Future Posts

Hi Guys,

Thank you for all the comments, retweets, mentions etc. since I started the blog a couple of months ago; they’ve been both incredibly supportive and constructive.

I was surprised nobody commented on the video of laughing Goats!?

I’ve created a list of the posts that I currently have planned and aim to have completed by the end of 2013 at the latest:

1 – Clinical Reasoning and Research Questions

2 – What is Evidence Based Practice?

3 – Literature Searching and Strategy Formation

4 – Quantitative Experimental Research and How to critically read an article

5 – Qualitative Research

6 – Quantitative Non-Experimental Research

7 – Pulling your critical appraisal together

8 – Systematic Reviews

9 – Synthesising Evidence

10 – Sources of Bias in Quantitative Experimental Research

As you can see, I’ve completed three already which is good going! I’ve been asked by a couple of people to write a post looking at diagnostic validity (i.e. specificity, sensitivity and the like) which I hope to be able to get up within the next week.

This leads me on nicely to the bigger picture of what I have planned for when I’ve completed the currently proposed series of posts. In 2014, I hope to produce a series of posts which introduces the concepts of psychometric properties of outcome measures and measurement tools that we each use regularly in clinical practice as well as dedicating some time and effort to stats (even the word makes me cringe!).

I hope this gives you a bit of a clearer view of where the blog is at present and where it’s going. Any comments, criticisms, suggestions etc. are all welcomed and I would love to hear from you.

A

 

 

Searching the Literature: That’s only in Systematic Reviews, right?

As a clinician it is important to ensure that you can undertake a relative simple, but effective, literature search or at the very least, know your way around a few electronic databases!

(A more detailed understanding of the search process in research will be considered when we cover the systematic review study design and appraisal).

Literature searching is a great CPD skill and one which you will use (or should be using!) monthly for certain throughout your career. I recall receiving lectures from the Librarian as an undergraduate each year and finding them incredibly boring as she spoke in a monotone voice about truncation and Boolean operators – all foreign language before a two week cram for my dissertation! I hope that this blog post will help you formulate a literature search in a slightly less monotone manner; I don’t think anybody could make it not boring, unfortunately!

So, literature searching, looks complex and incredibly confusing when reading a large systematic review or Cochrane review, eh?

They can be complex, I’m not going to lie, but I am hoping to now give you the fundamentals with regard to finding literature to inform your practice from a clinician’s perspective.

Where will you find the literature?

A good place to start if you are still an undergraduate (or postgraduate), is the library catalogue however, from there electronic databases are your best bet e.g. Medline, Cinahl, PEDro etc.

Most of them are a much of a much in terms of how to use them and you will no doubt develop a ‘favourite’. I’m a Medline Man (wow, what a term!) but must admit I find Google Scholar incredibly useful..shameful I know.

Or is it? A recent paper by Gehanno, Rollin and Darmoni (2013) showed that if all 29 Cochrane reviews published in 2009 had only utilised Google Scholar, no references would have been missed.

Key aspects of a search strategy?

• Databases
• Keywords
• Inclusion/Exclusion for studies
• What you found in each database*
• Filtering processes i.e. how did you choose your final papers?*

*There are maybe more relevant to writing an assignment or writing up a piece of research; the first three are more applicable for the practicing clinician.

Defining the Literature Search

If you remember, in my previous post I presented Sackett’s definition of EBP and went on to say that an effective clinician will interpret the value or significance of research findings to theor practice i.e. individuals or specific circumstances.

You therefore need to be selective when gathering relevant literature and should consider an inclusion/exclusion criteria; this doesn’t need to be incredibly formal when searching literature to inform your practice (it’s not your dissertation after all!).

CLINICAL TIP: Inclusion/Exclusion can reduce the generalisability of findings of a paper, however, in research they are needed and are considered ‘good’ science.

A way of structuring or creating inclusion/exclusion criteria can be to draft a table, sometimes called a ‘PICO’ (Kahn et al 2011), which you may have seen used more formally in papers; it can also be used for research question formulation.

	Inclusion	Exclusion
Population
Intervention
Control
Outcome

Population – Description of a group of participants or patients, their clinical problem and the healthcare setting.

Intervention – The main action(s) being considered.

Control – This can sometimes be a Comparison, what is the main alternative?

Outcome – The clinical changes in health state and other related changes.

