Evidence-Based Pain Management

1. 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

2. What got me into EBM…. What is a double blind study? Two orthopaedic surgeons reading an ECG

3. Can I use EBM in orthopaedics?

4. I will tell you NOTHINGabout pain management

5. I will show you how YOU can find EVERYTHINGabout pain management

6. Objectives • What is EBM? • How to ask an answerable question? • How to search for an answer? • How to assess the quality of the evidence?

7. GCC EBHC

8. National & Gulf Center for EBHP

9. Statistically speaking… Half an hour presentation is shorter than 5 days workshop (p<0.05)

10. What is EBM? Research Evidence Patients’ Preferences Clinical Expertise Clinical Circumstances Haynes et al. BMJ 2002;324:1350

11. 5As of EBM

12. Is this a good question? What is the best treatment of acute back pain?

13. Asking a good question (PICO)! • Population • Intervention • Control • Outcome

14. 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

16. How would you search for answers? • 50:50 • Ask the audience • Ask a friend • Flip through a textbook • Google it up!

17. 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excellent for the principles and basic knowledge • Usually single authored chapters • Likely biased, author’s opinion • Not peer-reviewed • Outdated (at least 4 years)

18. What’s wrong with googling?

19. What’s wrong with googling? • Reliability & credibility of source • Google Scholar is good

20. So what to do?

21. 5S Hierarchy of EvidenceHaynes RB. Evid Based Med 2006;11:162-164 RCTs, Cohort, Case control, Case series Expert Opinion: Classical Textbooks

22. Primary Sources • Original articles • Through databases: MEDLINE, EMBASE • Using: PubMed, OVID • You have to retrieve and appraise the articles • Strength (pyramid) of evidence

23. Pyramid of Evidence http://library.downstate.edu/EBM2/2100.htm

30. It’s time consuming

31. Secondary Sources Systematic Reviews

32. 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

33. How to search for “Syntheses”? • Same databases: MEDLINE, EMBASE • Cochrane Library

34. PubMed

36. Cochrane Library

40. Are all syntheses good? • You still have to appraise the quality of these systematic reviews and meta-analyses • It’s time consuming

41. So what’s next? Evidence-Based Guidelines & Textbooks Critically-Appraised Journal Articles & Abstracts

42. 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)

43. Summaries • Evidence-based guidelines and textbooks • Examples: • Clinical Evidence • National Guideline Clearinghouse • UptoDate

44. http://clinicalevidence.bmj.com/

45. http://www.guideline.gov/