EBP:

Formulating a
Clinical
Question

Sayu Aryantari Putri Thanaya

Learning Objective

– Explain the difference between

– Background and foreground questions
– Identify the components of a clinical research question (PICO)
– Population, Intervention/Comparison, Outcome
– Differentiate between the various types of clinical questions/study
designs
– Review Clinical Scenarios
Evidence Based Practice
 Evidence Based Practice

“The conscientious, explicit “The practice of evidence-

and judicious use of
current best evidence in
making decisions about
the care of the individual
patient”
– Sackett 1996
– Fetters and Tilson 2012.
“EBP is a method of based physiotherapy
clinical decision making should be informed by the
and practice that integration of relevant
integrates the best high quality clinical
available scientific research, patients'
research evidence with preferences and
clinical expertise and physiotherapists' practice
patient’s unique values knowledge”
and circumstances” - Herbert et al. 2005
Evidence Based Practice

Clinical • Clinician’s cumulated experience,

expertise education and clinical skills

Patient • Patient’s own personal and unique

values concerns, expectations and values

Best • Usually found in clinically relevant

research research that has been conducted
evidence using sound methodology
Evidence Based Practice

Aims of EBP:
– To provide the most effective care that is available, with the aim of improving
patient outcomes. Patients expect to receive the most effective care based on
the best available evidence.
– EBP promotes an attitude of inquiry in health professionals and starts us
thinking about: Why am I doing this in this way? Is there evidence that can
guide me to do this in a more effective way? As health professionals, part of
providing a professional service is ensuring that our practice is informed by the
best available evidence.
– EBP also plays a role in ensuring that finite health resources are used wisely and
that relevant evidence is considered when decisions are made about funding
health services.
EBP Process
EBP Process
Formulating a Clinical
Question
Clinical Question
 Why is it important to formulate a
good clinical question?

“One of the fundamental skills

required for practising EBM is the Clinical practice that’s
asking of well-built clinical questions. informed by evidence
To benefit patients and clinicians, such is based on well
questions need to be both directly formulated clinical
relevant to patients' problems and questions that guide us
phrased in ways that direct your search to search for the most
to relevant and precise answers” current literature
– Centre for Evidence Based
Medicine
Why is it important to formulate a
good clinical question?

– Every time you are presented with a patient case, we need new
information about some element of the diagnosis, prognosis or
management. However, there is usually a flood of details to digest.
– To effectively search for the best evidence, you first need to decide
what details are important to the case at hand.
– Because our time to try to find this information is often limited, we
need to be very efficient in our searching. To achieve this
efficiency, we need to become skilled at formulating clinical
questions
 Background vs.
Foreground Questions
 Background Questions
• General questionsabout a topic/condition.
• Asked by those who are relatively inexperienced with a topic;
when encountering a problem for the first time (Booth,
2006).
• Askswho, what, where, when, how & whyabout things
like a disorder, test, or treatment, or other aspect of
healthcare.
• Addressbasic information about a disease, disease
process/pathophysiology, basic drug/treatment,prevalence
of a condition, etc.
• Textbooks, reliable web pages, narrative review, etc.
 Background vs Foreground
Foreground questions
Questions
• Asked when a clinician is already aware of two or more competing
options and must make a clinical decision. The level of prior
knowledge with the topic must be greater to be able to pose this
type of question. (Booth, 2006).
• Asks forspecific knowledgetoinform clinical decisions or
actions(Weinfeld& Finkelstein, 2005)
• These questions typically concern a specific patient or particular
population.
• More specificand complex than background questions -
investigating comparisons, such as two drugs, or two treatments.
• Information found in primary literature/research, clinical guidelines,
or systematic reviews.
 Background vs Foreground
Questions
 What are the clinical manifestations of asthma?
 What causes a stroke?
 In patients with osteoarthritis of the hip, is water therapy more effective than land-based
exercise in restoring range-of-motion?
 How can I tell if my patient is dehydrated?
 In a 55 year old man with RA, what is the best physical therapy intervention to help restore wrist
function?
 What are the best treatments for back pain?
 Is exercise therapy or manual therapy more effective in reducing low back pain in adolescents?
 What are the causes of shoulder internal impingement in an overhead athlete?
 Background vs Foreground
Questions

 In patients with osteoarthritis of the hip, is water therapy more effective than land-based
exercise in restoring range-of-motion?

 In a 55 year old man with RA, what is the best physical therapy intervention to help restore
wrist function?
 What are the best treatments for back pain?
 Is exercise therapy or manual therapy more effective in reducing low back pain in adolescents?
Foreground Questions

Is this a good foreground question?

What is the best treatment for low

back pain?
Foreground Questions

Is this a good foreground question?

In adult patients younger than 50 years old with

acute low back pain (< 6 weeks), does bedrest
reduce the risk of recurrence of pain within one
year compared with physiotherapy?
Foreground Questions

Which is a better question?

What is the best treatment for back pain?

