EVIDENCE BASED PRACTICE

DR.MUHAMMAD RIZWAN
SHS UMT LAHORE
 Book

• Practical Evidence based physiotherapy By,

Rob Herbert, Gro Jamtdvedt, Judy Mead &
Kare Birger Hagen
 REVIEW OF PREVIOUS LECTURE
• Finding the evidence.
• World wide web.
• Selecting search terms.
• Use of AND & OR.
• Wild cards.
• Finding evidence of effect of intervention.
– Simple search.
– Advanced search.

• The Cochrane library

 REVIEW OF PREVIOUS LECTURE

• What does evidence say?

• Sensitivity and Specificity.
WHAT CONSTITUTE EVIDENCE?
 CONTENT
• Effect of intervention.

• Confounded extraneous factors.

• Hawthorne effect
• Theories about mechanism.
• Clinical research
– Case series.
– Case controlled.
• Randomized trials.
 Types of Evidence

• Effect of intervention
• Experiences
• Prognosis
• Diagnosis
 EFFECT OF INTERVENTION

Can be obtained through the following:

1. Clinical Observations
2. Theories about mechanisms
3. Clinical research
 Clinical Observations
• The practice of medical professional has
always been based on clinical observation.

• Some medical professionals supplement their

clinical observations with careful measures of
outcomes.

• The simplest way to interpret observations of

clinical outcomes is as effect of intervention.
• If condition of most patient improve with
intervention, intervention is effective.

• Alternatively, if intervention is designed to

prevent adverse effect, intervention is
effective.
• It may be incorrect to interpret clinical
observations of successful outcomes as evidence
of beneficial effect of intervention because
sometimes factors other than intervention are
determinants of outcome.

• It is because confusion of outcomes and effects of

intervention is reinforced by patients.
 CONFOUNDED EXTRANEOUS FACTORS

-All the factors and conditions that could interfere with

the actual recording of the outcomes-

1. Natural recovery

• Natural recovery may occur because underlying

condition or course of condition is of gradual
improvement.

• Example (arthritic pain)

CONFOUNDED EXTRANEOUS FACTORS
2. Statistical regression (spontaneous resolution
of episodic disease) e.g. M.S & R.A

3. Information about outcome is provided by

patient rather than directly observed by
medical professional. E.g. pain
4. HAWTHORNE EFFECT
• It refers to the fact that participants in research may
change their behaviour as a result of knowing that their
behaviors are under study.
• Polite patient behavior

5. Placebo effect.

6. Recall bias

(Medical professionals who have applied an intervention

many time needs to maintain an accurate mental ledger of
typical outcome with that therapy.)
• The simplest conclusion is that every day
clinical observations may provide misleading
estimates of effect of intervention.
 THEORIES ABOUT MECHANISMS
• The primary justification for intervention is provided
not by clinical observations but by theory.

• Mechanism of intervention leads us to believe that

intervention should be effective.

• Example
– Use of ultrasound in back pain.

– Stretching because it reduces muscle spasm.

 THEORIES ABOUT MECHANISMS
• We need to have theories about mechanisms of
intervention.

• Properly used theories about mechanism can provide

hypotheses about which intervention might be
effective.
• These are almost always incomplete.

• Direction for effect of intervention not about size of

effect of intervention. E.g. return to work after sports
injury.
 CLINICAL RESEARCH

• Clinical research potentially provides us with better

source of information about effect of intervention than
clinical observations and theories.

• High quality clinical research can provide us unbiased

estimate of effects.

• The systematic and critical use of high quality clinical

research is EBP.
 CASE SERIES
• The simplest studies of effect of intervention simply
involves assessment of patient with condition of
interest, applying intervention and average effect of
intervention.

• Such studies are called case series.

• Chances of bias are in these studies because we just

measure outcomes not considering extraneous
factors.
 CASE CONTROLLED
• Most sophisticated studies compare outcomes in
people who receive intervention /no intervention

• Provide better control of bias.

• Called control trials.

• Both groups pass through extraneous factors.

 TYPES OF CONTROLLED STUDIES

• We can distinguish three sorts of controlled studies that

differ in nature of intervention and control:

• One group receives intervention and other group receive

no intervention.

• One group receives standard intervention and other group

receives standard plus a new intervention.

• One group receives a particular intervention and other

receives a different intervention.
 TYPES OF CONTROLLED STUDIES

• A common feature of all three designs is that

difference in outcome is attributed to difference
of intervention they receive:

• First tell us effect of intervention over and above

no intervention.

• Second tells us whether benefit is in adding new

intervention.
 TYPES OF CONTROLLED STUDIES
• Third tells us which of two interventions is
most effective.

• Controlled studies can only be assumed to

provide unbiased estimate (group
comparable).
 RANDOMIZED TRIALS

• Some researchers try to match subjects in

treatment and control group on characteristics
that are thought to be important.

• Study of effect of exercise on lipid profile in

children undergoing exercise/not undergoing
exercise.
 RANDOMIZED TRIALS

• Matching on its own is unsatisfactory for two reasons:

– Limitation to number of variables that can be matched.

– Difficult to match subjects on two or three variables.

• There is only way we can assemble intervention and

control groups that will give us a high probability of
comparable groups is randomization.
 RANDOMIZED TRIALS
• Randomization ensures groups will be
comparable but it does not ensure that group will
be identical.

• There are many examples in which randomized

and non-randomized trials have examined the
effectiveness of same intervention and have
come up with different conclusions.

• Randomization comes in different ways.

 REVIEW TYPES
• Two types

• Narrative review
An expert in field locates relevant studies and
write a synthesis of what those studies have.

• Narrative reviews are attractive to readers

because they summarize vast literature.
 REVIEW TYPES
• Systematic review

‘A systematic review summarizes the results of available

carefully designed healthcare studies (controlled
trials) and provides a high level of evidence on the
effectiveness of healthcare interventions’.

• Judgments may be made about the evidence and

inform recommendations for healthcare.
 REVIEW TYPES
• First systematic reviews were called meta analysis
(overviews).

• Now meta analysis is usually reserved to describe

certain statistical methods.

• Meta analysis can be a part of systematic review/non

systematic review(narrative review)

• One concern with systematic review is that they are

conducted retrospectively.
Thank You