyword for energy conservation since the SH isn’t the same Discuss comparing exercise therapy and energy conservation (line 5): One 12 year old review and one trial with no results yet so I looked at just energy conservation alone, and found this review. Mention that I used the limit, but you don’t have to.
- #43 These databases all have subject headings, or controlled vocab Have to look for them in some databases—but some databases are very helpful and suggest subject headings to you!