Evidence Based Care in Athletics

Thomas RuedigerDPT, DSc, OCS, ECS, CSCSbearnakedfeet@gmail.com

2015 Northeast Indiana Sports Medicine Symposium

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In the next hour…

• Call for EBP• The pillars of making the better choice• Barriers and solutions• A bit of stats• Some examples from the literature• Your questions for me

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Call for Evidence Based Practice

• Physical Therapists– “there is a gap between research and practice”– “therapists had difficulty integrating research ..into care”– “therapists relied...on colleagues and previous experience

for clinical decision making”BMC medical education June 2014

• Athletic Trainers– “The shift to EBP in athletic training is a necessary

step…..most are not practicing in an evidence-based manner.”

JAT Mar/Apr 2014

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Pillars of Evidence Based Practice

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Pillars of Evidence Based Practice

Clinical Expertise• Academic training• Individual Reading• Certifications• Continuing Education• In-services with your clinical team• Journal clubs• Experience

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Pillars of Evidence Based Practice

Patient Values• Patient/client goals• Choices based on information– Risks– Benefits– Options

• These are influenced by many things– Team– Coach– Parents– Hope

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Pillars of Evidence Based Practice

Best Research Evidence• What is known about the condition– For a person like the one in front of me

• Age• Gender• Skill level

– To return to this sport• With one approach• Compared to another approach

– i.e. management of ACL tear• Operative management• Non-operative management• Delayed decision for choosing options

• The evidence is is a growing mountain

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Barriers

• Time constraints• Search challenges• Access to full text journal article• Clinician ability to assessing statistics• Clinician ability to assess application to their practice

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Solutions

• Peer discussion and mentorship– In-services with your clinical team– Journal clubs

• Exposure and repetition• Embrace our professional responsibility• Workshops with EBP focus• Individual Reading

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Searching the literature• This is a course by itself• PubMed, MedConnect, eMedicine etc……..• One readily available option is Google Scholar• Ask your clinical question in the search box• PICO is one strategy to ask a clinical question– P Patient– I Intervention– C Comparison Treatment– O Outcome of Interest

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Searching the literature• P ACL• I Operative• C Non-operative• O Return to sport

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Searching the literature

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Reliability(Consistency)

• Can I get the same result?– Measured at a different time– Assuming there is no change

• A picture of a target is a common visual representation

• In the following slides we are aiming at the bulleseye

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Reliability(Consistency)

• This is reliable– Also is accurate– It is also valid

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Reliability(Consistency)

• This is also reliable– It is not accurate– It is not valid

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Validity(Truth)

• Is my finding correct?• If it is there, can I find it?– Those with it, test positive for it– This is Sensitivity (Sn)

• If it isn’t there, do I not find it?– Those who don’t have it, test negative for it– This is Specificity (Sp)

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Validity(Truth)

• Sn and Sp – Qualify our thinking– Rule it in– Rule it out

• Likelihood ratios are derivatives of Sn and Sp– Quantify our thinking– I am this much more confident in my diagnosis– I am this much less confident in my diagnosis

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Truth

Test+

+

-

Sp

Sn

a b

c d

1-Sn = - LR

+ LR = 1-Sp

Sp = d/b+d

Sn = a/a+c

Computing the components of Validity

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ValidityRuling in/Ruling Out

• SpPin– With high Specificity, – a Positive tests rules in the diagnosis

• SnNout– With high Sensitivity, – a Negative tests rules out the diagnosis

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Validity(Truth)

• Sn and Sp qualify our thinking– Rule it in– Rule it out

• Likelihood ratios quantify our thinking– Is a derivative of both Sn and Sp– What is my clinical suspicion of a certain condition?

