E d u c a t i o n a l A r t i c l e A M o d e l f o r E v i d e n c e - B a s e d E l e c t r o t h e r a p y 1 \ in a n U n d e r g r a d u a t e C u r r ic u l u m PAPADOPOULOS M, MSc (Physio)'; JORDAAN R, M Phys I ’ 1 Department o f Physiotherapy, U niversity o f Pretoria. A B S T R A C T : A ll physiotherapists have a responsibility not only to their patients but also to their colleagues and health care fu nding sources to provide interventions that are sound in theory and supported by well-controlled experimental studies. The p rin ­ ciples o f evidence-based practice should be implem ented in an undergraduate curriculum in order to assist students to acquire skills to obtain and use relevant information. The aim o f this paper is to present a model to integrate the activities o f patient assessm ent and information processing, critical appraisal and evidence-based practice into clinical decision­ making o f electrotherapy application. The model as well as the results and evaluation thereof are discussed. KEYWORDS: EVIDENCE-BASED PRACTICE, PH YSICAL THERAPY, ELECTROTHERAPY, AN D EDUCATION. INTRODUCTION Physiotherapists, regardless o f the coun­ try and context in w hich they work, are facing increasing pressure to provide treatm en t, w hich is evidence-based. Evidence-based practice is defined as “using the best available scientific evi­ dence to guide practice” (Evidence- B ased M edicine W orking Group, 1992). T here is an increasing need for an evidence-based approach to patient care as the cost and choice o f treatm ent must be justified. Research and clinical practice must be integrated to ensure the growth of evidence-based practice in physiotherapy. Treatm ent approaches clearly dem on­ strated to be ineffective for a particular condition, m ust be discarded and clini­ cal practice guidelines, w here available, m ust be implem ented. Questions arising from the im plem entation o f new or altered treatm en t ap proaches should form the basis o f future studies, thus consolidating the link betw een clinical practice and research. Linking research and clinical practice is m andatory if we are to rem ain a credible health care profession and in all probability is essen­ tial for the survival o f the physiotherapy profession (Culham, 1998). Patients have the right to receive treatment, w hich has a theoretical base and has been dem onstrated to be effec­ tive for the m anagem ent o f their con­ dition. Each physiotherapist thus has a responsibility to patients, colleagues and to health care funding sources to provide interventions that are sound in theory and supported by w ell-controlled expe­ rim ental studies. The prim ary goal o f physiotherapy is to provide the highest quality o f care in order to achieve the best outcom e for patients in a cost-effective manner. The care process involves assessm ent, phy­ sical diagnosis, identification o f client- centred goals (outcom es), selection o f effective therapeutic interventions and evaluation o f progress. To make sound decisions throughout this process, phy­ siotherapists require valid inform ation (Thomson - O ’B rien & M oreland, 1998). How do we as professionals, move towards a more evidence-based approach to patient care? Three steps m ust be taken to achieve this outcome. The first involves knowledge generation (research); evidence m ust be available before prac­ tice can be evidence-based. The second involves knowledge transmission (edu­ cation); the inform ation must be readily available to physiotherapists. The third step, know ledge application; involves the incorporation o f new know ledge into clinical practice and evaluation o f out­ comes in the clinical setting (Culham, 1998). Perhaps the m ost prom ising m ethod o f im plem enting evidence-based prac­ tice is to assist undergraduate students to acquire skills to obtain and use relevant inform ation. T hose resp o n sib le for undergraduate curriculum developm ent and teaching thus have a key role in facilitating the process o f im plem enting valid research findings in clinical practice (Thomson - O ’B rien & M oreland, 1998). A t the Physiotherapy D epartm ent, U niversity o f Pretoria, the im portance o f follow ing an evidence-based approach during undergraduate training has been recognised. As students com plete their basic electrotherapy training at the end o f their second year o f study, a decision was made to follow an evidence-based approach with the im plem entation o f electrotherapy in clinical practice during the third year o f study. The new model o f electrotherapy application in the third year cu rricu lu m w as in tro d u ced in M arch 1999. AIM T he main aim