Keywords

So, you know where you’re going to look and roughly what you are looking for from your search via the inclusion/exclusion criteria well, how are you going to find them? – The search strategy.

When choosing your key words to include in your search it is useful to think quite broadly, consider synonyms, different spellings, different ways of describing the same thing to help you maximise your search.

Using a table at this stage is again a great way to structure your thinking and allow your search to begin to take shape (it will also help you with using Boolean operators later on in the search process).

	Key Words
Population
Intervention
Outcome
Study Design

Study Design – The appropriate ways to recruit participants or patients in a research study give them interventions and measure their outcomes.

When you have listed a few key words it can be useful to enter them  into the Medical Subject Heading Terms (MeSH) vocabulary browser on the U.S. National Library of Medicine database to ensure papers that have used different terminology are included in your search (Randy and Austin 2012).

A link to the vocabulary browser can be found here: http://www.nlm.nih.gov/mesh/MBrowser.html

It also useful to consider the use of truncation at this stage; * is used to signify truncation ensuring that all possible variations of a word are identified by the search.

Truncation is used to replace letters in words, allowing you to get more results than you would with one word.

For example, you are conducting an assignment on ‘stretching’ or are wanting to look into the effectiveness of stretching within a rehabilitation programme. You could enter the word, ‘stretching’ into the database, and all the papers with that word in would return (along with a 1000 more for some reason!?).

However, if you were to truncate and enter ‘stretch*’ you would receive the papers that have included the words ‘stretch’, ‘stretches’ or ‘stretching’ (along with a 1000 more!!).

Truncation is a way of broadening your search.

I am aware that at this stage, I may be losing you with technical gumpf so please enjoy this video, it is of goats laughing like humans: http://www.youtube.com/watch?v=NXpNdZpc7fg

So, we’ve reached the final straight whereby I introduce Boolean logic; this helps you to maximise the efficiency and efficacy of the search and appears very complex on the surface but fear not:

Let us revisit the second table:

	Key Words
Population	Athletes, Sportsman, Sports People
Intervention	Stretch*
Outcome	Range of Motion, ROM
Study Design	Controlled Trial

As you can see, I’ve added a few hypothetical words to aid my explanation of Boolean. If we considered each row as a group, we use the Boolean Logic word ‘OR’ within groups, for example:

Athletes OR Sportsman OR Sports People

We use the Boolean Logic word ‘AND’ between groups, for example:

Athletes OR Sportsman OR Sports People AND Stretch*

This print screen shows how these words may be added when using Pub Med (You may need to click on it to make it bigger!).

An alternative way to search the literature with Boolean logic, is to combine words with ‘OR’ as described as above however, without combining them with an ‘AND’; stay with me.

No	Search term (s)
1	Valid*
2	Back pain OR back ache OR lumbar OR lumbar spine
3	Goniomet* OR Schober sign
4	Range* of motion* or Assess*
5	1 AND 2 AND 3 AND 4

So if we were searching the literature to determine which methods of measuring lumbar spine range of motion were valid we may have a search box which looks like this.

So, I’ve performed four comprehensive searches (1-4) using the ‘OR’ operator; I’ve then combined the searches not the group to give me my fifth, comprehensive search. This is the same method in theory as the one previously described however, from my experience, this second way produces a better search and is usually way seen in the literature.

Search Strategy for the Clinician – A Recap

• Utilise electronic databases.
• Use a ‘PICO’ system to draft an inclusion/exclusion criteria.
• Use a ‘PIOS’ table to draft some key words; think broadly.
• Make these key words better by using a MeSH browser and truncation (see above)
• Utilise Boolean logic to maximise the effectiveness/efficacy of your search.
• Use your inclusion/exclusion criteria to identify the papers relevant to your practice.

Phew, well that was a difficult write! I hope you ‘enjoyed it’ and you were able to take something away from reading the post even if it’s just me jogging your memories! Now that you have been able to gather a body of literature, the blog posts will now move more towards critical appraisal and various study designs.

I will attempt to get the next blog post up within the month and this will be on Critical Appraisal and Experimental/Quasi-Experimental Study Designs! I’ve managed to get the first of my guest bloggers on board who will be making an appearance over the coming months 🙂

Thanks for reading and please comment below!

