Value and problems of Evidence Based Clinical Practice in Physical and Rehabilitation - PowerPoint Presentation

1. Value and problems of Evidence Based Clinical Practice in Physical and Rehabilitation MedicineUniversity of BresciaDepartment of Clinical and Experimental Sciences------Care & Research InstituteDon Gnocchi, MilanProf Stefano Negrini, MDChair - Physical and Rehabilitation Medicine

2. IntroductionPhysical and Rehabilitation Medicine is today challenged by Evidence Based MedicineThere are many doubts about EBM in PRMProblems of RCTs in PRMPRM is behaviours and not only a pillProblems of outcome in PRMEBM in PRM is only to cut costs…

3. HypothesisEBM is only the last step of methodological improvement of medicineEBM is a method and not an aim, and as such must be usedIf this is the case, we need a method to improve EBM approach in PRM

4. 1685 - Charles II, King of England and ScotlandHe had a stroke and was treated by the best physicians of his reign16 ounces bloodlettingNot allowed to sleep making him sittingGlass cups on the shouldersShoulders scarification for 8 ounces more of bloodlettingEmetics and laxative at high dosage, with repeated clystersShaven and sticked needles in the headWhite-hot cauteryLuckily the king died without awakeningThe so-called official medicine in 1685

5. 1747 - Dr. Lind and scarvyScarvy (vitamine C deficiency): cause of death in sea explorationsDr Lind was:affiliated to Royal College of Physicians that required to use sulfuric acidpaid by Admiralty that required to use vinegarThe idea: 12 patients, same diet, 6 groups of 2Treatments: sulfuric acid, vinegar, cider, sea water, nutmeg, 2 oranges and 1 lemonFirst controlled study in history

6. 1942 - Pre-terms epidemy of blindness1942-1954: epidemy of retrolental fibrodysplasiaYears of studies by epidemiologist before discovering the commonality: they were all pre-termsBeginning of 40ies: introduction of oxygen administration in incubators Very good new strategy for pre-terms survivalSome years of delay in discovering the cause – many more blind kidsMandatory to perform FOLLOW-UP studies after the application of new treatments (1955)

7. 1961 - ThalidomideDrug for nausea during pregnancyProper studies were performed and then it was sold on the marketFirst reports of phocomelias arrived at the industry and were archived as “random events”Reports increased, but the drug company did not disclose them until a scandal brokeMandatory to prove to FDA effectiveness of drugs before marketing (1962)

8. 1956 - Dr. Spock and the sudden infant death syndromeRenewed pediatrician, developer of a new educational model – kids should not be educated like animals, hitting themSuggestion: “Do not let infants sleep on their back to avoid choking on the vomit and to avoid compression of the head always on the same side” (1956)All infants on their stomach (or laterally)First small RCT 1965: no differencesFirst serious RCT 1985: better supineInfants in various positionsCochrane 2005: prone 4.15 (3.3-5.3) increase of SIDSImportance of RCTs and metanalysis

9. «Official» Medicine todayKing Charles IIDr LindPre-terms blindnessThalidomideSudden Infant Death SyndromeThe methodology of “official medicine” comes from our history

10. MedicinesOfficial MedicineAlternative (Complimentary) MedicineWhat about so-called Rehabilitation Methods ? (eg Bobath, Kabath, McKenzie, Mézières…)

11. Evidence Based MedicineThe explicit, conscientious, and judicious use of the current best evidence in making decisions about the care of individual patients (and populations)Sackett 1996

12. Growth of studies in PubMed

13. Studies hierarchy

14. Alternatives to EBMExperience Based MedicineEminence (tradition-authority) Based MedicineEarnings Based MedicineEloquence Based MedicineDefensive Based MedicineMedia Based MedicineMarketing Based Medicine

15. Megalomany of experienced cliniciansWhat experience tells usPatients with good resultsPatients with bad resultsAnother teaching of experiencePatients with bad results by other colleaguesExperience Based MedicineA professional disease

16. Evidence Based Clinical PracticeThe integration ofbest research evidencewith clinical expertiseand patient valuesSackett 2000

17. BestResearchEvidenceClinicalExpertisePatientValuesEBCP

18. The EBM Gold Standard: Cochrane

19. Archie Cochrane, MD (1909-1988)British epidemiologistResources will always be limitedWe can chose only according to EBMRCTs are the way to improve knowledgeSystematic Reviews of RCTs are a milestone in medicine history

20. What does Cochrane do ?Cochrane exists so that healthcare decisions get better.During the past 20 years, Cochrane has helped to transform the way health decisions are made.Cochrane gathers and summarizes the best evidence from research to help you make informed choices about treatment.

21. A case reportA physiotherapist – a very good a talented colleague and friendTwo very nice daughters with long, blond hairPediculosis – head lice got at schoolThey tried all known popular remedies to try avoiding to cut their hair, but no successSuddenly an IDEA – why not to try to check with Cochrane ?

22. Problem solvedNow he is the author of 2 systematic reviews in his field of competence

23. Who is Cochrane ?Global independent network of researchers, professionals, patients, carers, and people interested in health.Cochrane contributors (37,000 from more than 130 countries) work together to produce credible, accessible health information that is free from commercial sponsorship and other conflicts of interest. Cochrane work is recognized as representing an international gold standard for high quality, trusted information.

