At what level we listen usually?

Empathic listening is listening with intent to

understand other person's frame of mind,
reference and feelings. we must listen with
our eyes, ear and heart.

with our eyes, ear and heart.

How can we link it our emotions?
Just identify your Different Roles

Role as Physical Therapist

Evidence Based Practice
(EBP)
Dr. A Q Khan
BSPT, PP. DPT
Lecturer Physical Therapy
“Today’s Bones of Contention”
• Reflection and Reflective Practitioner
Once upon a time when you was a reflective
practitioner Tie your seat belts 
Formulating a Clinical
Ready the brain Question
and just make concepts

Just make concepts

Forms of evidence / Hierarchies of evidence
 STEPS FOR PRACTISING EBP
(Sackett et al 2000)
 Step 1: Convert information needs into
answerable questions.
 Step 2: Track down the best evidence with
which to answer those questions.  Research based

 Step 3: Critically appraise the evidence for evidence

 Expert opinions
its validity, impact and applicability.
 Patient feed
 Step 4: Integrate the evidence with clinical
back
expertise and with patients. unique biologics,  Clinical
values and circumstances. experience
 Step 5: Evaluate the effectiveness and  Clinical records
efficiency in executing steps 1–4 and seek
ways to improve them both for next time.
Forms of evidence

Not all evidence is judged to be of equal value, that is,

there are hierarchies of research design that are
evaluated to have different strengths, different levels of
value in the decision making process.
Research based evidence
Expert opinions
Patient feed back
Clinical experience
Clinical records
Reflective Practitioner
(EBP)
Asking ourselves
Seeing a mirror
Reflective Practitioner

 We should know the necessary factors for decisions-making:

a) Theoretical ground
b) Previous experience
c) Client/patient wishes
d) Environmental conditions
e) Research evidence.
 Reflection is a meta cognative process We are thinking about
our thinking).
Reflection a Powerful Learning
Tool !

 As Physical Therapists we should know the reasons

underlying Our action.
 We should use reflection in our action.
 In routine practice experienced Therapists do not pay any
attention.
 Only when they face a new challenge.
 Reflection represents the “art” of practice and knowledge
and evidence the “science” of practice.(Schon 1987)
Student Life
(preservice Experience)
Students learn the knowledge base of the discipline
and are exposed to the available evidence for current
treatment.
They learn how to use the available evidence and
knowledge.
They follow what they learn and do not ask question to
challenge the belief
Novice Practitioners

 Novice Practitioners need rules to help them organize their

thoughts, observations, and action.(Bnner,1984)
 They focus on objective findings.
 The complexities of the patients relationship, the
environment and the expectations are beyond the capacity
of the novice practitioners.
Experienced Professional Period

 In this period professionals have many information and

create their personal database
 The experienced professional established methods for
evaluating the effectiveness of selected interventions based
on their personal data base.
 Share the personal database with other colleagues.
Expert Practitioners

 Expert practitioners maintain these rules but shift them to

the background.
 They have the capability to handle new situations by using
their professional experience.
 They under stand the individual patient situation and can
create the environment too, based on knowledge and
experience.
Formulating Clinical Question
Evidence Based Practice (EBP)
Formulating Clinical Question
1.2 Background
Question may pertain to
(Clinical Question Categories)
1. The anatomic, physiologic or patho physiologic nature of the
problem.
2. The Medical and surgical management options
3. The usefulness of the diagnostic tests and measure to identify,
classify, and or quantify the problem.
4. Prognosis factors.
5. Advantage and disadvantage of the intervention.
6. The nature of outcome and how to measure them.

3,4,5,6
Foreground
Background Questions

 Background questions ask for general knowledge about a condition or thing.

 Background Questions reflect a desire to know the nature of the patient
problem or need.
 Often focus on the medical aspects of the situation rather than on the physical
therapy component.
 Physical therapy students and new graduates will use to learn about new
techniques or skills
 Experienced professionals will use background questions for new or unusual
situation.
Examples:
 “How long will it take for a total knee arthoplasty inscion to heal?”
 “What are the signs and symptoms of an exacerbation of multiple sclerosis?”
 “Will it be possible to play football after ACL Reconstruction surgery?”
Foreground Questions
 Foreground" questions ask for specific knowledge to inform clinical
decisions or actions.
Foreground Question have four key elements
1. Patient / Client details such as age, gender, diagnosis, severity and/ or
preferences
2. A specific test, predictive factor, intervention or outcome
3. (A specific test, predictive factor, intervention or outcome)
4. The consequence of interest for test, prediction, intervention or
outcome
Example: Is Proprioceptive Neuromuscular Facilitation (PNF) an
effective treatment technique for restoring core trunk stability in a
7-year old child with right hemiparesis due to stroke?

