* Supported by a New Investigator Award, Canadian Institutes of Health Research.
Evidence-based practice (EBP) is an approach to using the best quality evidence from clinical research, integrated with patient values and clinical experience as an ongoing process in the provision of high-quality hand therapy to individual patients.
There are five sequential steps to the process.
Defining a specific clinical question
Finding the best evidence that relates to the question
Determining if the study results are true and applicable to the patient
Integrating patient values and clinical experience with the evidence to make conclusions
Evaluating the impact of decisions through determination of patient outcomes
Specific skills are needed and challenges are presented when integrating EBP, but the learning curve can be decreased through the use of presynthesized evidence, EBP training opportunities, journal clubs, and other support systems.
Hand therapy recognizes the importance of EBP and continues to develop the training, expertise, emphasis, and resources required to support the use of EBP in practice.
EBP is now universally recognized as an advancement in the process of providing high-quality clinical care. When the British Medical Journal invited readers to submit nominations for the top medical breakthrough since 1840, evidence-based medicine was in the top 10 ( www.bmj.com/cgi/content/full/334/suppl_1/DC3 ). Originally focused on medical practice, there has been substantial transference into other health fields and even beyond health care. Hand therapy first focused on this topic with a special issue on EBP in the Journal of Hand Therapy in 2004. In 2009, Hand Clinics did so as well. This chapter provides an overview of evidence-based hand therapy. More detail on evidence-based rehabilitation can be found in a full textbook devoted to this topic.
McMaster University is usually recognized as the birthplace of EBP, due to leadership provided by David Sackett, who led the development of this unique approach, while establishing the first clinical epidemiology department at McMaster University and contributing to the development of the Oxford Centre for Evidence-Based Medicine. Both remain leaders in teaching others to use and teach evidence-based medicine and continue to develop innovative concepts and approaches in EBP. However, EBP would not have flourished without a variety of similar-minded individuals in other countries who also led efforts that enriched the concepts and sustained their international acceptance. As recognized by David Sackett, the field of clinical epidemiology predated evidence-based medicine, but provides a significant conceptual basis.
Evidence-based medicine became integrated in the training of physicians at McMaster University in Canada in the early 1970s within a new medical school that used innovative “problem-based” methods to train lifelong learners who could adapt to rapidly changing information. This training method was shared with other medical faculty and students in Sackett’s landmark and now widely used textbooks. The need for new practitioners to be able to access, evaluate, and apply new research knowledge is even more pressing today with the investment in health research and resultant explosion in availability of scientific reports in journals and other types of information resources. The information therapists learned during their training eventually becomes obsolete and must be replenished with the best new knowledge so as to be useful in optimizing patient care and outcomes. EBP provides a theoretical foundation, process, and associated tools to assist with making the best possible clinical decisions for specific clinical situations.
Definition of Evidence-Based Practice
The following one-sentence (first, bolded) definition of EBP has become widely known, but we find the longer version more explicit.
Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise, we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient-centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. External clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer ( www.cebm.net/index.aspx?O-1914 ).
Process of Evidence-Based Practice
EBP is based on a consistent five-step process ( Box 143-1 ) that is used to answer different types of clinical decisions. It provides a powerful framework for answering clinical questions, for ongoing personal growth as a therapist, and for better management of health-care resources. By continuing to practice these five simple steps throughout your career, you can become a lifelong learner and maintain the highest quality of care for your patients.
Ask a specific clinical question.
Find the best evidence to answer the question.
Critically appraise the evidence for its validity and usefulness.
Integrate appraisal results with clinical expertise and patient values.
Evaluate the outcome.
The unique piece of EBP is the assumption that clinical research based on unbiased observations of groups of patients observed within high-quality research studies should be predominant in the decision-making process for individual patients. The importance of clinical expertise and patients’ values in the process is also prominent. However, neither are replacements for finding, then evaluating the validity and relevance of clinical research. Rather, the following three components must be integrated when making clinical decisions.
Ask a Specific Clinical Question
The first step in EBP is defining the clinical question. Many clinical questions arise during a hand therapist’s clinical practice. One of the key elements in EBP is defining specific and answerable clinical questions. The PICO(T) approach ( Box 143-2 ) is commonly used to define answerable clinical questions. “P” stands for the important characteristics of the patient. This is where information from clinical experience and knowledge of basic science is integrated to help define logical, meaningful questions. Thus, clinical experience is the starting point of EBP. Typical questions asked by therapists include: What are the most important aspects of the disease or disability that must be addressed? What are the most important pathologic and prognostic features of the problem? What are realistic outcomes? What are potential longer-term risks? Therapists can make their EBP more patient-centered by integrating patient’s needs and values in the development and definition of specific questions.
