Introduction to Evidence-Based
Athletic Training Practice
MATA 2015
Mark Weber, PhD, ATC, PT, SCS
Objectives
• Following the presentation the participant will be
able to:
– define evidence-based practice and discuss it’s 3
components.
– develop a clinical question based on the PICO(T)
process
– identify search strategies for answering clinical
questions
– identify levels of evidence based on the CEBM scale
– interpret the results of the PEDro and QUADAS
internal validity scales
Disclosures
• No commercial interest in this presentation.
• No personal gain
• But my alma mater is the reigning national
champions!
Importance
• Steves and Hootman "......Athletic trainers need
to embrace the critical-thinking skills .............
[EBP] provides an important next step in the
growth of the athletic training profession." --- JAT
2004
• Welch et. al. "...... (EBP) in athletic training is a
necessary step …… advancement of athletic
trainers (ATs) as health care professionals..........
most ATs still are not practicing in an evidencebased manner." ---- JAT 2014
Disconnect
• AT’s valued the concept of EBP
BUT
• Demonstrated low knowledge of EBP
• Low to moderate confidence in their EBP
knowledge
Hankemeier et al. (JAT 2013)
BOC EBP Foundational vs Clinical
Evidence-Based Practice
Athlete’s
preferences
Best available
evidence
Resources
Athletic Trainer’s
expertise
EBP Steps
Assess - Clinical
scenario
Assess II
Ask - Develop
• Athlete outcome
• Self-assess
PICO(T)
Acquire -
Apply –
Search based on
PICO(T)
Integrate
Appraise Review Results
Clinician Component
• Clinical expertise/skills include:
– background knowledge
– clinical interpretation skill
– psychomotor skills
– ask relevant clinical questions
– find and interpret answers to clinical questions
• Practice
• Self-assessment
PICO(T)
•
•
•
•
•
P = population, patient, or problem
I = intervention or diagnostic test of interest
C = comparison or control
O = patient relevant outcome(s)
(T) = time frame
Example PICO(T)
• Clinical Scenario - What special tests should I
use to assess an athlete with suspected ACL
injury?
• P = ACL injury
• I = Lachman
• C = Anterior Drawer
• O = diagnostic accuracy
PICO(T) Based Search Strategy
Google?, Bing?, Yahoo?
(I)
(C)
(P)
(C)
(I)
(P)
ACL
Ant.
Drawer
Lachman
Shortcut
Results
Results
Results
Pooled results from the meta-analysis
• Lachman is much more sensitive than anterior
drawer or pivot shift
– SnNout – a negative Lachman rules it out…sort of
(Sn = 85 ok, not great)
• All three are similar in specificity
– SpPin – a positive Lachman, anterior drawer, or
pivot shift rules it in
• Clinician self-assessment
Tips from the Field
• Frame your questions in the PICO(T) format
– (P) and (I) are required
– (C) and (O) are recommended, not required
– (T) optional
• When possible, filter with meta-analysis or
systematic review
• Avoid Google, Bing, Yahoo, etc….
Examples from Steves and Hootman
JAT 2004;39(1):83–87
Not a Meta-analysis or Systematic
Review?
• Internal validity is key
– The degree to which a change in outcome can be
attributed to the intervention rather than to
extraneous factors
– “Believability” or “Truth”
– Control of bias
• Alphabet soup to the rescue
– CEBM
– PEDro
– QUADAS
Centre of Evidence-Based Medicine
• CEBM - http://www.cebm.net/
CEBM – Levels of Evidence
Level of Evidence
Intervention Studies
Diagnostic Studies
I
Systematic Review/Metaanalysis
Systematic Review/Metaanalysis
II
RCT
Cohort with consistently
applied standards
III
Non-randomized Clinical
Trial
Cohort without
consistently applied
standards
IV
Case-Control or Case Series Case-Control
V
Case Study, Expert Opinion, Case Study, Expert Opinion,
or Mechanism-Based
or Mechanism-Based
Reasoning
Reasoning
Level I = highest evidence (lowest potential for bias)
Level V = lowest evidence (greatest potential for bias)
Intervention Studies – CEBM, Bias,
Results
PEDro
• Designed to measure internal validity of
rehabilitation RCTs
• 0 to 10 scale
– 10 = highest internal validity (lowest potential
bias)
– 0 = lowest internal validity (highest potential for
bias)
• PEDro - http://www.pedro.org.au/
www.pedro.org.au
PEDro Simple Search
How is patellar tendinopathy treated?
Search Results
Scrolling Further Down
Detailed PEDro Results
Article
Advanced PEDro Search
PEDro
• Strengths
– Focus on rehab
interventions
– Scores the internal
validity
– Provides links
– Simple Search
– Advanced Search
• Weakness
– Only interventions, no
diagnostic studies
– Does not contain all
studies
Internal Validity in Diagnostic Testing
• QUADAS – QUality Assessment of Diagnostic
Accuracy Studies
• http://www.bris.ac.uk/quadas/
• QUADAS has 14 point scale
– Higher score – less bias
– Lower score more bias
• QUADAS 2 has a 7 item scale
• Does not have an article database like PEDro
• Is used by Cochrane Systematic Reviews
Clinical Utility
• Clinical skill – guides clinical decision making
• Rehab – shotgun approach wastes time,
money and may increase risk
• Diagnosis – tests with poor diagnostic
accuracy waste time, money, and increase risk
• Practice thinking in PICO(T) terms
Clinical Utility
• Identified barriers
–Time
– Role strain
– Knowledge
– Gap between clinical and educational settings
– Lack of mentors
Manspeaker et al. JAT 2011
McCarty JAT 2013
Addressing Time Issue
• PICO(T)
• Know where to search (PEDro, PubMed,
CINAHL, Cochrane Datebase)
• Look for applicable systematic reviews / metaanalyses
• Practice!
– Were you successful on your first Lachman?
Questions?
mweber@umc.edu