Evidence-based medicine: arguments for and against

In this article I will discuss the various definitions of evidence-based medicine (EBM), and summarize the application, criticisms and limitations of EBM. The spectrum of evidence, from pathophysiological inference to randomized controlled trials, will be presented as a mechanism for filtering bias with more rigorous evidence being required when bias is more likely. Although randomized controlled trials and meta-analyses are at the top of the evidence hierarchy, they are not always necessary, might not be the most appropriate forms of evidence for some clinical questions, and have their own limitation that need to be understood. Best available evidence, applied to individual patients, is the corner stone of EBM. Although there are valid criticisms and limitations of EBM, if these are understood then the practice of EBM can provide guidance to the clinician and enhance patient care.     

Outcomes research in the ICU: an aid in defining the role of physiotherapy

The economic reality of consumers, funders, and regulatory agencies demanding evidence regarding the quality of care patients are receiving in the intensive care unit (ICU) will have an effect on many of the routinely used practices in ICU, including physiotherapy. Outcomes research is a method that has been used to obtain evidence for the medical and respiratory management of patients in ICU. An overview of the literature was conducted to answer the following questions: 1. What is outcomes research? 2. Which outcomes should be measured in the adult critical care environment? 3. Which outcomes are physiotherapists currently including in research reports? Outcomes research is recognized by critical care specialists as a cost-effective method of determining what works in the real world. The value of physiologic measures is questioned, whereas the importance of patient centered, economic, and traditionally accepted outcome measures is increasingly being recognized. Most physiotherapy research reports still include physiologic measurements as the primary outcome of an intervention. Outcomes research provides researchers with the tools to define the role of the physiotherapist in the critical care environment. The outcomes measured must be relevant to patients, families, and funders.     

证据的来源与检索

循证医学是指认真、明确和明智地应用现有的最好证据,同时结合医生的个人专业技能和临床经验,考虑病人的愿望,对患者做出医疗决策.因此证据及其质量是循证医学的关键.本文旨在系统介绍证据的来源和如何检索证据,为卫生健康工作者的循证医学实践提供服务和帮助.     

循证神经病学的发展、问题与展望

评述国内外循证神经病学发展的简况、问题与展望;介绍神经疾病临床研究证据的来源;列举美国神经学会质量标准分委会部分实践参数(指南)的循证推荐意见;呼吁神经科临床医生积极开展当前能够开展的最高质量研究,使用当前可获得的最佳临床证据.     

The motivation of health professionals to explore research evidence in their practice: An intervention study

Aim. To assess the impact of multifaceted clinically focused educational strategies that concentrated on introducing dementia care research evidence on health professionals’ awareness and inclination to use research findings in their future practice. Background. The promise of evidence‐based practice is slow to materialize with the limitations of adopting research findings in practice readily identifiable. Method. A pre‐ and post‐test quasi experimental design. The study involved the administration of: a pretest (baseline), an intervention phase, and a post‐test survey, the same research utilization survey. Tool. The Edmonton Research Orientation Survey (EROS), a self‐report tool that asks participants about their attitudes toward research and about their potential to use research findings, was used to determine health professionals' orientation to research. Intervention. The introduction of dementia care research evidence through multifaceted clinically focused educational strategies to improve practice. This was achieved through a resource team comprising a Clinical Nurse Consultant, as a leader and resource of localized evidence‐based knowledge in aged care; an experienced Registered Nurse to support the introduction of strategies and a further experienced educator and clinician to reinforce the importance of evidence in change. Results. Across all the four subscales that are measured in the Edmonton Research Orientation Survey, statistical analysis by independent samples t‐test identified that there was no significant change between the before and after measurements. Relevance to clinical practice. Successful integration of changes based on evidence does not necessarily mean that staff become more aware or are more inclined to use research findings in future to address problems.     

Shaping the Future of Physiotherapy with Clinical Care Profiles

This paper reviews the current challenges facing the physiotherapy profession: meeting patients' needs, professional standard setting, measurement of health care outcomes, audit, research and development, the education of staff, organisational restructuring, reprofiling, resource management and contracting.It is argued that some of these challenges can be addressed through the development of multidisciplinary clinical care profiles which are described in relation to the practice of physiotherapy.     

