Evidence Based Practice
PTA 101 - Introduction to Clinical Practice 1

Instructional Use Statement

Lane Community College PTA Program attributes the following to Neil Henry of the Scottish Social Services Council. Material is replicated or derived through Creative Commons License 2.5 (CC - BY-SA2.5).

The following information is used for instructional purposes for students enrolled in the Physical Therapist Assistant Program at Lane Community College. It is not intended for commercial use or distribution or commercial purposes. It is not intended to serve as medical advice or treatment.

Learning Objectives

Evidence-based practice pyramid

(image courtesy of uncg.libguides.com)

Evidence-based practice (EBP) is a term that is often confused in its understanding and application. For certain, best practices in physical therapy include techniques and interventions supported in the scientific literature. However, EBP, includes the integration of patient/client experience and goals and the experience of the health care provider. This triad: the research, the practitioner, and the patient, are the core elements of evidence-based practice.

In PTA 100, we discussed EBP in regards to the PT Guide to Practice. In this lesson, we will introduce the use of EBP in clinical practice and explore opportunities and methodology in formulating answerable clinical questions.

Lesson Objectives

By the end of this lesson, the student should be able to:

  1. Define evidence-based practice as it is used in physical therapy
  2. Compare and contrast arguments for and against evidence-based practice
  3. Identify and describe the steps included in supporting evidence-based practice
  4. Classify question type as foreground or background in a given case example
  5. Define and describe types of studies in evidence-based practice
  6. Define and describe rating systems for evidence-based practice
  7. Examine the impacts of evidence-based treatment on patient preferences and clinical experience
  8. Discuss how evidence-based practice is incorporated into the course materials and texts
  9. Describe strategies to apply evidence-based practice to clinical cases

 

 

 

Knowledge-based Clinical Reasoning and Decision Making

This section looks at types of clinical decision-making and in particular the difference between practical knowledge and the kind of knowledge found in research. In patient care, Evidence-Based Practice is a triad of influences: Patient - Provider - Research.

When we talk about 'Evidence Based Practice' we mean providing physical therapy to our patients and clients using methods that are supported practice patterns, clinical reasoning, and research. In this section, we ask the question: when are everyday clinical practice patterns enough and when do we need to go research for evidence of clinical effectiveness for PT interventions? From single case studies to statistical analysis of multiple studies, PTs and PTAs are charged to constantly refine, implement, and assess treatment techniques and outcomes so we may develop our "best practices" as a profession.

The following exercise is adapted from work done by the National Center for the Study of Adult Learning and Literacy [NCSALL, 2007].

Please spend a moment or two drawing both sides of a penny. It is important that you do this entirely from your own memory and without looking at a real example of a penny. Once you have finished please compare your drawing with a real penny

 Hyperlink to Flash Card Activity 

Now complete the activity below to relate the photo album activity to clinical reasoning

 Hyperlink to DidYouKnow Activity 

There are a number of implications for your role as PTA. Firstly, given your role in assessing treatment response and outcomes, it is important to clarify and test out your subjective impressions of the patient's performance/outcome with some hard evidence. On what exactly do you base your view of the treatment outcome? It can very much help to have the views of others as these can help you to tell the difference between your subjective impressions and a more objective view. The more objective view is one that others also see.

If you are the only one with a particular impression it may be worth questioning yourself as to whether this view is well founded or not.

Secondly, you need to practice developing the habit of always basing your own assessments on clear evidence and justifying your choice of method by pointing to retrievable evidence. To find strong evidence you need to search the literature (and we will show you the way!)

Self-Reflection Questions

Consider the following:

Please take a few moments to record your answers to these questions before revealing the next part of the discussion

 Hyperlink to DidYouKnow Activity 

 

Attitudes to Research

This section considers some of the attitudes to research held by practitioners. These range from completely dismissing the relevance of research to embracing the opportunity to look at all aspects of practice anew. A key consideration here is the link between practice and theory. By listening to and considering practitioners' views you will be able to identify some of the ways research can enhance practice and understand some of the barriers.

