Best Evidence Topics BETs. Questions in clinical practice n What is the best treatment for…..? n...

Best Evidence TopicsBest Evidence Topics

BETsBETs

Questions in clinical Questions in clinical practicepractice

What is the best treatment for…..?What is the best treatment for…..? How sure is the diagnosis of……?How sure is the diagnosis of……? What is the prognosis for……..?What is the prognosis for……..? Is this likely to be harmful…….?Is this likely to be harmful…….? How does this affect my patient’s How does this affect my patient’s

life…?life…? etc.etc.

But…..But…..

Difficult to get ‘quick’ answers due to..Difficult to get ‘quick’ answers due to.. Time Time ‘‘Know how’Know how’ ResourcesResources

N.B. ‘quick’ does not mean cheap & nasty

What is a BET ?What is a BET ? Emergency Medicine DepartmentEmergency Medicine Department Manchester Royal Infirmary 1996 Manchester Royal Infirmary 1996 Started from a modified CATStarted from a modified CAT Can be ‘best available’ evidence rather than Can be ‘best available’ evidence rather than

‘highest quality’ ‘highest quality’ – (problem in physiotherapy & EmerMed)(problem in physiotherapy & EmerMed)

Systematic approach to answering ‘real world’ Systematic approach to answering ‘real world’ clinical questionsclinical questions

Pragmatic systematic review Pragmatic systematic review Clinical answers to clinical problems Clinical answers to clinical problems > 800 BET questions> 800 BET questions

BET structureBET structure

The clinical scenarioThe clinical scenario The 3 part questionThe 3 part question The literature searchThe literature search The critical appraisalThe critical appraisal The summary ( in a table)The summary ( in a table) The CommentThe Comment The ‘clinical bottom line’The ‘clinical bottom line’

Ask the right questionAsk the right question

Focus on a real clinical scenarioFocus on a real clinical scenario Pull out the key features from the Pull out the key features from the

scenario.scenario. Formulate the 3 part question.Formulate the 3 part question.

Why develop a 3 part Why develop a 3 part question?question?

To focus the problem.To focus the problem. To help define & formulate To help define & formulate

searching.searching.

Clinical scenarioClinical scenario

A 29 year old patient presents with a A 29 year old patient presents with a 3 month history of supraspinatus 3 month history of supraspinatus tendonitis.tendonitis.

You are planning to use some form You are planning to use some form of electrotherapy but the patient of electrotherapy but the patient mentions that he had laser for a mentions that he had laser for a similar problem in his tendo similar problem in his tendo Achilles that seemed to help. Achilles that seemed to help.

You wonder if this will apply to a You wonder if this will apply to a tendon in another part of the bodytendon in another part of the body..

What is the general What is the general question?question?

Can adult tendonitis be helped by Can adult tendonitis be helped by Laser?Laser?

What is the patient group?What is the patient group?

Adults?Adults? Chronic Tendinitis?Chronic Tendinitis?

Is there a comparison?Is there a comparison?

Laser?Laser? Other electrotherapy?Other electrotherapy? Other therapy?Other therapy? Nothing or not relevant?Nothing or not relevant?

What are the outcomes?What are the outcomes?

Less pain?Less pain? Better function?Better function? Quicker recovery time?Quicker recovery time? Success rate?Success rate? Cost??????Cost??????

The 3 part question.The 3 part question.

IN [adults with chronic tendonitis]IN [adults with chronic tendonitis] IS [laser beneficial] IS [laser beneficial] AT [decreasing pain and improving AT [decreasing pain and improving

function]function]

N.B. Therefore, this is not a systematic review on Laser

What is the patient group?What is the patient group?

All Adults?All Adults? Chronic Tendinitis?Chronic Tendinitis?

– Good: Adults with 2 month history of supraspinatus tendonitis

– Not so good: Patients with shoulder pain (too broad. Too much evidence)

– Worse: Manc men aged 18-28 with a calcified supraspinatus tendon on X-Ray due to repetitive javelin throwing (too narrow.Relevant but no evidence!!)