In adult patients younger than 50 years old with acute low back pain
(< 6 weeks), does bedrest reduce the risk of recurrence of pain within
one year compared with physiotherapy?
 Foreground Questions

Inform Provide
Foreground Ask specific clinical best care,
questions knowledge decision optimise EBP
making outcomes

• Specific • Patient • Helps the

questions management clinician and
patient to make
decisions about
the management
of their problems
PICO
 PICO Clinical Question

Components of a well-built question

Thepatient’sd Acomparisoni
isorder or Theinterventi ntervention
Theoutcomeo
disease onor finding (if applicable
f interest
orproblemof under review – not always
interest present)
PICO Clinical Question

Why do we need PICO?

 Keep the question patient oriented

– Patient-oriented evidence (POE) vs disease-oriented evidence (DOE)
 Make searching effective & focused
– Will help you in designing your search strategy
 Will make you think of what type of study you will be looking for
– What category
PICO Clinical Question

P • Patient, problem or population

Primary complaint? Disease? Sex, age, race, setting?

• Intervention
The acronym
PICO assists I Main intervention - what do you want to do? Treatment?
Prescribe a drug? Order a test?
in
remembering • Comparison
the steps C Comparisonintervention - what alternatives do you want
to compare the intervention to? Another treatment, drug,
placebo, etc.?

• Outcome(s)
O Outcome of interest - what do you want to accomplish,
improve or affect?
Types of Question and Studies

P • Patient, problem or population

I • Intervention
C • Comparison

O • Outcome(s)
T • Type of Question

T • Type of Study
Types of Questions and Studies
Type of Question Explanation Type of Study

Therapy (Treatment) Questions about the effectiveness of interventions in improving RCT

outcomes in sick patients/patients suffering from some
condition. These are the most frequently asked.

Does this treatment do more good than harm and is it worth the
effort and cost?
Prevention Questions on how to reduce the chance of disease by identifying RCT
and modifying risk factors and how to diagnose disease early by Prospective Study
screening.

How can we reduce the chance of disease? What interventions

have proven effective in modifying risk factors? (e.g. diagnostic
tests, therapeutic programs, health promotion activities).
Diagnosis Questions about the ability of a test or procedure to identify a RCT
disorder/condition in a patient presenting with specific symptoms Cohort Study

Which diagnostic test is most accurate in confirming or excluding

a diagnosis, based on a consideration of specificity, sensitivity,
likelihood ratios, expense, safety, etc.?
Types of Questions and Studies
Type of Question Explanation Type of Study
Prognosis/prediction Questions about the probable cause of a patient's disease or Cohort study
the likelihood that he or she will develop an illness. Case-Control study

How do we estimate the patient's likely clinical course over

time and anticipate likely complications of disease?
Etiology/harm Questions about the harmful effect of an intervention or Cohort study
exposure on a patient.

What causes the health care problem or makes it more likely?

E.g. Do tanning beds increase the risk of melanoma? Does
obesity lead to increased risk of cardiovascular disease? What
behavioural risk factors have been linked to lung cancer?
Limits of PICO

– This model works best for Therapy/Treatment &

Diagnosis questions.
– Remember, PICO (TT) is a model, not a rigid structure.
Clinical Scenarios
Writing a Good Clinical Question (1)
Therapy/treatment

CASE STUDY 1

A mother brings her 15-year-old son who is experiencing low back pain,
which is limiting some of his daily activities, to their primary care physician.
The mother expresses that she would like to avoid pain medications if
possible, and so they are referred to physical therapy. As there are many
physical therapy modality options available for the treatment of low back
pain, including exercise therapy and manual therapy, you would like to
know which treatment may be most effective for a patient of this age.
 Writing a Good Clinical Question (1)
Therapy/treatment

P 15 year old male Clinical Question:

In a 15-year-old male, is exercise
therapy or manual therapy more
I Exercise therapy
effective in reducing low back
pain?
C Manual therapy
T: Therapy/Treatment
O Reduction in low back pain T: SR (Meta-analysis), RCT
Writing a Good Clinical Question (2)
Diagnosis

CASE STUDY 2

A 17-year-old female presents to your clinic with radiating neck pain.

You know that Spurling’s test can be used to assess nerve root pain.
You wonder how sensitive and specific Suprling’s test for detecting
cervical radiculopathy.
 Writing a Good Clinical Question (2)
Diagnosis

P 17 year old female with radiating neck pain Clinical Question:

For a 17-year old female with
radiating neck pain, how sensitive
I sensitivity and specificity ofSpurling’stest
and specific is the Spurling’s test
for detecting cervical
C -
radiculopathy?

O detecting cervical nerve root impingement

T: Diagnosis
T: RCT, Cohort study
Writing a Good Clinical Question (3)
Prognosis

CASE STUDY 3

The parents of a high school swimming athlete with recurrent neck

pain are concerned about their son’s future health condition. They
ask you about the likelihood of their son developing chronic neck
pain.
 Writing a Good Clinical Question (3)
Prognosis

P Competitive high school swimmer Clinical Question:

For a high school swimming athlete
with recurrent neck pain,
I -
what is the likelihood that the
athlete will develop
C - chronic neck pain?

O Chronic neck pain T: Prognosis

T: Cohort study, Case-control
Summary

– The first step in EBP is to ask a clinical question.

