1. Evidenced – Based Practice Critical Inquiry (PTH 511) Presentations 4& 5
Evidence-Based Practice I: Definition – What is it?
Evidence Based Practice II: The 5 Levels of Evidence.
By Michael Parker, PT, PhD, FACSM

2. Evidence-Based Practice: “A Professional Responsibility”
What is Evidence-Based Practice (EBP)?
How is EBP different than just applying research results to clinical practice?
How is EBP Done?
Why should we use EBP?

3. What is Evidence-Based Practice (EBP)?
In its Infancy: Unclear if EBP is adopted beyond the APTA & University PT Programs (Academia)
EBP is clearly a critical component of quality patient care
EBP is a guide to clinicians for efficient, consistent, high quality patient care.

4. Evidence-Based Practice (EBP) is the integration of best research evidence with clinical expertise and patient values in making your clinical decision.
The best research evidence is patient-centered.
clinical expertise is effective use of your clinical skills to quickly identify the patient’s health status & diagnosis, unique risks and benefits of potential treatments, & the patients values & expectations.
patient values are unique preferences, concerns,expectations each patient brings to the clinical encounter.

5. EBP is the Addition of The Best Research Evidence Available to The Formulation of a Clinical Decision
Clinical
Decision
Clinical
Circumstances
Clinician Expertise
of The Physical Therapist
Best Research Evidence
Patient Values or
Preferences

6. What EBP Isn’t
Not just reading a professional journal or the recent research on a regular basis.
Not just attending Continuing Education courses on a regular basis.

7. What EBP Is:Not just applying research results to clinical practice- EBP is a more structured process.
Applying the knowledge from a journal (research results) and from a Continuing Education Course to a Specific Patient Problem or Patient Question

8. EBP – Patient Questions Come from The PT Practice Areas
Diagnosis
Prognosis
Intervention
Etiology
Harm
Use the PICO method to formulate your clinical research question.

9. The Steps of EBP: How EBP is done.
Actions 1
Convert a patient problem into a specific question. Using the PICO Method. 2
Search the literature related to the question. 3
Critically evaluate the pertinent literature 4
Integrate the literature with other clinical factors to make a decision about clinical care. 5
Add the information & decision into clinical practice 6
Re-eval the outcome, & ask another question

10. Example of Patient Problem as A Clinical Question : How EBP is done.
From the Intervention – Practice Area.
Patient Problem: Herniated lumbar Disk.
Clinical Question: Is static lumbar traction an effective intervention? (For PICO add information about Patient, Comparative Rx, & Outcomes)

11. Searching The Literature for Evidence Related to The Specific Question : How EBP is done.
Two Routes to Use:
Information Mastery. Systematic Reviews/Meta-analysis have already answered the specific question .
Traditional Approach. Personally Perform a systematic search and appraisal of the literature for specific elements of the specific patient question being asked using a Specialized and Standard Databases.

12. Use of Systematic Reviews from Specialized Databases to Answer a Clinical Question : How Information Mastery EBP is done.
The Systematic Review/Meta-Analysis has already:
Asked a Clinical Question
Searched and Appraised the Articles using pre-defined rigorous criteria
Made a Recommendation for Clinical Practice

13. Specialist Databases Use a Specific Study Design : How EBP is done.
Study Design: Meta-Analysis/Systematic Review
Level I Evidence
Specialist Databases
Combines data from many primary studies (PS). Summarize PS using rigorous criteria
Cochrane Database of Systematic Reviews
DARE
Others
Clinical Guidelines Produced from Conclusions
Hooked on Evidence-APTA
POEMS

14. The Traditional Approach to Answering a Clinical Question
“The clinician independently reviews and evaluates the literature with the goal of answering a clinical question.”