P Important characteristics of the patient
I Specific intervention that might potentially be used in managing a patient
C The comparative option
O Outcome(s) of interest
(T) Time (that the outcome of interest is determined)
“I” refers to the specific intervention (diagnostic test, prognostic feature, surgical, or rehabilitative treatment) that might potentially be used in treating a patient. “C” refers to the comparative option (if indicated). This might be a control option (no intervention) or a standard currently accepted therapy. “O” refers to the outcome(s) of interest. This might include specific impairments like hand strength, range of motion, and activity or participation measures that address concepts such as disability or quality of life (see Chapter 16 on measuring patient outcomes). Patient values, goals, and priorities should also be reflected in the outcomes that are measured. Outcomes are often time-dependent (the “T” in PICO[T]), so it is important to define meaningful time points for clinical outcomes to be evaluated. This is particularly true in surgical interventions for which postoperative discomforts, complications, short-term recovery, and longer-term maintenance of functionality are all important considerations.
A number of different types of clinical questions are recognized within the EBP framework. It is important to be familiar with these different types of questions because there are different types of optimal research designs to answer these questions, different threats to validity, and, hence, different levels of evidence classifications for these varying types of questions. The types of clinical questions include
Differential diagnosis and symptom prevalence
Treatment selection and effectiveness
Prevention (diseases, disorders, and complications, etc.)/Harm
Costs: Economic and decision analysis
Let us take a patient example to illustrate how these questions might evolve.
Your patient is a 62-year-old female who presents with painful thumbs that are limiting her ability to perform her usual tasks of everyday life. Her symptoms include aching pain, which becomes worse with activity, and difficulty grasping objects. On examination she has a positive grind test and a positive Finkelstein’s test, localized swelling at the carpometacarpal joint (CMC), and reduced grip and pinch strength compared with normative values.
Hand therapy (and surgery) has a tradition of reliance on expert opinion. Can you think of a therapist whose name is associated with a particularly useful CMC joint orthosis? Now name the author of a randomized controlled trial evaluating CMC orthotic positioning. If you could do the first, but had difficulty with the latter, then you may be practicing “eminence-based practice,” instead of EBP. Although experts are often thought of as having an elite level of knowledge or skills, how can we evaluate this? Unfortunately, there are many reasons why clinicians can make faulty assumptions based on their clinical observations. Patients may improve due to natural history, their own actions, or report improvements for socially desirable reasons. All of these tend to confirm for clinicians that what they are doing is effective—even when it is not.
If we wish to use an evidence-based approach to treating the patient described earlier, we can start by asking a specific clinical question. Example questions in each of the categories are
Diagnosis: What are the false positive and negative rates for grind test and Finkelstein’s test in patients with thumb pain?
Differential diagnosis: In a patient presenting with these symptoms, which diagnosis is more likely?
Symptom prevalence study: What is the rate of CMC osteoarthritis in women 60 to 65 years of age?
Treatment selection/effectiveness (therapy): Is conservative management or surgical management optimal for this patient in terms of symptom relief?
Harm: Which approach (surgical or conservative) is more likely to result in complications?
Prevention: Would a joint protection program reduce progression of the disease process?
Etiology: Does metacarpophalangeal (MCP) joint mobility or laxity contribute to development of CMC joint arthritis?
Prognosis: Does self-efficacy affect the likelihood of success with an orthotic positioning and joint protection program?
Cost-effectiveness: Which is more cost-effective: tendon interposition arthroplasty or titanium implant for CMC joint reconstruction?
It is unrealistic to expect that we might be able to research every single clinical question with every single patient. However, if we use the five-step EBP approach to answer patient-specific questions, we can often generalize our analysis to other similar patients and be more aware of when exceptions apply. Defining new EBP questions based on our clinical encounters on an ongoing basis allows us to deepen our understanding of how to treat patients according to best evidence and evolve into more evidence-based practitioners. So a specific clinical question for our scenario might be: In women older than 60 years of age with mild osteoarthritis, does an orthotic combined with a strengthening program result in better pain relief, grip strength, and functional ability than orthotic use alone?