A

References

Khan K, Kunz R, Kleijnen J and Antes G (2011) Systematic reviews to support evidence-based medicine: how to review and apply findings of healthcare research. London: Hodder Arnold.

Randy R and Austin T (2012) Using MeSH (Medical Subject Headings) to enhance PubMed search strategies for evidence-based practice in physical therapy. Physical Therapy. 92, 124-132.

What is Evidence Based Practice?

What is Evidence Based Practice?

Welcome back to ‘Applying Criticality’, may I first wish you all a Happy Easter and apologise for the time between my first and second posts; I’ve been incredibly busy with work, my MSc and various other activities I find myself unable to say no to, as well as being ill recently! All of which have conspired against me, but anyway, it’s written now!

Evidence based practice (EBP) has been a bit of a buzzword in healthcare since the 1990’s but what exactly is it? The textbook definition often quoted when discussing (EBP) is that from Sackett et al. 2000.

“Integration of the best research evidence with clinical expertise, the clients preferences & values an clinical circumstances”.

Imms and Imms (2005) – This picture demonstrates the interconnected nature of EBP; in the centre of the image where the arrows converge, represents the patient.

What does this definition mean when applied clinically or, when you think about it is an individual clinician?

It means that to be an effective clinician one must:

• Appraise/determine the quality of research presented in the literature (and in turn discarding poor quality research).
• Interpret the value or significance of research findings to your practice i.e. individuals or specific circumstances.

I’m hoping you are starting to see that reading the conclusion of a paper is not enough for individual clinicians to demonstrate EBP, sorry (well, I’m not!).

CLINICAL TIP – When I read a paper, I keep the definition of EBP in mind; whilst reading a high quality paper is fantastic, and excellent for broadening ones outlook, if the population, intervention or follow up does not replicate my practice, then the transferability of the paper is often limited.

There lies one of the current tensions between research and practice but that’s for another day, it is just worth bearing in mind that whilst high methodological rigour is required to trust the findings, the paper may not be applicable to your practice.

Introduction to Types of Evidence

The middle bulk of the posts on this blog will look at different study designs and their appraisal however, now may be a useful time to introduce them and get you thinking about the “hierarchy of evidence”.

Research can be Primary or Secondary.

Primary can be divided into Quantitative or Qualitative.

Qualitative refers to ‘what’, ‘why’ or ‘how’? It is considered to be the study design that reaches the parts that other methods cannot reach (Pope and Mays 2006).

Quantitative can be further divided into Experimental (RCT, Controlled Trial, Uncontrolled Trial) or Observational (Case Series, Cross-sectional, Cohort, Case-control).

Whilst within Secondary, the main type of design will be systematic reviews (however, literature reviews and ‘masterclasses’ may be seen).

I know what you are thinking: “Great, he’s listed all these designs I vaguely remember hearing but we only need to know about RCTs, right? They’re the gold standard, right!?”

Unfortunately not, RCTs are indeed the gold standard for intervention studies (although, consider early on that just because a paper utilised a RCT design, does not mean it is automatically rigorous or high quality) however, whilst the ‘Hierachy of Evidence’ provides a nice framework, it is limited as it doesn’t consider the research question (remember that last post?) or even ethics at times.

Depending on the research question, depends on what design should be used to answer the question and therefore it could be argued there are multiple gold standards.

Some Examples

Sensitivity/Specificity of shoulder special tests – Diagnostic Study

Risk factors – Cohort Study

Effectiveness of Mobilisation – RCT

Patients thoughts/satisfaction – Qualitative

As each of the study designs is considered in future posts, what they can tell us and for what research question they should be used for, will become apparent.

For more reading on What is Evidence Based Practice? Do check out this article from Sackett that many see as the foundation of EBP when started in the 1990s: http://www.bmj.com/content/312/7023/71

My next blog post will look at literature searching for the practicing clinician and I hope to have it up sometime over the next couple of days 🙂

Please leave a comment below.

A

References

Imms, W., & Imms, C. (2005) Evidence based practice: Observations from the Medical Sciences, implications for Education.

Pope, C,. & Mays, N. (2006). Qualitative Research in Health Care. 3rd Edition. London: BMJ Publishing Group.

Sackett, D. L., Straus, S.E., Richardson, W.S., Rosenberg. W. & Haynes, R.B. (2000). Evidence-based medicine: how to practice and teach EBM. Edinburgh: Churchill Livingstone.