Symptom pathways from referral to death: measuring palliative care outcomes

This article reports on the first stage of a process to develop a clinical performance indicator for a community-based palliative care service that may inform the development of an agreed set of indicators for the whole sector. The study explores whether symptom data that are routinely collected to plan and monitor the care being provided by a community-based palliative care service also have the potential to be used to audit care against standards, compare services, and inform funders or purchasers. The article looks at the symptom distress scores of patients over the whole episode of their care from referral to death, by constructing pathways for each symptom (pain, insomnia, appetite, nausea, bowel, breathing problems, fatigue and pain). How these data may provide a multi-purpose measure of clinical outcomes is then discussed. It is concluded that, following further research to establish the symptom assessment scale's reliability and validity in different settings, it should be considered for universal adoption by palliative care services.     

An evaluation of a teaching intervention to improve the practice of endotracheal suctioning in intensive care units

Endotracheal suctioning is a frequently performed procedure that has many associated risks and complications. It is imperative that nurses are aware of these risks and are able to practise according to current research recommendations. This study was designed to examine to what extent intensive care nurses' knowledge and practice of endotracheal suctioning is based on research evidence, to investigate the relationships between knowledge and practice, and to evaluate the effectiveness of a research-based teaching programme. This quasi-experimental study was a randomized, controlled, single-blinded comparison of two research-based teaching programmes, with 16 intensive care nurses, using non-participant observation and a self-report questionnaire. Initial baseline data revealed a low level of knowledge for many participants, which was also reflected in practice, as suctioning was performed against many of the research recommendations. Following teaching, significant improvements were seen in both knowledge and practice. Four weeks later these differences were generally sustained, and provide evidence of the effectiveness of the educational intervention. The study raised concern about all aspects of endotracheal suctioning and highlighted the need for changes in nursing practice, with clinical guidelines and focused practice-based education.     

Real Time Ultrasound: An Objective Measure of Skeletal Muscle

Abstract

Objective measurement of muscle size is an important aspect of physiotherapy, but current clinical assessment methods are unreliable. Whilst not in widespread clinical use, real-time ultrasound has the potential to determine accurately both the linear dimensions and crosssectional area of skeletal muscle, providing evidence for the effectiveness of physiotherapy interventions. This systematic review of current literature was undertaken to investigate the validity and reliability of real-time ultrasound as an objective measure in physiotherapy practice, to discuss the implications for practice and to identify future research requirements. Eight current databases were searched for studies that measured skeletal muscle. Eleven articles were identified which specifically met the search criteria, and these were reviewed systematically. All of the articles found real-time ultrasound to be a valid and reliable tool for measuring skeletal muscle size under controlled conditions; however, confounding variables, such as fat, fascia orientation, muscle shape and pathology, were identified which may affect the validity of measurements in the general population. Further research is needed into deep and irregular muscles, and into the wider population, including obese, physically trained and symptomatic subjects to validate its use as a generalised tool. Furthermore, the use of a strict protocol was highlighted to ensure valid and reliable measurements in clinical practice.     