– There are two types of clinical questions: Background or Foreground –
Foregrounds questions are used in EBP to inform clinical decision
making.
– A good clinical question should contain PICO elements. The PICO model
is a tool to help you refine a complex case down to a core question.
– Knowing what type of clinical question (T) you are asking will help you
know what is the best type of study (T) to provide evidence to answer
your clinical question.
 References

– Booth, A. 2006. Clear and present questions: formulating questions for evidence based practice. Library Hi Tech
24(3), pp. 355-368.
– Fetters, L. and Tilson, J. 2012. Evidence Based Physical Therapy. Philadelphia: F.A. Davis Company.
– Herbert R. et al. 2005. Practical evidence-based physiotherapy. Edinburgh: Elsevier Butterworth Heinemann.
– Leen, B. et al. 2014. Evidence-based practice: a practice manual [Online] Available at:
http://hdl.handle.net/10147/317326 [Accessed 10 February 2019].
– Melnyk, B. M. and Fineout-Overholt, E. 2011. Evidence-based practice in nursing & healthcare: A guide to best
practice. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.
– Stillwell, S.B. et al. 2010. Asking the Clinical Question: A Key Step in Evidence-Based Practice. American Journal
of Nursing 110(3), pp. 58-61.
– Straus, S. E. et al. 2011. Evidence-based Medicine: How to Practice and Teach EBM. 4th ed. Edinburgh: Elsevier
Churchill Livingstone.
– Weinfeld, J. M., & Finkelstein, K. 2005. How to answer your clinical questions more efficiently. Fam Pract
Manag, 12(7), 37-41.
Learning Task

– Skenario 1
– Anda adalah seorang mahasiswa semester 8 yang sedang melakukan pre-klinik
di Poliklinik Fisioterapi di suatu rumah sakit. Pada suatu hari, seorang pasien
datang dengan kondisi/kasus yang belum pernah Anda temui sebelumnya dan
Anda tidak banyak tahu tentang kondisi tersebut. Kasus tersebut adalah
Guillain-Barre Syndrome. Pertanyaan-pertanyaan seperti apa yang bisa Anda
tanyakan untuk menambah pengetahuan Anda tentang kondisi tersebut?
Learning Task

– Skenario 2
– Seorang laki-laki berumur 47 tahun mengalami nyeri punggung bawah unilateral
setelah mengangkat kotak berat di tempat Ia kerja. Pada pemeriksaan, Anda
menemukan bahwa pasien mengalami stiffness/kekakuan dan nyeri pada semua
ROM. Anda berpikir bahwa unilateral joint mobilisation akan membantu
menghilangkan nyeri dan mengembalikan ROM dalam beberapa sesi. Akan tetapi,
baru-baru ini Anda telah membaca dalam literatur bahwa terapi latihan saja
mungkin efektif dan lebih menghemat biaya. Anda bertanya-tanya apakah ini benar?
Learning Task

– Skenario 3
– Seorang pria berumur 55 tahun dengan rheumatoid arthritis (RA) dirujuk ke
fisioterapi untuk membantu mengurangi nyeri di pergelangan tangannya.
Selama ini, Anda telah menggunakan splinting/bidai dalam merawat pasien
dengan RA. Tetapi, Anda mendapatkan informasi dari rekan Anda bahwa
compressive gloves juga mampu mengurangi nyeri pada RA. Anda bertanya-
tanya intervensi mana yang akan lebih bermanfaat bagi pasien Anda?
Learning Task

– Skenario 4
– Anda bekerja di suatu klinik fisioterapi di suatu desa. Bu Wayan adalah pasien dengan hip
osteoarthritis yang rutin dating ke klinik Anda untuk mendapatkan tindakan fisioterapi. Ia
berumur 65 tahun, baru saja pensiun, dan tidak memiliki riwayat penyakit yang serius. Ia
dating menggunakan gelang magnet yang diberikan oleh putrinya. Putrinya bersumpah bahwa
gelang tersebut mampu membantu mengurangi nyeri pada pinggul. Tetapi, Bu Wayan sangat
skeptis dan Ia bertanya pada Anda apakah Anda merekomendasikan penggunaan gelang
magnet tersebut. Anda tidak tahu apakah terdapat bukti ilmiah/penelitian yang menunjukkan
keefektifan dari gelang magnet, tetapi Anda berjanji akan mencari tahu lebih lanjut. Akankah
gelang tersebut membantu mengurangi nyeri pinggul Bu Wayan?
– Skenario 5
– Seorang pria berumur 45 tahun datang dengan keluhan nyeri pada bahu sejak 2
bulan yang lalu, pada saat pria tersebut mengajak anjingnya jalan-jalan kemudian
anjingnya secara tiba-tiba mengejar kucing dan menarik talinya dengan keras. Anda
curiga pria tersebut mengalami rotator cuff tear. Beberapa tes/pemeriksaan dapat
dilakukan untuk mengkonfirmasi apakah pria tersebut mengalami rotator cuff tear,
diantaranya adalah Neer’s Test dan Hawkin’s test. Anda ingin tahu, diantara 2 tes
tersebut, yang mana lebih akurat dalam mendiagnosis rotator cuff tear?