1. Advanced PubMed
Finding Evidence for Clinical Questions
in Physical Therapy
Jessica Cole, MLIS, AHIPPT 685
November 12, 2013

2. Evidence-Based Practice
“Evidence based medicine is the conscientious, explicit, and judicious use of current best
evidence in making decisions about the care of individual patients. The practice of
evidence based medicine means integrating individual clinical expertise with the best
available external evidence from systematic research.”

3. EBP Research Steps
1. ASK-Convert information need into a question.
2. ACQUIRE-Find best evidence to answer question.
3. APPRAISE-Critically appraise evidence.
4. INTEGRATE evidence with clinical expertise &
patient values to apply in practice.
5. EVALUATE performance.
Database Searching Skills

4. Don’t Expect Research to be a Linear Process!

5. Define Research Question
 Convert the information need into a specific
question. This will guide your research process.
 Convert question to PICO format to help you break
it down and plan a database search strategy.
 Determine “best” concepts/terms to represent each
PICO element. These are the terms you will string
together to build your database search.
1. ASK

6. PICO Question
Include the following PICO elements in your question
P Patient characteristics/condition
I Intervention (or diagnosis/prognosis)
C Comparison intervention (if applicable)
O Outcome of interest
For a 17-year-old female swimmer with neck pain, is a
combination of manual therapy and exercise effective for
reducing pain and improving function?
1. ASK

7. Intervention Question: For a 17-year-old female swimmer with
neck pain, is a combination of manual therapy and exercise
effective for reducing pain and improving function?
Diagnosis Question: For a 17-year-old female swimmer with
neck pain, how sensitive and specific is the Spurling’s test for
detecting cervical nerve root impingement ?
Prognosis Question: For a competitive swimmer with recurrent
neck pain, what is the likelihood that the athlete will develop
chronic neck pain?
Sample Question
From Fetters text; see pgs. 16-22
1. ASK

8. QuestionSearch Strategy
Transition from Step 1. Asking the Question to Step 2.
Acquiring evidence:
Planning the database search strategy
1. ASK

9. Planning the Search
For a 17-year-old female swimmer with neck pain, is a
combination of manual therapy and exercise effective
for reducing pain and improving function?
2. Acquire

10. Big Picture:
Fast Forward to Strategy
This is what our search strategy will look like in the
end. What follows in the next slides are the steps
taken to build this search:
For a 17-year-old female swimmer with neck pain, is a combination of manual
therapy AND exercise therapy effective for reducing pain and improving function?
2. Acquire

11. Planning the Search
 List the main terms/concepts from your PICO
question.
 Which terms are most important for the search?
 Always search for the P and I elements with the
“best” terms to capture a concept.
 See process of selecting search terms in Table 2.4
on page 22 of Fetters textbook.
2. Acquire

12. Planning the Search
Keywords vs. MeSH
(Medical Subject Headings)
Strengthen a search by using
terminology the database understands!
2. Acquire

13. Cola, Pop, Soda, Coke, Soda Pop? Bill, Money, Dollar, Cash, Currency?
2. Acquire

14. Planning: MeSH Database
Search your keywords in the MeSH database for
other terms more likely to be recognized by the
database. Write down the MeSH for later.
2. Acquire

15. Find “Best” Search Terms
A search for “manual therapy” in the MeSH Database
mapped to the term “Musculoskeletal Manipulations” which
is the same concept as manual therapy.
2. Acquire

16. Find “Best” Search Terms
When to search with “OR”
 When searching for a term you believe is commonly
used in your field that has a different MeSH heading.
 (Manual therapy OR Musculoskeletal manipulations)
will retrieve results that use EITHER term.
 Physical therapy language varies – experiment with
OR!
2. Acquire

17.  Neck pain
 Manual therapy
 Exercise
 Neck pain
AND
 (Musculoskeletal
manipulations OR
manual therapy)
AND
 Exercise therapy
Our Original Keywords from
Clinical Question
Decision: Terms to Search after
finding MeSH Terms (with AND)
Find “Best” Search Terms 2. Acquire

18. Remember Filters!
 Many times the “P” of PICO question has filters to
apply at the end of the search so you don’t need to
search for terms like “female” or “adolescent.”
 Examples: Age groups, gender
 “For a 17-year old female swimmer with neck
pain, is a combination of manual therapy &
exercise therapy effective for reducing pain and
improving function?”
2. Acquire