24. Acute Respiratory Infections Airways Anaesthesia, Critical and Emergency Care Back and Neck Bone, Joint and Muscle Trauma Breast Cancer Childhood Cancer Colorectal Cancer Common Mental Disorders Consumers and Communication Cystic Fibrosis and Genetic Disorders Dementia and Cognitive Improvement Developmental, Psychosocial and Learning Problems Drugs and Alcohol Effective Practice and Organisation of Care Ear Nose and Throat disorders Epilepsy Eyes and Vision Fertility Regulation Gynaecological, Neuro-oncology and Orphan Cancer Gynaecology and Fertility Haematological Malignancies Heart Hepato-Biliary HIV/AIDS Hypertension Inflammatory Bowel Disease Incontinence Infectious Diseases Injuries Kidney and Transplant Lung Cancer Metabolic and Endocrine Disorders Methodology Review Movement Disorders Multiple Sclerosis and Rare Diseases of the CNS Musculoskeletal Neonatal Neuromuscular Oral Health Pain, Palliative and Supportive Care Pregnancy and Childbirth Public Health Schizophrenia Skin Sexually Transmitted Infections Stroke Tobacco Addiction Upper Gastrointestinal and Pancreatic Diseases Urology Vascular Work Wounds 53 Cochrane Review Groups

25. 17 Cochrane Methods Groups Adverse EffectsBiasComparing Multiple InterventionsEconomicsEquityGRADEingInformation RetrievalIndividual Participant Data Meta-AnalysisNon-Randomized Studies for InterventionsPatient Reported OutcomesPriority SettingPrognosisProspective Meta-AnalysisQualitative and ImplementationRapid ReviewsScreening and Diagnostic TestsStatistics

26. 15 Cochrane CentresSupport Cochrane contributors in their area, and act as a point of contact between Cochrane and their regional health communities.

27. 10 Cochrane Fields and NetworksChild HealthComplementary MedicineConsumer NetworkHealth Care of Older PeopleInsurance MedicineJustice HealthNeurosciencesNursing CarePre-hospital and Emergency CarePrimary Care

28. European White Book of PRMEura Medicophys 2006J Rehabil Med 2007

29. Cochrane FieldCochrane GroupCochrane GroupCochrane Group(e.g. Stroke Group)(e.g. Musculo-skeletal Disorders Group)(e.g. Back Group)

30. Role of Cochrane Fields: a bridge to facilitate the work of Cochrane Review Groups (CRG)to ensure that Cochrane reviews appropriate to their area of interest are both relevant and accessible to their fellow specialists and consumersPhysical and RehabilitationMedicine stakeholders sideCochrane Groupsside

31. Importance of Cochrane PRMPRM sideIncrease scienceImprove methodsAttract researchersStrengthen professional roleImprove visibilityCochrane sideBeyond diseases: functionBehavioral aspects of MedicineMethods in challenghing fieldshttps://www.surveymonkey.com/r/CochranePRM

32. What has been doneEuropean Bodies9/2014: ESPRM EBM Committee3/2015 ESPRM decision to develop Cochrane PRM3/2015 UEMS PRM Section & Board approval2/2016 ISPRM supportEditorials/letters6/2015 European Journal of PRM4/2016: American Journal of PM&RScientific Sessions6/2015 ISPRM Berlin4/2016: ESPRM Estoril5/2016: ISPRM Kuala LumpurFund raisingUniversity of Brescia (Ita) Care & Research Institute Don Gnocchi (Ita)https://www.surveymonkey.com/r/CochranePRM

33. People162 interested131 PRM physicians11 PT115 want to actively contribute45 countriesEurope 74 participants (19 countries)Asia 47 participants (16 countries)North America 20 participants (2 countries)Oceania 9 participants (2 countries)South America 7 participants (4 countries)Africa 2 participants (2 countries)https://www.surveymonkey.com/r/CochranePRM

34. The promotersStefano Negrini, MD (Italy) - stefano.negrini@unibs.it Carlotte Kiekens, MD (Belgium) - carlotte.kiekens@uzleuven.be William Levack, PT, PhD (New Zealand) - william.levack@otago.ac.nz Frane Grubisic, MD (Croatia) - franegrubisic@gmail.com Francesca Gimigliano, MD, PhD (Italy) - francescagimigliano@gmail.com Elena Ilieva, MD, PhD (Bulgaria) - elena_md@yahoo.com Meyer Thorsten, Psy, PhD (Germany) - Meyer.Thorsten@mh-hannover.de Julia Patrick Engkasan, MD (Malaysia) - julia@ummc.edu.my https://www.surveymonkey.com/r/CochranePRM

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37. Next steps19 September 2016: Exploratory Meeting (Rovato – Brescia – Italy) 20 September 2016: Cochrane Meeting (Brescia – Italy) Official Agreement Cochrane, Don Gnocchi, UNIBS30 September 2016 : submission Final Action Business PlanEnd of October 2016: Cochrane Colloquium (Seoul) Cochrane PRM Approval ? https://www.surveymonkey.com/r/CochranePRM

38. Proposals and ideasLeave name, email, and availabilityfor the Cochrane PRM Field developmenthttps://www.surveymonkey.com/r/CochranePRM

39. Thank youStefano Negrinistefano.negrini@unibs.itwww.isico.it www.unibs.itwww.ejprm.it www.dongnocchi.it