The InterventionThe Interventioni.e what are we going to do to our patient i.e what are we going to do to our patient

group?group?

diagnostic questionsdiagnostic questions– Gold standard against new techniqueGold standard against new technique

prognosprognostictic questions questions– Define a factor that may affect the Define a factor that may affect the outcomeoutcome

therapeutic questionstherapeutic questions– compare treatments?compare treatments?

A A diagnostic questiondiagnostic question

Is MR scanning better than U/S Is MR scanning better than U/S scanning at diagnosis supraspinatus scanning at diagnosis supraspinatus tendonitis?tendonitis?

A A prognosprognostictic question question

The ‘empty can’ test as a prognostic The ‘empty can’ test as a prognostic test in supraspinatus tendonitis ?test in supraspinatus tendonitis ?

A therapeutic questionA therapeutic questionUsually the case for physiotherapy BETsUsually the case for physiotherapy BETs

Laser compared to nothing (or not Laser compared to nothing (or not relevant)relevant)

Other electrotherapy?Other electrotherapy? Other therapy?Other therapy?

What are the outcomes?What are the outcomes?Often problematicOften problematic

Clinically relevant Clinically relevant Patient orientated Patient orientated Definable Definable Measurable Measurable May be several for 1 interventionMay be several for 1 intervention

– Less pain?Less pain?– Better function?Better function?

RoM, strength, etcRoM, strength, etc

– Quicker recovery time?Quicker recovery time?– Cost?Cost?

The 3 part questionThe 3 part question

PP Adult Adult

chronic tendonitischronic tendonitis

I1I1 LaserLaser

I2I2 NothingNothing

(? Other electrotherapy)(? Other electrotherapy)

OO PainPain

DysfunctionDysfunction

Using the 3 part question Using the 3 part question for searching.for searching.

A patient group Intervention 1

An outcome

Intervention 2(Not always present

or necessary)


Patient groupDisease

AgeGender

Intervention What Action / treatment

you are considering

OutcomeWhat are you looking to achieve

Pain / functionOr

BP, HR, LA, Life etc inEm.Med


Tendonitis

Tendinosis

Tendinopathy

we want all these papers

OR

OR

supraspinatus tendonitis

OR

Using the 3 part question for Using the 3 part question for searchingsearching

Laser Laser therapy

Low level Laser

we want all these papers

OR

OR

LLLT

OR


ALLTendonitispapers

ALLLaser papers

we want JUST these papers

AND

ALLTendonitispapers

ALLLaser papers

JUST these papers

NOT

Summary so far..Summary so far..

Focused questions are answerable Focused questions are answerable questions.questions.

Questions should be based on a Questions should be based on a clinical scenario.clinical scenario.

The 3 part question should be used The 3 part question should be used to help develop a search strategy.to help develop a search strategy.

Search StrategySearch Strategy As comprehensive as possibleAs comprehensive as possible

– Tip: go broad Tip: go broad thenthen narrow down narrow down As many databases as possibleAs many databases as possible

– MedlineMedline– CINAHLCINAHL– AMEDAMED– EMBASEEMBASE– SPORTDiscusSPORTDiscus– CochraneCochrane– PEDroPEDro

Beware of only using ‘PubMed’ !!Beware of only using ‘PubMed’ !!

Search StrategySearch Strategy Medline, CINAHL, AMED, SPORTDiscus, Medline, CINAHL, AMED, SPORTDiscus,

EMBASE: [{(exp tendonitis OR EMBASE: [{(exp tendonitis OR tendinosis.mp OR tendinopathy.mp)} tendinosis.mp OR tendinopathy.mp)} OR “supraspinatus tendonitis”.mp] AND OR “supraspinatus tendonitis”.mp] AND [(low level laser.mp OR low level laser [(low level laser.mp OR low level laser therapy.mp OR laser therapy.mp OR therapy.mp OR laser therapy.mp OR therapeutic laser.mp). LIMIT to human therapeutic laser.mp). LIMIT to human AND English language.AND English language.