Evidence based practice: a survey of physiotherapists' current practice

Backgound and Purpose . Evidence‐based practice is the explicit use of current best evidence in making decisions about the care of individual patients and is a concept of growing importance for physiotherapy. The aim of the present study was to investigate Australian physiotherapists' self‐reported practice, skills and knowledge of evidence‐based practice and to examine differences between recent and experienced graduates, physiotherapists with low and high levels of training and physiotherapists working in private practice and hospital settings. Method . A survey was sent to 230 physiotherapists working in hospitals and in private practice. One hundred and twenty‐four were completed and returned. Results . Although 69.4% of respondents said they frequently (at least monthly) read research literature, only 10.6%, 15.3% and 26.6% of respondents, respectively, searched PEDro, Cochrane and Medline or Cinahl databases frequently, and only 25.8% of respondents reported critically appraising research reports. Recent graduates rated their evidence‐based practice skills more highly than more experienced graduates, but did not perform evidence‐based practice tasks more often. Physiotherapists with higher levels of training rated their evidence‐based practice skills more highly, were more likely to search databases and to understand a range of evidence‐based practice terminology than those with lower levels of training. Private practice and hospital physiotherapists rated their evidence‐based practice skills equally and performed most evidence‐based practice activities with equal frequency. Conclusions . Respondents had a positive attitude toward evidence‐based practice and the main barriers to evidence‐based practice were time required to keep up to date, access to easily understandable summaries of evidence, journal access and lack of personal skills in searching and evaluating research evidence. Efforts to advance evidence‐based practice in physiotherapy should focus on reducing these barriers. Copyright © 2006 John Wiley & Sons, Ltd.     

Translating research evidence into clinical practice: new challenges for critical care

High quality research evidence is now available to guide and shape the practice of critical care. As the generation of such evidence increases, the challenge facing critical care medicine will be translation of this evidence into measurable improvement in patient outcome. Significant barriers to this process of translation exist that will require substantial effort and resources to overcome. We briefly review the nature of translational barriers to incorporation of research evidence into clinical practice and the conventional approach to surmounting these barriers, and provide examples of barriers and potential solutions to emerging therapies in critical care.     

Challenging the epistemological foundations of EBM: what kind of knowledge does clinical practice require?

This paper raises questions about the epistemological foundations of evidence‐based medicine (EBM). We argue that EBM is based upon reliabilist epistemological assumptions, and that this is appropriate – we should focus on identifying the most reliable processes for generating and collecting medical knowledge. However, we note that this should not be reduced to narrow questions about which research methodologies are the best for gathering evidence. Reliable processes for generating medical evidence might lie outside of formal research methods. We also question the notion of the knower that is assumed by EBM. We argue that EBM assumes an enlightenment conception of knowers as autonomous, substitutable individuals. This conception is troubled by the way that clinicians learn the role of anecdote in health care and the role of patient choice, all of which bring into play features of clinicians and patients as situated individuals with particular backgrounds and experiences. EBM's enlightenment conception of the knower is also troubled by aspects of the way evidence is produced. Given these limitations, we argue that EBM should retain its reliabilist bent, but should look beyond formal research methodologies in identifying processes that yield reliable evidence for clinical practice. We suggest looking to feminist epistemology, with its focus on the standpoints of individual situated knowers, and the role of social context in determining what counts as knowledge.     

A Review of “Imaging in Rehabilitation”

ABSTRACT

Research suggests that healthcare professionals, including students, can demonstrate negative attitudes toward older patients. Effective education is proposed as the way to change negative attitudes, but evidence is conflicting. This study explored physiotherapy students’ perceptions of older people and their rehabilitation. Data were collected utilizing semistructured, focus group interviews with the United Kingdom's physiotherapy students aged between 20 and 40 years. A thematic analysis was undertaken. Two themes from the main study pertinent to clinical education are presented. Issues identified as adversely affecting care for older adults included organizational intransigence, lack of resources, lack of motivation and activity on wards, and stereotypical attitudes. These findings suggest that clinical placements clearly influenced participants’ perceptions. While more negative experiences had the potential to adversely influence perceptions, they engendered in the participants a sense of injustice and increased their determination to be proactive in the rehabilitation of older people.     

