A quick reference to literature searches P.I.C.O. A quick reference to literature searches

Where do I start? Ask a well built clinical question: Start with the patient -- a clinical problem or question arises from the care of the patient Construct a well built clinical question derived from the case

What is important in the question? PICO is a mnemonic that helps one remember the key components of a well focused question. The question needs to identify the key problem of the patient, what treatment or tests you are considering for the patient, what alternative treatment or tests are being considered (if any) and what is the desired outcome to promote or avoid.

P.I.C.O. P= Patient Problem: This may include the primary problem, disease, or co-existing conditions Sometimes the gender, age or race of a patient might be relevant I= Intervention, prognostic factor or exposure: What do you want to do for the patient? manipulation? a drug?

P.I.C.O. C= Comparison: O= Outcome: What is the main alternative to compare with the intervention? manipulation and a drug? a drug and no manipulation? There may not always be a specific comparison. O= Outcome: What can you hope to accomplish, measure, improve or affect? Improve function or test scores, reduce symptoms or number of adverse events, etc.

Case Scenario 25 year old female patient with chronic migraine headache Patient has 2-3 migraines per month. The patient does not like taking medication and is wondering if chiropractic care might help reduce the intensity and/or frequency of her migraines. Examination confirms a migraine history and associated upper cervical dysfunction. You share with her that you have had some inconsistent success in treating migraine patients with associated cervical dysfunction and spinal manipulation. After discussing the findings with the patient a decision is made to proceed with a trial of up to 12 manipulative treatments over 8 weeks. At the end of the 8 weeks the frequency and intensity of the headaches has not materially changed. The patient asks if you know of other treatment options she might consider and is specifically wondering if acupuncture treatments may be helpful. You share with the patient that you have only referred a few migraine patients for acupuncture and want to review the literature before giving her an opinion.

Let’s turn it into a clinical question Is acupuncture compared to drug therapy effective in preventing migraine headaches?

O prevention, frequency Is acupuncture compared to drug therapy effective in preventing migraine headaches? P migraine I acupuncture C drug therapy O prevention, frequency

How else might this term be referred to in the literature? Identify synonyms, if any P migraine I acupuncture C drug therapy, pharmacologic O frequency, prevention, prophylaxis

Combine and order terms. Boolean Operators The “connector” terms: AND = both OR = either NOT = only one and not the other

Tells search function: When you use AND and OR together in search string you also need ( ) Parentheses order the search: migraine AND acupuncture AND (prevention OR prophylaxis) Otherwise… Tells search function: do this part first.

The search will be read like this: migraine AND acupuncture AND prevention OR prophylaxis (including lots of irrelevant literature on just prophylaxis)

Let’s transform our entire PICO into a search string using Boolean and parentheses… P migraine AND I acupuncture AND C (drug therapy OR pharmacologic) AND O (frequency OR prevention OR prophylaxis) Notice there are few words to avoid confusing searches

So here’s the search string migraine AND acupuncture AND (drug OR pharmacologic) AND (frequency OR prevention OR prophylaxis) So let’s try it out in PubMed!

To narrow the search, use “PubMed Tools” – Clinical Queries

What to Look For: Type of studies As you move up the pyramid the study designs are more rigorous and allow for less bias or systematic error that may distract you from the truth. Clinical decision making is affected most by the top half of the pyramid. Higher levels are best for clinical decisions. Definitions (click on each hyperlink to learn more on the subject): Meta-analysis: https://himmelfarb.gwu.edu/tutorials/studydesign101/metaanalyses.html Systematic Review: https://himmelfarb.gwu.edu/tutorials/studydesign101/systematicreviews.html Practice Guideline (our Case Types & Management Plans in HC Manual): https://himmelfarb.gwu.edu/tutorials/studydesign101/practiceguidelines.html Randomized Control Trial (RCT): https://himmelfarb.gwu.edu/tutorials/studydesign101/rcts.html Cohort Study: https://himmelfarb.gwu.edu/tutorials/studydesign101/cohorts.html Case Control Study: https://himmelfarb.gwu.edu/tutorials/studydesign101/casecontrols.html Case Report: https://himmelfarb.gwu.edu/tutorials/studydesign101/casereports.html

Results – look for a relevant citation By clicking on “See all (8)” you may find the best citation(s) – see results on next slide RCTs will be found in this list

Here is the systematic review list: Notice NYCC has full access to 3 citations Two citations More filters to narrow the search if necessary We see at least two relevant citations

A Word About Systematic Reviews and Meta-Analysis A grading system is used for inclusion of RCTs in systematic review and meta-analysis citations Poorly designed or biased studies are eliminated Strict parameters are used for inclusion i.e. double blinding Manual therapies rarely are able to fit all parameters Providers and patients often know what therapy is being delivered (not able to be double blind) Manual therapy trials are often listed as low or medium grade – may bias some readers but still important results

Other search engines Cochrane Database of Systematic Reviews PEDro Full-text articles and protocols focusing on the effects of healthcare. The reviews are highly structured and systematic, with evidence included or excluded based on explicit quality criteria to minimize bias. Data is evidence-based medicine and is often combined statistically (with meta-analysis) to increase the power of numerous studies, each too small to produce reliable results individually. PEDro the Physiotherapy Evidence Database. PEDro is a free database of over 30,000 randomized trials, systematic reviews and clinical practice guidelines in physiotherapy. NYCC Clinic Libguides Customized web pages to assist you with your research. Pre-vetted citations of relevant subjects.

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