• 20%• 50%• 80%

– Apply the Appropriate LR• If the RESULT of your test is positive use the Positive LR (+LR)• If the RESULT of your test is negative use the Negative LR (-LR)

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Applying Likelihood Ratios

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Applying Likelihood Ratios

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A couple examples

• Strength of clinical tests– Lachman’s for ACL tear

• Clinical Prediction Rules– Ottawa Ankle Rules– Predicting Coping Ability after ACL tear– Low back pain responders to manipulation

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Validity of the Lachman’s Test

• Reported by many researchers– Sensitivity• 0.65 to 0.99 depending on article• Fair to Excellent of test being positive if ACL deficient• Fair to Excellent at ruling it out IF your test result is Negative

– Specificity• 0.42 to 0.97 depending on article• Fair to Excellent at being negative if ACL sufficient • Fair to Excellent at ruling it in IF your test result is Positive

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Clinical Prediction Rules

• Incorporates Sensitivity, Specificity

• Quantifies the contributions of different variables

• Used to increase diagnostic utility– Is the patient at risk for a certain outcome?– Does the patient have this pathology

• Ottawa ankle rules a good example

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Ottawa Ankle (and Foot)Rules• Need for radiographs after acute injury if there is pain AND any ONE of the following :

• 1. Inability to bear weight for 4 steps immediately after injury or in the Emergency Department. Limping is ok

• 2. Bone tenderness at any one of these locations- Distal 6 cm of posterior edge of tibia or to the tip of medial malleolus- Distal 6 cm of posterior edge of fibula or to the tip of lateral malleolus- Base of the fifth metatarsal (Foot injury)- Navicular (Foot injury)

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A picture is always nice

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Copers and Non-Copers after ACL tear

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Calculate Sn, Sp, LRs

Copers and Non-Copers after ACL tear

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Did you get this?

Copers and Non-Copers after ACL tear

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Athletes have back pain – often you see them acutely

Test Item Cluster for patients Likely to Benefit from Spinal Manipulation

1. Current episode of pain 16 days or less2. No symptoms distal to the knee3. FABQ (Work subscale) score 18 points or les4. At least one hypo-mobile spinal segment5. One or both hips has at least 35° IR

- At least 4 criteria met: +LR = 13.2 - 2 or fewer met: -LR = 0.10

Thank You

Thomas RuedigerDPT, DSc, OCS, ECS, CSCSbearnakedfeet@gmail.com

2015 Northeast Indiana Sports Medicine Symposium

What questions may I answer?

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Selected Bibliography• Welch, C. E., Hankemeier, D. A., Wyant, A. L., Hays, D. G., Pitney, W. A., & Van Lunen, B. L. (2014). Future

directions of evidence-based practice in athletic training: Perceived strategies to enhance the use of evidence-based practice. Journal of athletic training, 49(2), 234-244.

• Tilson, J. K., & Mickan, S. (2014). Promoting physical therapists' use of research evidence to inform clinical practice: I: theoretical foundation, evidence, and description of the PEAK program. BMC medical education, 14(1), 125.

• Jette, D. U., Bacon, K., Batty, C., Carlson, M., Ferland, A., Hemingway, R. D., ... & Volk, D. (2003). Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Physical therapy, 83(9), 786-805.

• Manns, P., Norton, A., Darrah, J. (2015). Cross-sectional study to examine evidence-based practice skills and behaviors of physical tehrapy graduates: is there a knowledge-to-practice gap? Physical therapy, 95, 568-578.

• Portney, L. G., & Watkins, M. P. (2008). Foundations of clinical research: applications to practice. Prentice Hall, Upper Saddle River, NJ.

• Flynn, T., Fritz, J., Whitman, J., Wainner, R., Magel, J., Rendeiro, D., ... & Allison, S. (2002). A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine, 27(24), 2835-2843.

• Moksnes, H., Snyder-Mackler, L., & Risberg, M. A. (2008). Individuals with an anterior cruciate ligament-deficient knee classified as noncopers may be candidates for nonsurgical rehabilitation. Journal of orthopaedic & sports physical therapy, 38(10), 586-595.

• Hartigan, E. H., Axe, M. J., & Snyder-Mackler, L. (2010). Time line for noncopers to pass return-to-sports criteria after anterior cruciate ligament reconstruction. Journal of orthopaedic & sports physical therapy, 40(3), 141-154.