o f this paper is to present a model o f integrated activities o f patient assessm ent and inform ation processing, critical appraisal and evidence-based CORRESPONDENCE: M Papadopoulos D epartm ent o f Physiotherapy U niversity o f Pretoria PO Box 667, Pretoria 0001 Tel: (012)354-2023 Fax: (012) 354-1226 E-mail: m papadop@ postillion.up.ac.za SA Jo u r n a l OFt Ph y s io t h e r a p y 2000 V o l 56 N o 4 3111 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:mpapadop@postillion.up.ac.za practice in clinical decision-m aking o f electrotherapy application. A secondary aim is to evaluate the model and to present the results. DEFINITION OF TERMS Evidence: A nything that establishes a fact or gives reason for believing som e­ thing (O xford p ap erb ack dictionary, 1979). The strength o f the evidence is related to the m ethods o f obtaining it. Som e m ethods are m ore subject to bias than others eg, the evidence derived from a case series study is w eaker than that derived from a random ised con­ trolled trial (Cook DJ et al, 1992). Evidence-based practice: The process o f using the results o f sound research (as determ ined by critical appraisal) to guide clinical care within the context of the individual client and local environ­ ment. (Thom son- O ’Brien & M oreland, 1998). C ritical Appraisal: The evaluation o f research papers to determ ine the validity and applicability o f the conclusions. As a result o f the critical appraisal process, a reader is able to ju d g e how m uch con­ fidence to place in the conclusions o f the study and w hether the results apply to their patient/clients (Thom son - O ’ Brien & M oreland, 1998). METHOD AND MODEL Students had to com plete 3 assignments based on the m odel that consists o f 5 stages, throughout the year. Students are tested in a clinical setting to determ ine if they have m astered the required learn­ ing in electrotherapy. The theory com po­ nent is evaluated by means o f a written assignm ent that the students hand in 2 weeks after the practical assessment. This consists o f 2 parts namely the criti­ cal appraisal o f an article (stage III) and the educational prescription (stage I, II, IV and V). The different stages o f the m odel will be described briefly. Stage I D uring the first stage the student is required to assess and treat a patient. A t any point during this stage students may identify the need for further infor­ m ation about the patient’s condition. This w ould assist them to provide the best possible care. A num ber o f ques­ tions may arise concerning the m anage­ m ent o f the patient, eg the effectiveness o f different treatm ent m odalities may not be know n to the student. The student is required to form ulate a question con­ sisting o f the follow ing components: clinical task, patient or problem , inter­ vention and outcom e (see figure I). C linical task refers to the type o f ques­ tion that is posed and may be regarding a clinical finding, differential diagnosis, prognosis, therapy etc (Sackett et al, 1997). Thus, the need for certain infor­ m ation is specified during stage one. Stage II D uring the second stage, inform ation regarding the p atient’s condition and m ost effective treatm ent m odality must be obtained and processed. Traditio­ nally, in fo rm atio n has been located in textbooks or journals in libraries. FIGURE 1: An integrated model for evidence-based electrotherapy STAGE I Assessment a n d tre atm e nt o f the p a tie n t F o rm u la ting a n an s w e ra b le question STAGE II O b ta in in g a n d processing o f in fo rm a tio n STAGE III C ritic a l a p p ra is a l o f in fo rm a tio n o b ta in e d < c STAGE IV • V a lid ity a n d a p p lic a b ility o f c ritic a lly a p p ra is e d a rtic le ■ A c c o u n t o f patient's expectancies ■ A lte rin g o f the m a nage m en t o f the p a tie n t ( if a p p lic a b le ) < c STAGE V S elf-e valuatio n: H o w w ell y o u th in k y o u d id , in c o m p le tin g this task? A : Elements o f a n a n s w e ra b le question Clinical Task Patient or problem Intervention Comparison Outcome Therapy eg In a patient with a sprained anterior talo-fibular ligament of the ankle would treatment with interferential therapy compared to treatment with ultrasound be the most effective in reducing the oedema? B: C ritic a l a p p ra is a l o f an a rtic le : S pecific aspects student should com m ent on Introdu ction a n d B ackground 1. Is the problem clearly stated? 2. Is important background literature included? Research M e th o d 1. Are the methods appropriate to the goals of the study? 2. Is the sample appropriate, given the nature of the study? 