• Patient and/or problem

P I C O Method •
•
Intervention
Comparative intervention
• Clinical outcome
Clinical Questions

Clinical questions about Diagnosis

Clinical questions about Prognosis
Clinical questions about Interventions
Clinical questions about Outcomes
Clinical questions about Diagnosis
Foreground Question Foreground Question
Simple Comparison
Will the “SLR Test” help Is the “SLR Test” more
me detect sciatic nerve accurate than “Slump
entrapment in a 25 year Test” in detecting
old male computer sciatic nerve
operator with pain entrapment in a 25 year
radiating to right leg? old male computer
operator with pain
radiating to right leg?
Clinical questions about Prognosis
Foreground Question Foreground Question
Simple Comparison
Is muscle strength a Which is a better
predictor of fall in a predictor of fall risk,
76-year old female muscle strength or
with diabetes? proprioception, in a
76-year old female
with diabetes
Clinical questions about Intervention
Foreground Question Foreground Question
Simple Comparison
Is Soft Tissue Is Soft Tissue
Mobilization an Mobilization more
effective treatment effective than stretching
technique for relaxing as treatment technique
spasmodic paraspinal for relaxing spasmodic
muscles of 32 year old paraspinal muscles of
male with history of 32 year old male with
weight lifting history of weight lifting
Clinical questions about Outcome
Foreground Question Foreground Question
Simple Comparison
Does participating in a Does participating in a
cardiac rehabilitation cardiac rehab program
program increase the increase the chance of
chance that 58 year old returning to work more
man will return to than a home walking
work following a program in a 58 year
myocardial infarction? old man following
myocardial infarction?
 Lets Listen A Story
Evidence Based Practice (EBP)
Lets Listen A Story
Evidence Based Practice (EBP)
 Once upon a time when you were a
reflective practitioner………
As we know that Physical therapists are not only interested in the benefits of manual
medicine and manipulation of the spine, they have created Doctor of Physical Therapy
programs, with certification in manipulation, to better compete for the patients.
Let us say that you just completed a consult and examination of a 59-year-old female
who presented with chief complaints of low back pain, upper back pain, neck pain and
parasthesia in her hands. This patient was a previous patient of yours and was satisfied
with the help she received for the mid back pain when she was treated with spinal
manipulative therapy three years ago. However, now her exam shows swelling in her
hands and feet and her face looks full. You sense this is a different condition from
what you usually treat. It reminds you of some conditions you learned about in school,
but you can’t put your finger on it. You decide that treating her with spinal
manipulation, as you did a few years ago, may not be the best course and may even be
contraindicated. You enjoy good outcomes on your patients and want to keep your
batting average up. As you were thinking to what to do, Suddenly you realized that
you are a reflective Physical therapist …..
Once upon a time when you were a
reflective practitioner………
The question may be constructed to include background questions of
general knowledge on the prospective condition along with foreground
questions of specific knowledge that applies to your patient. This will
allow you to make an appropriate clinical decision. The foreground
questions should consist of the patient or problem, intervention and
clinical outcome. It also might consist of a comparison, if relevant to the
decision.

In this case, the initial background question would be:

What type of conditions would encompass the broad array of symptoms of chronic,
recurring – full-spine pain, parasthesias and swelling?
The foreground question would be: In a 59-year-old female with chronic,
recurring, full-spine pain, parasthesias and swelling, would spinal manipulation
be the best course of treatment for the best outcome of this patient, or would
either pharmacological care or no care be better options?
Once upon a time when you were a
reflective practitioner………
You tell the patient that in your opinion, her case is not the same as three years
ago and you want to make sure she gets the appropriate care. Since there is
joint swelling, you decide to order an arthritic profile blood test and you
will be investigating her condition further. She is pleased that you are taking
her seriously and want to give her the best care, even though she was sure
that if you just “cracked her like last time” she would feel much better.
At lunch, you take these questions back to your computer and perform a quick
literature search.
A quick search of PubMed with the search terms “polyarthralgia AND
swelling” reveals a number of papers on various inflammatory
arthropathies.
You then refer to your old Robbins pathology text and note systemic lupus
erythematosus and scleroderma as having similar presentations and
additional findings that the patient mentioned in the consult
Once upon a time when you were a
reflective practitioner………
The test comes back positive for HLA B27 with a low-
moderate titer, and negative for RF factor. The
evidence indicates this is a red flag for manipulation.
You are happy you did not provide any high-velocity
manipulative procedures, as it could have aggravated the
condition. You subsequently refer the patient for consult
with a rheumatologist. She insists on seeing a local
doctor. However, they send the patient back without any
diagnosis or treatment and reportedly tell the patient that
it’s nothing and will go away. She, of course, is
dissatisfied and feels the doctor did not take her seriously.
Once upon a time when you were a
reflective practitioner………
You now have the information from text and current literature regarding the
condition. On her return visit, she is getting progressively worse. You,
therefore, convince the patient of the importance of another referral. Armed
with this information you call another rheumatologist and discuss the case,
along with the evidence on which you base your concerns. They agree to a
consult, and subsequently diagnose CREST syndrome and send you the report.
(Gosh, CREST syndrome! What’s it got to do with her brushing her teeth?) The
patient returns and wants you to explain her condition. When you received the
report, a quick Google search informed you that CREST syndrome is a subset
of scleroderma and it outlined the common treatments and limited success. You
explain this to the patient. She is so pleased to know you managed her case and
found out the cause of her problem, even though you cannot give her a lot of
relief. She subsequently tells all her friends about how you cared for her when
no one else could and you start receiving multiple referrals from her. In
addition, the rheumatologist refers you a couple of patients with non-
inflammatory low back pain.
Once upon a time when you were a
reflective practitioner………
This evidence-based care is looking better every day. You got the
gratification of caring for a patient to whom you could have caused
harm, and you are building your practice on solid referrals without
the overhead expense of advertising. All it took was a few minutes
on two occasions. It built up your credibility in the community and
helped a patient.

