Evidence-Based Pain Management

Sohail Bajammal, MBChB, MSc, FRCS(C), PhD(c)

Assistant Professor of Orthopaedics, Umm Al Qura UniversityConsultant Orthopaedic Surgeon, Al-Noor Specialist Hospital

February 23, 2010

What got me into EBM….

What is a double blind study?

Two orthopaedic surgeonsreading an ECG

Can I use EBM in orthopaedics?

I will tell you

NOTHING about pain management

I will show you how YOU can find

EVERYTHING about pain management

Objectives

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

GCC EBHC

National & Gulf Center for EBHP

Statistically speaking…

Half an hour presentation is shorter than 5 days workshop (p<0.05)

What is EBM?

Clinical Circumstances

Clinical Circumstances

Research EvidenceResearch Evidence

Patients’ Preferences

Patients’ Preferences

Clinical ExpertiseClinical

Expertise

Haynes et al. BMJ 2002;324:1350

5As of EBM

Is this a good question?

What is the best treatment of acute back pain?

Asking a good question (PICO)!

• Population• Intervention• Control• Outcome

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

How would you search for answers?

A. 50:50B. Ask the audienceC. Ask a friendD. Flip through a textbookE. Google it up!

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• Usually single authored chapters• Likely biased, author’s opinion• Not peer-reviewed• Outdated (at least 4 years)

What’s wrong with googling?

What’s wrong with googling?

• Reliability & credibility of source• Google Scholar is good

So what to do?

5S Hierarchy of EvidenceHaynes RB. Evid Based Med 2006;11:162-164

RCTs, Cohort, Case control, Case seriesRCTs, Cohort, Case control, Case series

Expert Opinion: Classical TextbooksExpert Opinion: Classical Textbooks

Primary Sources

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

Pyramid of Evidence

http://library.downstate.edu/EBM2/2100.htm

It’s time consuming

Secondary Sources

Systematic ReviewsSystematic Reviews

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

How to search for “Syntheses”?

• Same databases: MEDLINE, EMBASE• Cochrane Library

PubMed

Cochrane Library

Are all syntheses good?

• You still have to appraise the quality of these systematic reviews and meta-analyses

• It’s time consuming

So what’s next?

Critically-Appraised Journal Articles & Abstracts

Critically-Appraised Journal Articles & Abstracts

Evidence-Based Guidelines & Textbooks

Evidence-Based Guidelines & Textbooks

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)

Summaries

• Evidence-based guidelines and textbooks

• Examples:– Clinical Evidence– National Guideline Clearinghouse– UptoDate

http://clinicalevidence.bmj.com/

http://www.guideline.gov/

Systems

• This is the ultimate goal• Computerized decision support

• Too sophisticated for us to think about now

All what we’ve talked about

Research EvidenceResearch Evidence

To practice EBM, we need all the four

Clinical Circumstances

Clinical Circumstances

Research EvidenceResearch Evidence

Patients’ Preferences

Patients’ Preferences

Clinical ExpertiseClinical

Expertise

We need…..

• To apply the evidence as it applies to our local hospitals

• To involve the patients actively in the decision making

• To have our own studies:– Different social, cultural, ethnic, and economical

backgrounds

http://www.andrews-clinic-natural-therapies.co.uk/documents/54.html

http://eapps.ngha.med.sa/ebm/

http://ebmjeddah.info/

This presentation is available online

www.uqu.edu.sa/ssbajammal

المحاضرات

Thank Youssbajammal@uqu.edu.sa