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Introduction to Evidence-Based Athletic Training Practice
MATA 2015Mark Weber, PhD, ATC, PT, SCS
Objectives
• Following the presentation the participant will be able to: – define evidence-based practice and discuss it’s 3
components.– develop a clinical question based on the PICO(T) process– identify search strategies for answering clinical questions– identify levels of evidence based on the CEBM scale– interpret the results of the PEDro and QUADAS internal
validity scales
Disclosures
• No commercial interest in this presentation.• No personal gain• But my alma mater is the reigning national
champions!
Importance
• Steves and Hootman "......Athletic trainers need to embrace the critical-thinking skills ............. [EBP] provides an important next step in the growth of the athletic training profession." --- JAT 2004
• Welch et. al. "...... (EBP) in athletic training is a necessary step …… advancement of athletic trainers (ATs) as health care professionals.......... most ATs still are not practicing in an evidence-based manner." ---- JAT 2014
Disconnect
• AT’s valued the concept of EBPBUT
• Demonstrated low knowledge of EBP• Low to moderate confidence in their EBP
knowledge
Hankemeier et al. (JAT 2013)
BOC EBP Foundational vs Clinical
Evidence-Based Practice
Athlete’s preferences
Athletic Trainer’s expertise
Best available evidence
Resources
EBP StepsAssess - Clinical
scenario
Ask - Develop PICO(T)
Acquire - Search based on
PICO(T)
Appraise - Review Results
Apply – Integrate
Assess II• Athlete outcome• Self-assess
Clinician Component
• Clinical expertise/skills include:– background knowledge– clinical interpretation skill– psychomotor skills– ask relevant clinical questions– find and interpret answers to clinical questions
• Practice • Self-assessment
PICO(T)
• P = population, patient, or problem• I = intervention or diagnostic test of interest• C = comparison or control• O = patient relevant outcome(s)• (T) = time frame
Example PICO(T)
• Clinical Scenario - What special tests should I use to assess an athlete with suspected ACL injury?
• P = ACL injury• I = Lachman• C = Anterior Drawer• O = diagnostic accuracy
PICO(T) Based Search Strategy
Google?, Bing?, Yahoo?
(P)(I)
(C)
ACL Ant. Drawer
Lachman
(P)(I)
(C)
Shortcut
Results
Results
Results
Pooled results from the meta-analysis
• Lachman is much more sensitive than anterior drawer or pivot shift– SnNout – a negative Lachman rules it out…sort of
(Sn = 85 ok, not great)• All three are similar in specificity– SpPin – a positive Lachman, anterior drawer, or
pivot shift rules it in
• Clinician self-assessment
Tips from the Field
• Frame your questions in the PICO(T) format– (P) and (I) are required– (C) and (O) are recommended, not required– (T) optional
• When possible, filter with meta-analysis or systematic review
• Avoid Google, Bing, Yahoo, etc….
Examples from Steves and Hootman
JAT 2004;39(1):83–87
Not a Meta-analysis or Systematic Review?
• Internal validity is key– The degree to which a change in outcome can be
attributed to the intervention rather than to extraneous factors
– “Believability” or “Truth”– Control of bias
• Alphabet soup to the rescue– CEBM– PEDro– QUADAS
Centre of Evidence-Based Medicine
• CEBM - http://www.cebm.net/
CEBM – Levels of EvidenceLevel of Evidence Intervention Studies Diagnostic Studies
I Systematic Review/Meta-analysis
Systematic Review/Meta-analysis
II RCT Cohort with consistently applied standards
III Non-randomized Clinical Trial
Cohort without consistently applied standards
IV Case-Control or Case Series Case-Control
V Case Study, Expert Opinion, or Mechanism-Based Reasoning
Case Study, Expert Opinion, or Mechanism-Based Reasoning
Level I = highest evidence (lowest potential for bias)Level V = lowest evidence (greatest potential for bias)
Intervention Studies – CEBM, Bias, Results
PEDro
• Designed to measure internal validity of rehabilitation RCTs
• 0 to 10 scale– 10 = highest internal validity (lowest potential
bias)– 0 = lowest internal validity (highest potential for
bias)• PEDro - http://www.pedro.org.au/
www.pedro.org.au
PEDro Simple Search
How is patellar tendinopathy treated?
Search Results
Scrolling Further Down
Detailed PEDro Results
Article
Advanced PEDro Search
PEDro
• Strengths– Focus on rehab
interventions– Scores the internal
validity – Provides links– Simple Search– Advanced Search
• Weakness– Only interventions, no
diagnostic studies– Does not contain all
studies
Internal Validity in Diagnostic Testing
• QUADAS – QUality Assessment of Diagnostic Accuracy Studies
• http://www.bris.ac.uk/quadas/ • QUADAS has 14 point scale– Higher score – less bias– Lower score more bias
• QUADAS 2 has a 7 item scale• Does not have an article database like PEDro• Is used by Cochrane Systematic Reviews
Clinical Utility
• Clinical skill – guides clinical decision making• Rehab – shotgun approach wastes time,
money and may increase risk• Diagnosis – tests with poor diagnostic
accuracy waste time, money, and increase risk• Practice thinking in PICO(T) terms
Clinical Utility
• Identified barriers
–Time– Role strain– Knowledge– Gap between clinical and educational settings– Lack of mentors
Manspeaker et al. JAT 2011McCarty JAT 2013
Addressing Time Issue
• PICO(T)• Know where to search (PEDro, PubMed,
CINAHL, Cochrane Datebase)• Look for applicable systematic reviews / meta-
analyses• Practice!– Were you successful on your first Lachman?