Learning starts with the right question

 

Across the world, a new search is initiated on the Physiotherapy Evidence Database (PEDro) every 12 seconds. However, in order to get the right answer to a clinical conundrum, you have to know how to pose the right question to get the best results. PEDro founding director Anne Moseley discusses how to refine the perfect search.

Type ‘low back pain’ into the search engine and users of the PEDro database are slammed by a tsunami of reports on trials, reviews and guidelines. Page after page of indexed articles covering everything from stress management programs in chronic low back pain through to percutaneous electrical nerve stimulation for low back pain are listed among the more than 2290 responses. So how do clinicians elicit the right response when searching the database to answer a specific question?

It all comes down to how you frame that question, says Anne Mosely, APAM. ‘The most common search term is low back pain. That’s valid if you want to say “I wonder how many trials there are about low back pain”. But it’s not when a clinician has got a patient in front of them who has low back pain and they want to work out how to treat them, because essentially, searching low back pain will return a really large number of papers,’ Anne Moseley says. ‘What we suggest to physiotherapists is that they stop and think about their question before they do a search, because they probably need to specify a few things.’

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Anne, who will present ‘How to search PEDro to answer clinical questions’ with Joshua Zadro, APAM, for the musculoskeletal stream at this month’s TRANSFORM 2019 conference, says clinicians risk ‘getting lost’ or bogged down in piles of research unrelated to their query if they do not craft the right question—a situation that is certainly not unique to PEDro but one regularly encountered by users trying to answer a clinical question. ‘Analysis of what search terms people are using on PEDro has determined that many of the questions posed are vague, although gauging the user’s intent or purpose for the search is problematic,’ Anne says. ‘All we know is what they have typed in the search fields; we don’t know what’s in their heads or what they’re asking,’ she says.

‘In evidence-based practice, there’s a pneumonic or a memory aid called PICO [Patient Intervention Comparison Outcome], which necessitates thinking about the patient, the intervention, the comparison, or what you want to compare the intervention to, and what the outcome is,’ Anne says. ‘Being a bit more nuanced in what you use as your search terms will help reduce the search output. We also teach physiotherapists to adjust their search, because very rarely do you do a perfect search first go. You might need to go back and add some more search terms, or remove them, depending on how many search results you get.

‘For example, if I was wondering whether it was worthwhile to do exercise to prevent recurrent back pain, and I typed in “low back pain” and got thousands of results, what I’d do then is add a search term, in this case put in the word “prevent”. The outcome is you want to prevent recurrence. You might also want to put a term in for the intervention, so something about exercise. Adding those extra elements in means you could quickly get to a short list of articles that answer your question, rather than saying “oh there’s too much on this, I’m not going to read anything”,’ she says.

How to ask a clinical question in PICO format

Tools to help users sharpen and refine their questions are available on the PEDro website through video tutorials, through the use of pop-up feedback on the search page and through the database interface that doesn’t require the use of Boolean operators such as the word ‘and’. ‘We’ve done analysis of search terms twice and after the first time we realised there were some really common errors people were making,’ Anne says. ‘We have been providing feedback and these errors have reduced. But the most recent evaluation says we’ve still got a long way to go, because users still go to the website and type in “low back pain” or “stroke” and have a bad experience.’

Other tutorials on the PEDro website include ‘Is the trial valid?’ to help differentiate those clinical trials which are likely to be valid from those that might not be; and ‘Is the therapy clinically useful?’ which looks at how therapists might use the findings of properly performed studies to make clinical decisions.

Last year, PEDro answered 2.6 million questions from searches in 213 different countries and territories. ‘And at the current rate of growth, the database is doubling in size every six years,’ Anne says. Such a substantial body of evidence about the effects of physiotherapy is a goldmine for clinicians, who can integrate their clinical expertise and patient preferences with the results of high-quality clinical research to provide the best care for their patients. And to assist clinicians to interpret the results of the research, the PEDro scale was introduced in 1999. This tool, developed to rate the quality of physiotherapy trials, has been widely adopted by other professions to judge the quality of trials in their discipline.

‘The PEDro scale has been really useful to identify trials that are more likely to be valid and contain enough information to guide practice,’ Anne says. ‘Users tend to click on articles that have higher PEDro scores, so we think it’s a useful tool, but then it’s also not the only element you use to decide whether a trial is well done. You could have a paper that has a high PEDro score but the trial might not be answering a very important question.’

This month marks the 20th anniversary of PEDro, which was started in 1999 by Anne, Rob Herbert, Cathie Sherrington, and Chris Maher, and joined soon after by Mark Elkins. That same year the APA came on board as a founding partner. ‘The APA took a bright idea from four young physios saying “we’ve got a stack of printed articles about the effects of physiotherapy intervention and we want to make them accessible to physiotherapists in Australia” and that little idea has grown into a preeminent global resource. The APA has been really critical in providing us with financial support and also brokering some really good collaborations . . . we now have partners from 40 other countries to help support PEDro. PEDro is free to the physiotherapy community but it does cost money to produce, and that is done by industry funding,’ she says.

The 20th anniversary milestone will be celebrated several ways this year: the website will be refreshed to keep it contemporary, and a database looking at diagnostic tests that physiotherapists use and how accurate those tests are will be linked to PEDro. ‘We’ll also be developing an alternate searching space that provides much more granularity for users, so hopefully that will improve the search experience because we want to make searching and finding answers very easy,’ Anne says.

And the five most influential trials published in 2014–2019 will be revealed later this year, adding to the 15 best trials in physiotherapy that were announced to coincide with PEDro’s 15th birthday in 2014. Calls for nominations for the top five trials began in April this year, and the winners are expected to be announced next month (November).

 

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