3. W hat variables are being measured and how are they measured? 4. Does the procedure do what it is supposed to do? Results 1. W hat answers were obtained to the questions posed? Discussion an d C onclusion 1. Are the findings correctly interpreted? 2. Is the level of generalisation appropriate? 3. Are procedural weaknesses noted and the limitations of the study discussed? 4. Are conclusions drawn from the study? 32 SA J o u r n a l o f P h y s io th e ra p y 2000 V o l 56 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) O ther recent options that should be used to obtain relevant citatio n s include M ED LIN E and CIN A H L databases. The student has to report on the type of search that was perform ed, the key­ words used during the search, as well as the type o f inform ation found as a result o f the search. STAGE III S tage three con sists o f the critical appraisal o f one o f the articles the student found during his/her literature search. T he student should motivate why this article seems to be appropriate in pro­ viding the inform ation he/she requires to answer the question posed in stage 1. With the critical appraisal the students are expected to com m ent on certain spe­ cific aspects o f the article (see figure 1). STAGE IV D uring stage four, the student has to decide w hether the inform ation obtained from the critically appraised article is applicable to his/her patient. Students have to com m ent on the validity and applicability o f the critically appraised article, and give an opinion on how this new know ledge will alter the m anage­ m ent o f or approach to the patient. It is essential how ever that the stu­ dent should acknow ledge at this stage the personal beliefs of the patient, the com m unity and cultural environm ent that may influence the type o f treatment that the patient may find acceptable. The student should realise that' this factor could influence the im plem entation o f this evidence-based approach. STAGE V Stage five is a self-evaluative stage where students are expected to com m ent on how well they think they did in com plet­ ing the task. An aspect that should be considered during this stage is w hether the student is still having difficulty in form ulating an answ erable question. The self-evaluation should include aspects reg ard in g the students own perform ance in searching for the best external evidence. Self-evaluation should also assess the student’s perform ance in critically appraising external evidence for its validity and potential usefulness as well as the accuracy and efficiency in adjusting some o f the critical appraisal m easures to fit the individual patient. EVALUATION OF THE MODEL T he m odel w as ev alu ated during O ctober 1999 by means o f a qualitative method. Students were asked to com ­ m ent on their experience o f this model. RESULTS A total o f 125 com m ents were received from 39 students. Com m ents were clas­ sified either as positive or negative experiences o r responses. Seventy posi­ tive responses (see figure 2) and 55 neg­ ative responses (see figure 3) were iden­ tified. Further results will consequently be discussed. DISCUSSION T he incorporation o f evidence from clinical research into clinical practice FIGURE 2: Positive comments on the integrated electrotherapy model (70 positive responses). SA J o u r n a l o f P h y s io th e ra p y 2000 V o l 56 No 4 33 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) requires that the student m asters and m aintains a continually expanding set of skills. In much the sam e way that time and effort is required to be able to accu­ rately detect, characterise and assess a clinical problem , evidence- based prac­ tice requires that students learn how to form ualte a question and learn to obtain a published article or inform ation rele­ vant to such a question. In addition the student learns to assess validity o f rele­ vant inform ation, learns to identify the clinically useful results and place these results into a form at that can be applied to patient care. The success o f learning by inquiry depends heavily on being able to find the current best evidence to manage cli­ nical problems. Such a task can be achieved quickly and be highly rew ard­ ing, or be time consuming and frustrating. D uring this process the student will learn w here to search for the best evi­ dence and to design a search strategy. Skills in the utilisation of electronic media and other databases are needed or need to be developed. Considering the positive responses from students, 11,4% indicated that they learnt how to use databases and the library more effectively (see figure 2). D uring the p rocess o f critical appraisal