introduction to evidence-based athletic training practice mata 2015 mark weber, phd, atc, pt, scs

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?

Questions?

mweber@umc.edu