In addition the Cochrane database and In addition the Cochrane database and PEDro database were also searched PEDro database were also searched

Search Strategy Search Strategy RESULTSRESULTS

5 papers including 1 systematic review 5 papers including 1 systematic review were found. A further paper was also found were found. A further paper was also found in conference proceedings via a personal in conference proceedings via a personal communication making a total of 7 papers.communication making a total of 7 papers.

Of the 6, one was a commentary on the Of the 6, one was a commentary on the systematic review. The conference systematic review. The conference proceedings paper was laser therapy to proceedings paper was laser therapy to shoulder trigger points, not tendonitis and shoulder trigger points, not tendonitis and so was considered irrelevant. All the papers so was considered irrelevant. All the papers found predated the systematic review so found predated the systematic review so this is presented in the table onlythis is presented in the table only

Summarise the papersSummarise the papers

CRITICAL APPRAISAL IS KEYCRITICAL APPRAISAL IS KEY– BETs is not a short cut to proper CAT!!BETs is not a short cut to proper CAT!!

What are the key points?What are the key points? If someone read this would they know If someone read this would they know

what was done in appraisal?what was done in appraisal? Describe the exact numbers & p Describe the exact numbers & p

values values Concentrate on the issue at hand Concentrate on the issue at hand

– IS it relevant to 3 part Question?IS it relevant to 3 part Question? List any weaknesses in papersList any weaknesses in papers

Search StrategySearch StrategyAuthor, Date & Country

Patient Group

Study Type

Outcomes Key results

Study weaknesses

Bjordal et al 2001, Norway

12 placebo controlled RCTs with subacute/.chronic tendonitis. N = 687

Systematic review (1a)

% improvement in pain over placebo. Effect v size plots. Laser v placebo plots

Including 3 trials with no or worse effect of laser over placebo (n=12) pooled mean effect = 21% (95% CI, 5.9-36.1) in favour of laser over placebo. Excluding these 3 trials (n=9) Pooled mean effect 32% (95% CI 23-41) in favour of laser v placebo

Only analyses pain as outcome, but states this in methods.

CommentsComments

What does the evidence tell us?What does the evidence tell us? Is it applicable to my 3 part Is it applicable to my 3 part

question?question? Is it applicable to my clinical practice?Is it applicable to my clinical practice? Have the authors missed something?Have the authors missed something? Is further research needed?Is further research needed?

CommentsComments

““The systematic review is the most recent The systematic review is the most recent paper concerning low level laser therapy paper concerning low level laser therapy on tendinopathy and seems to favour its on tendinopathy and seems to favour its use over placebo in decreasing the pain use over placebo in decreasing the pain associated with tendonitis. It comments associated with tendonitis. It comments that the use of laser therapy is dependent that the use of laser therapy is dependent on power density and dose applied and on power density and dose applied and the pooled mean effects will alter when the pooled mean effects will alter when studies do not meet optimal irradiation studies do not meet optimal irradiation doses.”doses.”

The Clinical Bottom LineThe Clinical Bottom Line

OOne sentence statement ne sentence statement The next patient you see today… The next patient you see today… What are you going to do?What are you going to do? Has the BET given you enough Has the BET given you enough

evidence to change your practice?evidence to change your practice?

The Clinical Bottom LineThe Clinical Bottom Line

““Laser therapy is superior to placebo Laser therapy is superior to placebo in reducing pain of chronic in reducing pain of chronic tendinopathy by about 32%.”tendinopathy by about 32%.”

Your turn!!!Your turn!!! A 30 year old female patient presents A 30 year old female patient presents

with a 7 day history of patellar with a 7 day history of patellar tendonitis. You think of treating her with tendonitis. You think of treating her with oral NSAIDs. However, recently you oral NSAIDs. However, recently you have seen some information about have seen some information about NSAIDs in a gel form. This seems an NSAIDs in a gel form. This seems an appealing alternative and you wonder if appealing alternative and you wonder if there is any evidence of its efficacythere is any evidence of its efficacy ..