Find the Best Evidence to Answer the Question
The next step in EBP is to search the literature for specific studies or evidence resources that answer our specific clinical question. This typically requires searching electronic databases to find the best studies that match the specifics of the clinical question. This is an area where EBP and improvements in technology have supported innovation. The exponential increase in information has been partially offset by increased ways to identify, sort, and evaluate clinical evidence through electronic databases, search engines, and other tools. In fact, research now focuses on optimizing search strategies, and significant efforts have been invested in providing database access to health professionals. Informatics has become a large area of inquiry and development, with the end result that there is now much better information management and more usable information resources than ever existed in the past. Despite this, locating high-quality research studies is commonly reported as a barrier to practicing EBP.
Hand therapists need to know how to search for research studies using PubMed/Medline. PubMed is an easily accessible free search engine ( www.ncbi.nlm.nih.gov/pubmed/ ) that is the most comprehensive source of medical research. It provides the abstract and in some situations a link to the full-text article. However, only a small proportion of journals provide free open access to their full text. Therefore, in majority of cases, therapists will need to purchase a copy or gain access to a local university library. It is important to realize that many rehabilitation journals are not indexed in Medline, therefore, it is important to search additional databases. CINAHL, the Cumulative Index to Nursing and Allied Health Literature, is the most comprehensive resource for nursing and allied health literature ( www.ebscohost.com/cinahl/ ). It is available through universities and to individuals at a subscription rate. PEDro is the Physiotherapy Evidence Database ( www.pedro.org.au ). It was developed to give free access to bibliographic details and abstracts of randomized controlled trials, systematic reviews, and evidence-based clinical practice guidelines in physiotherapy. Most trials on the database have been rated for quality using the PEDro quality-rating scale. OTseeker is a similar database that contains abstracts of systematic reviews and randomized controlled trials relevant to occupational therapy ( www.otseeker.com/ ).
A natural outgrowth of EBP has been the proliferation of an entire discipline around the best methods for synthesizing evidence. Systematic reviews (SRs), meta-analysis, and evidence-based clinical practice guidelines are the most common evidence syntheses used in clinical practice. When properly performed, evidence syntheses are valuable to clinicians as they bring together the best information across multiple studies because they reduce the burden on the individual to do so. The Cochrane collaboration has been a leader in the development of these methods. In addition, the Database of Abstracts of Reviews of Effects (DARE) ( www.york.ac.uk/inst/crd/ ) is a searchable database of SRs which includes both a summary and critical appraisal of the SR. This can be a valuable resource for hand therapists. Unfortunately, few hand therapy issues have a sufficient number of studies that definitive evidence syntheses can be performed. However, The Journal of Hand Therapy was one of the first rehabilitation journals to highlight EBP and published a series of systematic reviews on hand therapy topics in 2004.
Because finding evidence has been a persistent barrier for clinicians, a potential solution would be to remove the burden of searching and appraising evidence on individual therapists and placing it on skilled “extractors” who would find and classify the best evidence as it emerges. This has encouraged the move from “pull-out” toward “push-out” of evidence within EBP. An example of rudimentary push-out is a journal sending out the electronic table of contents of their latest issues to those who sign up for this service. Push-out customized alerting services are a more advanced form of pushing out high-quality evidence. Using technology, users can sign up for information on their clinical interests and receive alerts of evidence pushed out to them based on those needs or clinical interests and preferences for frequency of alerts and quality/relevance cut-offs. Customized user push-out of evidence through alerting service is currently available through MacPLUS/BMJ Updates (plus.mcmaster.ca/EvidenceUpdates), although it primarily focuses on medical journals and areas of expertise. It is possible to sign up for both orthopedic surgery and plastic surgery clinical specialties to receive literature relevant to hand therapy, but less relevant studies from other areas of the specialties can also be forwarded. The author and colleagues have developed and pilot-tested a rehabilitation version called MacPLUS Rehab. Hand therapy is one of the subspecialties that can be selected, allowing users to filter for this type of evidence. It is now accessible for public use (plus.mcmaster.ca/rehab/Default.aspx).
Regardless of these advances, for some clinical questions primary searching is still required. The clinician who is not familiar with electronic searching may find this first step a barrier. Fortunately, there are many excellent ways to gain these skills. A variety of written texts and articles are helpful. PubMed offers excellent online tutorials ( www.nlm.nih.gov/bsd/disted/pubmed.html ). Most university libraries offer (usually free) courses in searching the larger databases. Searching the literature is a skill, and like most skills, you will become more proficient with practice. You will quickly learn that overly broad search terms yield too many articles to review and will therefore need to build more efficient searches. Some databases have tools such as Clinical Queries ( www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml ) in MEDLINE that help you run a more efficient search. Clinical Queries allows you to pick the specific type of clinical question you are asking and creates filters to make your search more efficient.
