Best Evidence Topics
BETs
Questions in clinical practice
What is the best treatment for…..?
 How sure is the diagnosis of……?
 What is the prognosis for……..?
 Is this likely to be harmful…….?
 How does this affect my patient’s life…?
 etc.
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But…..
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Difficult to get ‘quick’ answers due to..
Time
‘Know how’
Resources
N.B. ‘quick’ does not mean cheap & nasty
What is a BET ?
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Emergency Medicine Department
Manchester Royal Infirmary 1996
Started from a modified CAT
Can be ‘best available’ evidence rather than
‘highest quality’
– (problem in physiotherapy & EmerMed)
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Systematic approach to answering ‘real world’
clinical questions
Pragmatic systematic review
Clinical answers to clinical problems
> 800 BET questions
BET structure
The
 The
 The
 The
 The
 The
 The

clinical scenario
3 part question
literature search
critical appraisal
summary ( in a table)
Comment
‘clinical bottom line’
Ask the right question
Focus on a real clinical scenario
 Pull out the key features from the
scenario.
 Formulate the 3 part question.
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Why develop a 3 part
question?
To focus the problem.
 To help define & formulate searching.
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Clinical scenario
A 29 year old patient presents with a 3
month history of supraspinatus
tendonitis.
You are planning to use some form of
electrotherapy but the patient mentions
that he had laser for a similar problem
in his tendo Achilles that seemed to
help.
You wonder if this will apply to a tendon
in another part of the body.
What is the general question?

Can adult tendonitis be helped by
Laser?
What is the patient group?
Adults?
 Chronic Tendinitis?