19. Planning the Search:
What’s the MeSH?
“For a 17-year old female swimmer with neck pain, is a
combination of manual therapy & exercise therapy effective
for reducing pain and improving function?”
Terms from question, re-ordered from most to least important:
Neck pain (most important)
Manual therapy
Exercise therapy
Function
17-year-old
Swimmer
Female
• Tip: Start by searching P+I
• Remember: Age & Sex can be
applied with filters after
building and conducting the
search (with keywords/MeSH.)
• Focus on most important
concepts first & keep it simple.
2. Acquire

20. Conduct the Search
Neck pain AND (Musculoskeletal manipulations OR manual therapy) AND Exercise therapy
2. Acquire

21. Conduct the Search
Filters to try after the
search:
• Female (sex)
• Adolescent (ages)
2. Acquire

22. Apply Filters
 First see # results and review article titles without
applying the filters.
 View results with filters applied: Be aware that
filters might also remove some “good” results.
Always try both ways.
 Use filters for levels of evidence here or at a later
point of refining/appraising the search.
 Remember to clear filters!
2. Acquire

23. View Results
Before filters: 152 results
After filters (Females & Adolescent):
only12 results
2. Acquire

24. Filters: Levels of Evidence
 Filters for types of evidence can also be applied
now.
2. Acquire

25. Filters: Article Types
 Systematic Reviews/Meta-Analysis are strongest
level of evidence for most types of questions
because they synthesize several studies.
 For individual studies, best design/article type is:
2. Acquire

26. Review ResultsAppraise
 Transition from Step 2. Acquiring the evidence
to Step 3. Critically appraise the evidence –
Overlap.
 SAVE “good” results as you go!
 Even if you are not yet critically appraising
individual articles while scanning results, hold
onto those that look promising.
2. Acquire

27. Save “Good” Articles 2. Acquire

28. Critical Appraisal
Are the results valid?
 Did intervention and control groups start with the same
prognosis? Were patients randomized?
 Was group allocation concealed?
 Were patients in the study groups similar with respect to
known prognostic variables?
 Was prognostic balance maintained as the study progressed? To
what extent was the study blinded?
 Were the groups prognostically balanced at the study's
completion? Was follow-up complete?
 Were patients analyzed in the groups to which they were first
allocated?
 Was the trial stopped early?
Users' Guide to Medical Literature: A Manual for Evidence-Based Clinical Practice, 2nd Edition.
3. Appraise

29. Critical Appraisal
What are the results?
 How large was the treatment effect?
 What was the relative risk reduction?
 What was the absolute risk red
 How precise was the estimate of the treatment effect?
What were the confidence intervals?
Users' Guide to Medical Literature: A Manual for Evidence-Based Clinical Practice, 2nd Edition.
3. Appraise

30. Critical Appraisal
How can I apply the results to patient care?
 Were the study patients similar to my population of interest?
 Does your population match the study inclusion criteria?
 If not, are there compelling reasons why the results should not
apply to your population?
 Were all clinically important outcomes considered?
 What were the primary and secondary endpoints studied?
 Were surrogate endpoints used?
 Are likely treatment benefits worth the potential harm and costs?
 What is the number needed to treat (NNT) to prevent 1 adverse
outcome or produce 1 positive outcome?
 Is the reduction of clinical endpoints worth the increase of cost
and risk of harm?
Users' Guide to Medical Literature: A Manual for Evidence-Based Clinical Practice, 2nd Edition.
3. Appraise

31. Critical Appraisal
 Critical appraisal information at JAMA Evidence
3. Appraise

32. Summary
1. ASK
2. ACQUIRE
3. APPRAISE
First, know what you are looking for! Write a focused
clinical question based on PICO format to help you plan
your search strategy – translate your question into the
best search terms.
Conduct an Advanced PubMed search with the best
terms identified from PICO, using Boolean operators
and applicable filters to limit results. Save good results
as you go and experiment for different sets of results.
Always search P & I concepts at minimum.
Critically appraise individual articles/studies. Upon
closer examination, is it still relevant to your PICO
question? Are results valid, and have you carefully
looked for the “best” highest levels of evidence
available on this topic?

33. Tip: How to Cheat
If struggling, identify one article that is most relevant
to your topic/PICO question and take a closer look.
 Examine MeSH terms for ideas for terms to search.
 Also view Related Citations.