In our case scenario, we first used Clinical Queries in PubMed searching using the key words splinting † and arthritis. From this, we were able to locate a systematic review on orthotic positioning for osteoarthritis of the CMC joint. The authors anticipated a small number of studies and, therefore, included all identified studies. From this approach, seven studies on orthotic positioning of the CMC joint were identified and appraised. The authors concluded that positioning does decrease pain for many patients, that it does decrease subluxation on pinch for individuals with stage I and stage II CMC joint osteoarthritis, and that it does not appear to decrease the eventual need for surgery for persons with advanced disease or for those in whom immediate pain relief is not achieved. They also concluded that there do not appear to be any clear indications for any specific type of orthosis, other than patient preference. They noted the different types of orthoses appear to have characteristics that make them more or less attractive to patients depending on the types of activities they routinely perform. No studies specifically addressed the role of exercise in conjunction with orthotic positioning. A second search for primary studies using search terms of splinting AND exercise AND arthritis did not locate any studies that were relevant to the topic.
Critically Appraise the Evidence for Its Validity and Usefulness
† Although hand therapists prefer the term orthotic, splinting is more commonly used in the current literature and, thus, more likely to reveal relevant studies; as an alternative you could search ( splinting OR orthotic ) AND arthritis.The next step involves appraising the evidence to determine whether it is true (valid) and applies to your individual patient (useful). EBP has led to the proliferation of different critical appraisal tools and critical appraisal. This can make the transition into EBP easier because different tools are available for different study designs or depths of appraisal. Although hand therapists can, and should, take advantage of critical appraisal done by others, it is not advisable to abdicate all responsibility for critical appraisal to experts since they do not have the content knowledge of hand therapy. It is often during the critical appraisal process that flaws in the clinical logic of a study are revealed. Even a single (critical) design flaw may prevent a study from providing a valid clinical conclusion or may mean that the conclusion does not pertain to the patient of interest. For example, if a study enrolled patients with one surgical procedure that allowed early mobilization into one group and compared them with patients who had hand therapy, but could not be mobilized because of a different surgical technique, in the comparison group, then any conclusions about the role of hand therapy would be flawed. Clinical sensibility (researchers call this external validity ) and quality of the research design (researchers call this internal validity ) must be considered simultaneously when determining whether to believe and apply the results of any individual research study.
These skills can be acquired in a number of ways. The classic EBP text written by Sackett is highly readable and has assisted many clinicians to gain these skills (a sample chapter of the third edition of the EBP text can be accessed at www.elsevierhealth.com/product.jsp?isbn=9780443074448#samplechaptertext ). Law and MacDermid recently published the second edition of Evidence-Based Rehabilitation , which provides detailed information and tools within a rehabilitation context. Exemplars of critical appraisal and use of evidence-based practice methods are also available on the web ( www.fetchbook.info/Evidence_Based_Medicine.html ) .
Perhaps the best method to develop critical appraisal skills is through participation in journal clubs, where both the merits of the research design and the application of the evidence can be discussed with other practitioners. Critical appraisal forms (for evaluation of effectiveness studies, diagnostic test studies, and psychometric evaluations of outcome measures) are available from the author and are also published in the textbook Evidence-Based Rehabilitation . The Centre for Evidence-Based Medicine ( www.cebm.net ) also provides excellent guidance, forms, and tools to assist with critical appraisal. In general, critical appraisal focuses on making decisions about the extent to which the study design provides confidence that the results are true. Key issues are random sampling and allocation to groups, blinding raters and patients, valid outcome measures, techniques to assess statistical significance (e.g., sample size and power, analysis methods), and clinical importance (size of the effect).
Levels of Evidence
One of the most recognizable features of EBP is the “levels of evidence.” Basically, levels of evidence are simple ordinal scales that create hierarchical categories based on key elements of study design. By nature these are gross divisions, but have proved to be very useful in increasing awareness of the importance of design quality and in prioritizing and sorting the volume of information available. For example, Cochrane reviews commonly limit themselves to the highest level of evidence as a means of managing the volume of information and ensuring the best evidence is emphasized. The most consistently used and most accessible levels rating scale is available on the Oxford Centre of Evidence-Based Practice website ( Table 143-1 ). The hierarchy of evidence consists of five levels of evidence with number one being the highest level of evidence.