Is there a comparison?
Laser?
 Other electrotherapy?
 Other therapy?
 Nothing or not relevant?
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What are the outcomes?
Less pain?
 Better function?
 Quicker recovery time?
 Success rate?
 Cost??????
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The 3 part question.
IN [adults with chronic tendonitis]
 IS [laser beneficial]
 AT [decreasing pain and improving
function]
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N.B. Therefore, this is not a systematic review on Laser
What is the patient group?
All Adults?
 Chronic Tendinitis?
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– Good: Adults with 2 month history of
supraspinatus tendonitis
– Not so good: Patients with shoulder
pain (too broad. Too much evidence)
– Worse: Manc men aged 18-28 with a
calcified supraspinatus tendon on XRay due to repetitive javelin throwing
(too narrow.Relevant but no evidence!!)
The Intervention
i.e what are we going to do to our patient
group?
diagnostic questions
– Gold standard against new technique
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prognostic questions
– Define a factor that may affect the outcome
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therapeutic questions
– compare treatments?
A diagnostic question
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Is MR scanning better than U/S
scanning at diagnosis supraspinatus
tendonitis?
A prognostic question
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The ‘empty can’ test as a prognostic
test in supraspinatus tendonitis ?
A therapeutic question
Usually the case for physiotherapy BETs
Laser compared to nothing (or not
relevant)
 Other electrotherapy?
 Other therapy?
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What are the outcomes?
Often problematic
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Clinically relevant
Patient orientated
Definable
Measurable
May be several for 1 intervention
– Less pain?
– Better function?
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RoM, strength, etc
– Quicker recovery time?
– Cost?
The 3 part question
P
I1
I2
O
Adult
chronic tendonitis
Laser
Nothing
(? Other electrotherapy)
Pain
Dysfunction
Using the 3 part question for
searching.
A patient group
Intervention 1
Intervention 2
(Not always present
or necessary)
An outcome
Using the 3 part question for
searching.
Patient group
Intervention
Disease
Age
Gender
What Action / treatment
you are considering
Outcome
What are you looking to achieve
Pain / function
Or
BP, HR, LA, Life etc in
Em.Med
Using the 3 part question for
searching.
OR
Tendonitis
Tendinosis
OR
Tendinopathy
supraspinatus
tendonitis
OR
we want all these papers
Using the 3 part question for
searching
OR
Laser
therapy
Laser
Low level
Laser
OR
LLLT
OR
we want all these papers
Using the 3 part question for
searching.
AND
ALL
Tendonitis
papers
ALL
Laser
papers
we want JUST these papers
NOT
ALL
Tendonitis
papers
ALL
Laser
papers
JUST these papers
Summary so far..
Focused questions are answerable
questions.
 Questions should be based on a clinical
scenario.
 The 3 part question should be used to
help develop a search strategy.
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Search Strategy
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As comprehensive as possible
– Tip: go broad then narrow down
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As many databases as possible
–
–
–
–
–
–
–
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Medline
CINAHL
AMED
EMBASE
SPORTDiscus
Cochrane
PEDro
Beware of only using ‘PubMed’ !!
Search Strategy
Medline, CINAHL, AMED, SPORTDiscus,
EMBASE: [{(exp tendonitis OR
tendinosis.mp OR tendinopathy.mp)}
OR “supraspinatus tendonitis”.mp] AND
[(low level laser.mp OR low level laser
therapy.mp OR laser therapy.mp OR
therapeutic laser.mp). LIMIT to human
AND English language.
 In addition the Cochrane database and
PEDro database were also searched
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Search Strategy
RESULTS
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5 papers including 1 systematic review were
found. A further paper was also found in
conference proceedings via a personal
communication making a total of 7 papers.
Of the 6, one was a commentary on the
systematic review. The conference
proceedings paper was laser therapy to
shoulder trigger points, not tendonitis and so
was considered irrelevant. All the papers
found predated the systematic review so this
is presented in the table only
Summarise the papers
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CRITICAL APPRAISAL IS KEY
– BETs is not a short cut to proper CAT!!
What are the key points?
 If someone read this would they know
what was done in appraisal?
 Describe the exact numbers & p values
 Concentrate on the issue at hand
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– IS it relevant to 3 part Question?
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List any weaknesses in papers
Search Strategy
Author, Date
& Country
Patient
Group
Study
Type
Outcomes Key
results
Bjordal et al
2001, Norway
12 placebo
Systemat %
controlled
ic review improvem
RCTs with
(1a)
ent in pain
subacute/.ch
over
ronic
placebo.
tendonitis.
Effect v
N = 687
size plots.
Laser v
placebo
plots
Including 3
trials with no
or worse
effect of laser
over placebo
(n=12) pooled
mean effect =
21% (95% CI,
5.9-36.1) in
favour of
laser over
placebo.
Excluding
these 3 trials
(n=9) Pooled
mean effect
32% (95% CI
23-41) in
favour of
laser v
placebo
Study
weaknesses
Only analyses
pain as
outcome, but
states this in
methods.
Comments
What does the evidence tell us?
 Is it applicable to my 3 part question?
 Is it applicable to my clinical practice?
 Have the authors missed something?
 Is further research needed?
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Comments
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“The systematic review is the most recent
paper concerning low level laser therapy on
tendinopathy and seems to favour its use
over placebo in decreasing the pain
associated with tendonitis. It comments that
the use of laser therapy is dependent on
power density and dose applied and the
pooled mean effects will alter when studies
do not meet optimal irradiation doses.”
The Clinical Bottom Line
One sentence statement
 The next patient you see today…
 What are you going to do?
 Has the BET given you enough evidence
to change your practice?
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The Clinical Bottom Line
“Laser therapy is superior to placebo in
reducing pain of chronic tendinopathy
by about 32%.”
Your turn!!!
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A 30 year old female patient presents with a
7 day history of patellar tendonitis. You think
of treating her with oral NSAIDs. However,
recently you have seen some information
about NSAIDs in a gel form. This seems an
appealing alternative and you wonder if there
is any evidence of its efficacy .
Questions
– Patient group ?
– Treatment / interventions ?
– Outcome ?
The 3 part question
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IN [Adults with acute tendonitis]
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IS [topical or oral NSAIDs]
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BETTER AT [reducing pain and
improving function]
Using the 3 part question for
searching.
Patient group
Intervention 1
Adults
tendonitis
Oral NSAIDs
Intervention 2
Topical NSAIDs (gel)
Outcome
Pain / function
P
Adult
Tendonitis
I1
Oral NSAIDs
I2
Topical NSAIDs
O
Pain
Function
Your turn again!!!
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A middle aged lady is receiving physiotherapy
for her OA knee. She mentions that her
husband has heard that Glucosamine tablets
are great for arthritis and is thinking of
buying some from a health-food shop. She
asks what you think about them. Before
imparting wise words, you decide to check
the evidence first.
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Questions
– Patient group ?
– Treatment / interventions ?
– Outcome ?
The 3 part question
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IN [adults with OA knee]
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DO [glucosamine tablets]
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IMPROVE [pain and function]
Using the 3 part question for
searching.
Patient group
Intervention 1
Adults
OA knee
Glucosamine tablets
Outcome
Pain / function
P
I1
Adult
OA
Glucosamine tablets
I2
(none)
O
Pain
Function
And again…!
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A 65 year old lady has had a total knee
replacement for osteoarthritis. She has had
an uneventful post op recovery and, as per
protocol, has an appointment for outpatient
physiotherapy. With the pressure on
appointments you wonder whether instruction
on a home exercise programme will be just as
effective as outpatient physiotherapy at
improving function and range of knee flexion.
3 PART QUESTION:
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IN [Adults following TKR]
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IS [a home exercise programme better
than an outpatient programme]
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AT IMPROVING [RoM and function]
Using the 3 part question for
searching.
Patient group
Intervention 1
Adults
Post TKR
Outpatient physio
Intervention 2
Home physio
Outcome
RoM / function
P
I1
Adult
Post TKR
Outpatient physiotherapy
I2
Home physiotherapy
O
RoM
Function
What next?
Don’t keep it yourself
 Get it on the web
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http://www.bestbets.org/
You decide to do a BET
Find a scenario
One week
Formulate a 3 part Q
Get it checked
Do a search
Get it checked
Get the papers
1-12 weeks
Critically Appraise
Complete the BET
GET IT CHECKED
Summary
The BET is the best way to put all your
work together
 The BET can be used to change practice
 The BET can improve journal clubs
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http://www.bestbets.org/