QuestionsQuestions– Patient group ?Patient group ?– Treatment / interventions ?Treatment / interventions ?– Outcome ?Outcome ?


IN [Adults with acute tendonitis]IN [Adults with acute tendonitis] IS [topical or oral NSAIDs] IS [topical or oral NSAIDs]

BETTER AT [reducing pain and BETTER AT [reducing pain and improving function]improving function]


Patient groupAdults

tendonitis

Intervention 1 Oral NSAIDs

OutcomePain / function

Intervention 2Topical NSAIDs (gel)

PP Adult Adult

TendonitisTendonitis

I1I1 Oral NSAIDsOral NSAIDs

I2I2 Topical NSAIDsTopical NSAIDs

OO PainPain

FunctionFunction

Your turn again!!!Your turn again!!! A middle aged lady is receiving A middle aged lady is receiving

physiotherapy for her OA knee. She physiotherapy for her OA knee. She mentions that her husband has heard mentions that her husband has heard that Glucosamine tablets are great for that Glucosamine tablets are great for arthritis and is thinking of buying some arthritis and is thinking of buying some from a health-food shop. She asks what from a health-food shop. She asks what you think about them. Before imparting you think about them. Before imparting wise words, you decide to check the wise words, you decide to check the evidence first.evidence first.

QuestionsQuestions– Patient group ?Patient group ?– Treatment / interventions ?Treatment / interventions ?– Outcome ?Outcome ?


IN [adults with OA knee]IN [adults with OA knee]

DO [glucosamine tablets]DO [glucosamine tablets] IMPROVE [pain and function]IMPROVE [pain and function]


Patient groupAdults

OA knee

Intervention 1 Glucosamine tablets

OutcomePain / function

PP Adult Adult

OAOA

I1I1 Glucosamine tabletsGlucosamine tablets

I2I2 (none)(none)

OO PainPain

FunctionFunction

And again…!And again…!

A 65 year old lady has had a total knee A 65 year old lady has had a total knee replacement for osteoarthritis. She has replacement for osteoarthritis. She has had an uneventful post op recovery and, had an uneventful post op recovery and, as per protocol, has an appointment for as per protocol, has an appointment for outpatient physiotherapy. With the outpatient physiotherapy. With the pressure on appointments you wonder pressure on appointments you wonder whether instruction on a home exercise whether instruction on a home exercise programme will be just as effective as programme will be just as effective as outpatient physiotherapy at improving outpatient physiotherapy at improving function and range of knee flexion.function and range of knee flexion.

3 PART QUESTION:3 PART QUESTION:

IN [Adults following TKR] IN [Adults following TKR]

IS [a home exercise programme IS [a home exercise programme better than an outpatient better than an outpatient programme] programme]

AT IMPROVING [RoM and function] AT IMPROVING [RoM and function]


Patient groupAdults

Post TKR

Intervention 1 Outpatient physio

OutcomeRoM / function

Intervention 2Home physio

PP Adult Adult

Post TKRPost TKR

I1I1 Outpatient physiotherapyOutpatient physiotherapy

I2I2 Home physiotherapyHome physiotherapy

OO RoMRoM

FunctionFunction

What next?What next?

Don’t keep it yourselfDon’t keep it yourself Get it on the webGet it on the web

http://www.bestbets.org/


You decide to do a BET

Find a scenario

Formulate a 3 part Q Get it checked

Do a search Get it checked

Get the papers

Critically Appraise

Complete the BET

One week

1-12 weeks

GET IT CHECKED

SummarySummary

The BET is the best way to put all The BET is the best way to put all your work togetheryour work together

The BET can be used to change The BET can be used to change practicepractice

The BET can improve journal clubsThe BET can improve journal clubs

Best Evidence Topics BETs. Questions in clinical practice n What is the best treatment for…..? n...

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