Please consider the following three statements and highlight the one that most closely corresponds to your own view:

These three statements broadly conform to three positions on research taken up by groups of teachers studied by Zeuli & Tiezzi (Reference: Creating contexts to change teachers' beliefs about the influence of research 1993. 6/1/09).

As PTAs you may see similar positions taken up by colleagues.

The activities below are based on three practitioner scenarios.

Once you have completed your reflections you can click on the 'Did You Know' below to compare your thoughts.

 Hyperlink to DidYouKnow Activity Hyperlink to DidYouKnow Activity Hyperlink to DidYouKnow Activity 

This editorial on Evidence Based Practice by Sackett, et. al is a wonderful resource that summarizes what EBP is, and more importantly what it is NOT. Key points in this article will be assessed on the Unit 3 exam. It reinforces the role of attitude, systematic questioning and answering, and the values of the patient in the clinical reasoning process.

Implementing Evidence Based Practice

Evidence Based Practice relies on background knowledge of disease and disorder to formulate a clinical question. While respecting scope of practice, a PTA should be able to self-identify a need for more information, research the question, and appropriately apply the outcome of the researched information in clinical practice. Steps in Implementing EBP can be summarized as follows:

  1. Convert the purpose or need for information (prevention, diagnosis, prognosis, therapy, causation, etc.) into an answerable question
  2. Find the best evidence to help you answer your question
  3. Evaluate your evidence for validity (is it truthful?), impact (size of its effect), applicability (usefulness in your setting with your patient)
  4. Integrate evidence with your clinical expertise and unique patient needs, values and circumstances
  5. Evaluate outcomes in the context of evidence and patient outcomes
  6. Assess your effectiveness and efficiency in performing steps 1-4 above; identify areas for improvement
  7. Repeat, repeat, repeat!

 

Consider a scenario you have recently practiced in lab to reinforce how clinical reasoning, and reflecting on clinical reasoning and evidence, reinforces your understanding and effectiveness in applying electrical stimulation to a clinical case:

 

Henry is a 55 yo male 7 days s/p L RTC repair in a sling with pain rated 9/10 immediately following PROM exercises last visit.   He has not been taking his pain medication regularly due to stomach irritation.   Decreasing pain and increasing PROM are treatment goals and therex, pain management, patient education, modalities, and functional training is in the plan of care.  The PT has asked you to select a modality for symptom management and to help progress the patient. The pt. is not allowed muscle contraction for 3 more weeks.

1. What is our clinical purpose in this situation? Is there a need for additional information?

2. Evidence: PTA 101lecture, Dutton text, web searches, lab experiences

3. Evaluate: What modality will you select based on your research?

4. What additional "evidence" (clinical reasoning, patient information and feedback) will you use to finalize your treatment approach?

5. What tests, measures, or other data will you collect to help determine the treatment outcome?

6. Was the treatment outcome expected or unexpected? Why? What, if anything, will be done differently?

7. Repeat all these processes next visit.....

 

In short, evidence-based practice and active clinical reasoning are integrating. Thinking about your thinking and questioning assumptions and reasons for outcomes will prompt more questions....

(just for fun)

 

http://www.ted.com/talks/stuart_firestein_the_pursuit_of_ignorance.html )

Librarians - Get to Know Them!

Librarians are experts in how to access and search for information. LCC has excellent library faculty and staff to help guide your research efficiently and effectively.

Evidence-based practice hinges on our ability to formulate (and then answer) a question. This research guide will help structure your research methods"

Are you new to LCC or new to using LCC as a source for books and articles? Use the Ask a Librarian library feature to get personalized help:

 

Formulating an Answerable Question

Evidence-based practice starts with a question:

What is the best intervention for this patient/client?

In clinical research, some questions are intended to lead toward a deeper understanding of the background of a disease or condition. Other studies ask foreground questions in order to analyze patterns and for predicting outcomes based on a given set of conditions.


