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Evidence-Based Pain Management. Sohail Bajammal, MBChB, MSc, FRCS(C), PhD(c ) Assistant Professor of Orthopaedics , Umm Al Qura University Consultant Orthopaedic Surgeon, Al- Noor Specialist Hospital February 23, 2010. What got me into EBM…. What is a double blind study? - PowerPoint PPT Presentation
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Evidence-Based Pain Management
Sohail Bajammal, MBChB, MSc, FRCS(C), PhD(c)
Assistant Professor of Orthopaedics, Umm Al Qura UniversityConsultant Orthopaedic Surgeon, Al-Noor Specialist Hospital
February 23, 2010
What got me into EBM….
What is a double blind study?
Two orthopaedic surgeonsreading an ECG
Can I use EBM in orthopaedics?
I will tell you
NOTHING about pain management
I will show you how YOU can find
EVERYTHING about pain management
Objectives
• What is EBM?• How to ask an answerable question?• How to search for an answer?• How to assess the quality of the evidence?
GCC EBHC
National & Gulf Center for EBHP
Statistically speaking…
Half an hour presentation is shorter than 5 days workshop (p<0.05)
What is EBM?
Clinical Circumstances
Clinical Circumstances
Research EvidenceResearch Evidence
Patients’ Preferences
Patients’ Preferences
Clinical ExpertiseClinical
Expertise
Haynes et al. BMJ 2002;324:1350
5As of EBM
Is this a good question?
What is the best treatment of acute back pain?
Asking a good question (PICO)!
• Population• Intervention• Control• Outcome
Is this a good question?
• In adult patients younger than 50 years old with acute low back pain, does bedrest reduce the risk of recurrence of pain within one year compared with physiotherapy?
• P: Adult patients <50yr with acute LBP• I: Bedrest• C: Physiotherapy• O: Recurrence of pain within one year
How would you search for answers?
A. 50:50B. Ask the audienceC. Ask a friendD. Flip through a textbookE. Google it up!
What’s wrong with textbooks?
• Textbooks are excellent for the principles and basic knowledge
• Usually single authored chapters• Likely biased, author’s opinion• Not peer-reviewed• Outdated (at least 4 years)
What’s wrong with googling?
What’s wrong with googling?
• Reliability & credibility of source• Google Scholar is good
So what to do?
5S Hierarchy of EvidenceHaynes RB. Evid Based Med 2006;11:162-164
RCTs, Cohort, Case control, Case seriesRCTs, Cohort, Case control, Case series
Expert Opinion: Classical TextbooksExpert Opinion: Classical Textbooks
Primary Sources
• Original articles• Through databases: MEDLINE, EMBASE• Using: PubMed, OVID• You have to retrieve and appraise the articles• Strength (pyramid) of evidence
Pyramid of Evidence
http://library.downstate.edu/EBM2/2100.htm
It’s time consuming
Secondary Sources
Systematic ReviewsSystematic Reviews
Syntheses
• The authors have done the work for you
• Hopefully:– They asked a good question– They searched the literature systematically– They identified the studies and assessed their quality
• This is called Systematic Review• If they did statistical combination of results, this
is called Meta-analysis
How to search for “Syntheses”?
• Same databases: MEDLINE, EMBASE• Cochrane Library
PubMed
Cochrane Library
Are all syntheses good?
• You still have to appraise the quality of these systematic reviews and meta-analyses
• It’s time consuming
So what’s next?
Critically-Appraised Journal Articles & Abstracts
Critically-Appraised Journal Articles & Abstracts
Evidence-Based Guidelines & Textbooks
Evidence-Based Guidelines & Textbooks
Synopses
• Physicians with training in research methodology:– Read the articles– Assess their quality– Summarize them for you
• Many journals: – ACP Journal Club– Database of Abstracts of Reviews of Effects (DARE)
Summaries
• Evidence-based guidelines and textbooks
• Examples:– Clinical Evidence– National Guideline Clearinghouse– UptoDate
http://clinicalevidence.bmj.com/
http://www.guideline.gov/
Systems
• This is the ultimate goal• Computerized decision support
• Too sophisticated for us to think about now
All what we’ve talked about
Research EvidenceResearch Evidence
To practice EBM, we need all the four
Clinical Circumstances
Clinical Circumstances
Research EvidenceResearch Evidence
Patients’ Preferences
Patients’ Preferences
Clinical ExpertiseClinical
Expertise
We need…..
• To apply the evidence as it applies to our local hospitals
• To involve the patients actively in the decision making
• To have our own studies:– Different social, cultural, ethnic, and economical
backgrounds
http://www.andrews-clinic-natural-therapies.co.uk/documents/54.html
http://eapps.ngha.med.sa/ebm/
http://ebmjeddah.info/
This presentation is available online
www.uqu.edu.sa/ssbajammal
المحاضرات
Thank [email protected]