New Concepts and Evidence Based Practice in Physiotherapy：Examples from Stroke Rehabilitation

Objective:The purpose of this paper is to give an overview of new concepts and evidence based physiotherapy practice in stroke rehabilitation in the acute,post acute and chronic stage of stroke. Background:Historically physiotherapy has developed through the years from a focus on health,beauty,and equilibrium between spiritual,moral and physical powers,to a client centered service to people and populations to develop,to maintain and to restore maximum movement and functional ability throughout the lifespan. Still the health perspective is strong and divided into first,second and third prophylaxis. New concepts like Evidence Based Medicine,Evidence Based Practice,International Classification of Function and research within neurophysiology have had a deep impact on physiotherapy services,practice and education. The highest levels of documentation are Meta analyses and Randomised Controlled Trials,and today many of the physiotherapy methods used in rehabilitation of neurological conditions are tried out in different trials,bringing up-to date knowledge into practice. This paper focuses on rehabilitation of persons with stroke and physiotherapy methods in particular. Result:Physiotherapy in the acute stage improves motor function and enhances mobility. Rehabilitative efforts within the first few weeks as opposed to later favors better recovery. Type of physiotherapy in the acute stage is task oriented training with a focus on intensity and variability. Post acute therapy-based rehabilitation services targeted towards stroke patients living at home appear to improve independence in personal activities of daily living. In the chronic stage there is good evidence that aerobic exercise is beneficial for improving aerobic capacity in people with mild and moderate stroke. Progressive resistance strength training programmes reduce musculoskeletal impairment after stroke,without increasing tone or spasticity.     

Effective Synthesized/preappraised Evidence Formats in Emergency Medicine and the Use of Supplemental Knowledge Translation Techniques

Most clinicians, and especially emergency physicians, are increasingly faced with the need for valid and reliable evidence upon which to base practice decisions in a timely fashion. Despite the accumulation of synthesized evidence in emergency medicine over the past decade, knowledge gaps still exist between what is known and what is practiced. In many cases, this failure in knowledge uptake relates to barriers in uptake as well as the difficulty of translating evidence from research to the bedside. Preappraised evidence syntheses represent a potential partial solution to these problems by providing condensed summaries of the large volume of scientific literature in our field. The participants in this workshop examined the availability, utility, and impact of preappraised evidence and examined innovative ways to translate this knowledge into practice. In addition, the workshop participants also explored more globally all knowledge translation methods that are distinct from clinical pathways (e.g., audit and feedback, academic detailing, reminders, and local opinion leaders). These are initiatives that are instituted at the level of a particular hospital or with respect to a certain condition, and emergency physicians need to understand their definition and application. Overall, the recommendations arising from this workshop have the potential to alter future emergency care in important ways.     

Toward a theory of patient satisfaction with physiotherapy: Exploring the concept of satisfaction

Patient satisfaction is increasingly seen as an important area of research because it has been found that satisfied patients are more likely to benefit from their health care. However, there has been comparatively little work in this field within physiotherapy. Eliciting patients' expectations and needs of their care and addressing these during treatment could not only influence their subsequent health-related behaviour but could also contribute to a more favourable evaluation of the whole therapeutic experience. While various determinants of satisfaction have been identified and examined in the literature, there has been little work to develop a theory to underpin the concept of satisfaction. Such a theory is important in physiotherapy because it can inform current practice and its evaluation and have implications for future patient care. In this article satisfaction with physiotherapy is defined on the basis of a review of the satisfaction literature in health care. A theory of patient satisfaction with physiotherapy is then developed by exploring the concepts of need and expectations that are proposed as being important determinants of the construct in relation to the physiotherapeutic approach to care, drawing on need theory and relevant social science and marketing theories.     

The Case for Real-world Evidence in the Future of Clinical Research on Chronic Myeloid Leukemia

Purpose

In light of recently published guidelines from the US Food and Drug Administration (FDA) on the communication of real-world data (RWD) and real-world evidence (RWE) to support regulatory decision making, it is important to understand how such data are developed, the limitations of these data, and how to best use RWD to improve patient care. Historically, the use of RWE has been approached with skepticism because of its often-retrospective nature compared with data from conventional randomized controlled trials (RCTs). This review discusses the role and function of RWE and RWD in clinical research. We summarize the types of RWE used in clinical research, outline the challenges and limitations involved with these data, and suggest how these types of analyses can supplement results from clinical trials to foster a more complete understanding of a drug or disease area of interest. In particular, we focus on the role of RWE in investigating chronic myeloid leukemia (CML) and tyrosine kinase inhibitor therapy for CML.