15. Traditional Approach : Clinician Reads the Literature & Makes-up Her/His Own Mind
Study Design
Primary Studies
Randomized Control Trial
Level II Evidence
Most rigorous, cause & effect, best for diagnosis & intervention questions
Cohort Studies
Level III Evidence
Data collected over a period of time, best for prognosis & etiology questions.
Case-Control Series
Subjects with problem matched to control, best for etiology questions
Case Studies
Level IV Evidence
Single patient with unusual problem or Rx – course of care described

16. Presentation 5 - Evidence Based Practice II: The 5 Levels of Evidence.

17. Evaluating the Literature: Assigning Levels of Trust via Parker’s Qualitative Continuum
Level I Evidence: Excellent, Most valid, reliable; “you can trust this most”.
Level II Evidence: Good to Excellent
Level III Evidence: Fair to Good
Level IV Evidence: Fair
Level V Evidence Poor to Fair

18. Level I Evidence1,2 Systematic Reviews/Meta-Analysis
Summary of many well-designed randomized controlled trials (RTC)
Authors describe specific methods to search, critically evaluate and synthesize the results of research to answer a clinical question.
1Dockter MK. Evidence-Based Practice: PTH
2 Moore A, McQuay H. Evidence-based everything. Bandolier. Available hppt:// February 1995.

19. Level II Evidence1,2
A Randomized Controlled Trial with a large sample size (n), which is representative of the defined population
Random group assignment
Most valid design for confirming effects of an intervention
1Dockter MK. Evidence-Based Practice: PTH
2 Moore A, McQuay H. Evidence-based everything. Bandolier. Available hppt:// February 1995.

20. Level III Evidence1,2 Non-Randomized Trials
These quality planned designed trials include:
Pre-Post (Before-After) Single Group
Pre-Post Cohort Groups (prospective, moving forward)
Case-Controlled Study Groups (retrospective)
1Dockter MK. Evidence-Based Practice: PTH
2 Moore A, McQuay H. Evidence-based everything. Bandolier. Available hppt:// February 1995.

21. Level IV Evidence1,2
“Non-Experimental Studies” from more than 1 clinic/”center or research group” includes evidence from:
Case Reports
Single Case Designs
1Dockter MK. Evidence-Based Practice: PTH
2 Moore A, McQuay H. Evidence-based everything. Bandolier. Available hppt:// February 1995

22. Level V Evidence1,2 Expert Opinions or “Clinical Expertise”
These are Opinions of “respected authorities” based on:
Clinical evidence
Descriptive studies
Reports of “expert committees”
1Dockter MK. Evidence-Based Practice: PTH
2 Moore A, McQuay H. Evidence-based everything. Bandolier. Available hppt:// February 1995

23. Other Ratings of Levels of Evidence: A, B, C1,3
Level A:
RCT > 100 patients (with multi-center & meta analysis)
RCT < 100 patients (with > 1 institution & meta-analysis)
Well Conducted (has control group) Cohort Study
1Dockter MK. Evidence-Based Practice: PTH
3Hadorn et al. 1996

24. Other Ratings of Levels of Evidence: A, B, C1,3
Level B:
Well conducted case-control study
RCT with 1 or more major methodological errors.
RCT with 3 or more minor methodological defects.
Case Reports or Single Case Design
1Dockter MK. Evidence-Based Practice: PTH
3Hadorn et al. 1996

25. Other Ratings of Levels of Evidence: A, B, C1,3
Level C: Expert opinion
1Dockter MK. Evidence-Based Practice: PTH
3Hadorn et al. 1996

26. PT in Terms of Science: A Developing Profession- Why do EBP?
The Challenge:
Scientific Evidence to validate physical therapy practice and provide an Evidence-Base for a clinical decision is often INADEQUATE.

27. Evidence-Base for Practice is Frequently NOT Adequate
Bridging the Evidence-Gap in PT Practice
Clinical Decision
Effectiveness Evidence
PT’s Clinical Expertise
Patient’s Preference
Clinical Judgment
Harm
Intervention
Patient Problem
Primary Research
Needed