Background Questions

  1. Uses a question root (who, what where, when, how, why)
  2. Includes an aspect of the condition or item of interest (disorder, test, treatment, or other health care aspect)

What are the effects of electrode size on patient comfort during large muscle NMES treatments?

Why are supraspinatus muscles the most commonly torn rotator cuff muscle?

When is it safe for adolescents to initiate a weight training program?

How does pulsed ultrasound enhance the inflammatory response in superficial soft tissue?

Foreground Questions

Foreground questions ask for specific knowledge to inform clinical decisions or actions. There are four general categories of foreground questions:

  1. Therapy/prevention - Questions which look to support or rule out a therapeutic approach (e.g., PT, bed rest, etc.)
  2. Diagnosis - Questions which look to support or rule out methods for diagnostic classification (e.g., carpal tunnel syndrome, herniated disc)
  3. Etiology - Questions which look to support or rule out the origin or contributing factors to the impairment, functional limitation, etc.
  4. Prognosis - Questions which look to support or rule out the conditions for recovery or progression of a condition/limitation.

A foreground question should contain for main elements in order to increase the specificity and applicability of the answer to the question. The acronym PICO is used to recall the four essentials of a foreground question:

PICO

Patient/Problem/Population - identifies who you are limiting your question to
Intervention - identifies the specific circumstances or conditions of treatment
Comparison - related to another patient/problem/population and/or intervention (e.g., control groups)
Outcomes - result of the intervention (e.g.., least, most, best, longest duration, fall frequency, patient satisfaction, etc.)

Now, take a look at the Asking a Good Question page
Answerable foreground questions rely on specific constraints or conditions to address a specific problem through standardized quantitative and/or qualitative measures. Once you have crafted a good question, you will be able to proceed with a directed search of the evidence to-date which addresses your clinical question. Useful resources (databases) to answer foreground questions (note: databases in red are not currently available through LCC library)

 

 

Many databases can be searched for specific levels of evidence on a research topic. Levels of evidence are discussed in more detail in this lecture.

The LCC Library is linked to many of the databases above. In many cases, you have free access to full text articles if you access related databases through the LCC Library website.

Other sources of evidence include links and publications through professional associations (APTA) and national authorities (CDC, NIH)

 

 

 

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Types of Research Studies

Quantitative

Qualitative

 Toggle open/close quiz question

 

Considerations for Research Study Designs

Research Study Design

Case Reports

Cohort Study

Pilot Studies

Randomized Controlled Trials

Systematic Review

Meta Analysis

Levels of Evidence

From reading a professional journal to performing an advanced search in a database, a PTA can evaluate the level of evidence available for a research (foreground) question.

 

Level I

 

Systematic review of meta analysis of all relevant randomized controlled trials or evidence based on clinical practice guidelines based on systematic review of RCTs

 

Level II

 

Evidence obtained from at least one properly designed randomized controlled trial

 

Level III

 

Evidence obtained from well designed controlled trials without randomization

 

Level IV

 

Evidence obtained from well designed case controlled and cohort studies

 

Level V

 

Evidence from systematic reviews of descriptive and qualitative studies (meta-synthesis)

 

Level VI

 

Evidence from a single descriptive or qualitative study

 

Level VII

 

Evidence from opinion or authorities and/or reports of expert committees

 

 

EBP and the Vision 2020 Statement for Physical Therapy

The APTA adopted the Vision 2020 statement to frame the role of the PT by the year 2020. One heading of Vision 2020 is Evidence-Based Practice:

Evidence-based practice is access to, and application and integration of evidence to guide clinical decision making to provide best practice for the patient/client. Evidence-based practice includes the integration of best available research, clinical expertise, and patient/client values and circumstances related to patient/client management, practice management, and health care policy decision making. Aims of evidence-based practice include enhancing patient/client management and reducing unwarranted variation in the provision of physical therapy services.

Source: http://www.apta.org/AM/Template.cfm?Section=Research&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=39951. Cited 11.15.09

 

In our EBP discussion forum, consider the lecture material and Sackett editorial when posting and responding to the discussion question.

End of Lesson