References
 Childs JD, Fritz JM, et al. A clinical prediction rule to identify patients with low back pain most likely to
benefit from spinal manipulation: A validation study. Ann Intern Med, Dec. 21, 2004;141(12):920-8.
 U.S. Department of Health & Human Services. Available at www.ahrq.gov/questionsaretheanswer.
 Straus SE, Richardson WS, Glasziou P, Haynes RB. Evidence-Based Medicine, 3rd edition. New York:
Churchill Livingston, 2005.
 Haldeman S, Chapman-Smith D, Petersen D. Guidelines for Chiropractic Quality Assurance and
Practice Parameters. Sudbury, MA: Jones and Bartlett, 1993.
 Clinical Scenario EXERCISE
80 years old man referred to physical therapy after ® hip
fracture because of his poor balance, he is the 5th person in
the last month with the same problem.
Using PIOC criteria what will be the answerable
question ?
PICO Question
P ( Patirnt Situation): 80 years old man with ® hip
fracture due to poor balance
I (Intervention) Balance training with ROM and
muscle strengthening program.
C (Comparison) 5 patients with same age had hip
fracture due to same problem
O (Outcomes) Fall prevention in old age population to
live independent.
An answerable Question
What will be the affective intervention strategies for
poor balance in old age population ?
Could hip fracture be prevented with balance training
in the old age population?
 hank You 
Clinical Activity Case Based ? ? ? ?

What is my Professional attitude towards senior

Physical Therapists???
Forms of evidence / Hierarchies of evidence
(EBP)
Hierarchies of evidence
Study designs & Evidence
hierarchy

1. Systematic Reviews and meta-analyses

2. Randomized Controlled Trails with definitive
Results
3. Randomized Controlled Trails with no definitive
Results
4. Cohort studies
5. Case control studies
6. Cross-sectional surveys
7. Case reports
Systematic Reviews and meta-
analyses
Comprehensive review of the literature
Provide an overview of the validity of the research
methods and of results for a particular topic
Meta-analysis is a systemic review in which a
statistical summary is used
Meta-analysis provide an unbiased summary of
effectiveness of any intervention strategy
Gold standard for evidence evaluation
Randomized Controlled Trails with
definitive Results
RCT is a study design in which participants are
randomly assign to ether experimental or control group
RCTs are below systematic reviews because RCTs
represent one study while systematic reviews represent
the combined results of many studies.
RCTs may be double blinded or single blinded
Randomized Controlled Trails with
nondefinitive Results
Level three to apprise evidence
RCTs with definitive results must have 95 % CI but
RCTs with none definitive have CI value slightly less
than zero.
The only difference in both studies are the results.
Cohort studies
Cohort studies are lengthy
May be one or more than one group involves
Cohort studies are not randomized so the participants
of the group or groups may not be same in all
characteristics.
Cohort study design is not strong as RCTs or
Systematic reviews.
Case control studies

Similar to cohort but retrospective in time

Both study designs identify possible causative events
and make predictions but they do not prove causality.
Cross-sectional surveys
Easy to do
Large number of participants
Focus on topic in one time
The conclusion will be made based on the return
questionnaire
There is no control for the researcher
The outcome may be biased because less control and
number of returned questionnaire
 Case reports

Case report is the last level on the evidence but convey

important health information.
Provide basis for future work
A written summary of clinical suspicion or
possibilities.
 hank You 
Clinical Activity Case Based ? ? ? ?

What is my Professional attitude towards senior

Physical Therapists???