o f the relevant literature (stage III), the students are exposed to research term inology, and m ethodology. The highest num ber o f the positive responses (see figure 2) indicated that this model helps students to “ learn how to do research” (22,8% ) and “to learn how to w ork w ith literatu re” (21,4% ). This aw areness could have a positive effect on the student’s future research career as potential research topics and the need for research could be highlighted and exposed as is evident in 4,2% o f the positive responses (see figure 2). In the field o f physiotherapy, the student is also confronted with the lack o f lite­ rature (31,15% o f negative responses) and the low m ethodological quality of existing research. O f the negative responses, 45,45% indicated that students experience this model to be very tim e consum ing. The process o f finding literature (gaining experience with using electronic data­ bases) and critically appraising an arti­ cle is a tim eous process. R esponses o f “stressfu l” (1,8% ) and “library not always very helpful” (1,8%) can proba­ bly be linked to the inexperience o f students in finding literature or to the time lim it o f 2 weeks in which students have to com plete the assignment. H ow ­ ever, it is the view o f the authors, that as the student becom es m ore experi­ enced in finding the relevant literature, and becom es more know ledgeable and gains m ore co n fid en ce in critically appraising the literature, the less time consum ing the process will be. A lthough both physiotherapy edu­ cators and clinicians really do need to keep up to date with clinically im portant inform ation, it is a general fact that they fail to do so for m any different reasons eg, the lack o f tim e to read clinical jo u r­ nals (1,4% o f positive student responses (figure 2) m entioned that they realised that w hat they were taught in class is out o f date). The result o f this is that unfor­ tunately, it leads to progressive declines FIGURE 3: Negative comments on the integrated electrotherapy model (55 negative responses). 34 SA J o u r n a l o f P h y s io th e ra p y 2000 V o l 56 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) in clinical com petencies o f physiothera­ pists after com pletion o f the form al training (Ramsey, et al 1991; Evans et al, 1986). The student on the other hand needs constant individualised feedback about what he is doing correctly or incorrectly. Very often the student may be in the difficult position o f receiving conflicting advice and opinions from different educators and clinicians. The positive responses( 28,8% ), indicated that this model enables students to learn more about the possibilities and effec­ tiveness o f electrotherapy m odalities (see figure 2). Ten percent (10%) o f the responses further indicated that students learn better when clinically applying electrotherapy and the m odel enabled them to w ork with confidence on their own (see figure 2). D ue to logistic reasons it was occa­ sionally expected from students to do an electrotherapy assignm ent during a clin­ ical block (18% o f negative responses) where it was difficult to find an appro­ priate problem to be m anaged with elec­ trotherapy. This resulted in inappropri­ ate clinical question form ulation and problem m anagem ent. In order to over­ com e this, the departm ent decided to utilise this m odel in other clinical set­ tings, eg pulm onary physiotherapy, not ju st in the field o f electrotherapy. It is thus evident that this model enables the student to becom e m ore effi­ cient in articulating w hat he/she needs to know and how to learn it. T he experience of this model amongst educators and clinicians with respect to student know ledge, technique appli­ cation and confidence still needs to be assessed. As Harris (1996) stated: “We can choose to rem ain non-reflective practi­ tioners, learning about and practising new treatm ent techniques because they are new and different and exciting, or we can m ove forward as professionals - with sound theoretical and scientific support underlying our treatm ent practices” . CONCLUSION Both physiotherapy educators and clini­ cians face a great challenge in trying to integrate sound research findings into c linical p ractice. D ifficulties ex p eri­ enced include the am ount o f new infor­ m ation, as well as a lack o f skills in accessing and appraising relevant stu­ dies. This model provides a fram ew ork for linking clinical decision m aking and relevant research at an undergraduate level, thereby p rep arin g students to becom e life-long, self-directed learners. 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