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5. Testing Your Knowledge

Case: Acupuncture for the old knee

This is a self-correcting exercise. Click on Answer for a pop-up box with the response.

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ASSESS
the patient
1. Start with the patient — a clinical problem or question arises out of the care of the patient
George is an active 83 year old male. He used to swim three times a week for 45 minutes, garden, and walk to church. But for the last several months, he has had trouble walking and bending his knees. It has made gardening difficult and restricted his daily activities.His family physician made the diagnosis of osteoarthritis and prescribed Voltaren (diclofenac), a nonsteroidal anti-inflammatory drug.  He is still in pain and wants to know if acupuncture would help.  He says he would like to stay away from more medication.  You are not sure about the effectiveness of acupuncture for this patient and need to do a little research before you can address his question. George
ASK
the question
2. Construct a well-built clinical question derived from the case

Based on this scenario, choose the best, well-built clinical question:

A. Can acupuncture help an elderly 83 year-old male?

B. Is acupuncture or diclofenac effective for a painful knee?

C. In elderly patients with osteoarthritis of the knee, can acupuncture combined with an anti-steroidal inflammatory agent, improve mobility and reduce pain?

ACQUIRE
the evidence
3. Select the appropriate resource(s) and conduct a search

Based on question C, choose the best search strategy to address the question.

A. Search: acupuncture AND osteoarthritis knee Limits: Aged: 65+ years, Randomized Controlled Trial

Search: B. acupuncture AND Anti-inflammatory agents, non-steroidal AND osteoarthritis, knee Limits: Aged: 65+ years, Randomized Controlled Trial,

C. knee AND acupuncture AND diclofenac

APPRAISE
the evidence
4. Appraise the evidence for its validity (closeness to the truth) and its applicability (usefulness in clinical practice)

Read the following article to determine if the article meets the criteria for validity. As stated previously, evaluating the medical literature is a complex undertaking. You will find that the answers to the questions of validity may not always be clearly stated in the article and that you may have to use your own judgment about the importance and significance of each question.

Vas J. Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomised controlled trial. BMJ. 2004 Nov 20;329(7476):1216. PubMed PMID: 15494348. Free PMC article.

Are the results valid?

1. Randomization: Were patients randomized?

2. Concealed allocation: Was group allocation concealed?

3. Similar baseline characteristics of patients: Were patients in the study groups similar with respect to known prognostic variables?

4. Blinding: To what extent was the study blinded?

5. Follow-up: Was follow-up complete?

6. Intention to Treat: Were patients analyzed in the groups to which they were first allocated?

7. Was the trial stopped early?

What are the results?

How large was the treatment effect?
What was the relative risk reduction?
What was the absolute risk reduction?

How precise was the estimate of the treatment effect?
What were the confidence intervals?

RESULTS: 88 patients completed the trial. In the intention to treat analysis, the WOMAC index presented a greater reduction in the intervention group than in the control group (mean difference 23.9, 95% confidence interval 15.0 to 32.8) The reduction was greater in the subscale of functional activity. The same result was observed in the pain visual analogue scale, with a reduction of 26.6 (18.5 to 34.8). The PQLC results indicate that acupuncture treatment produces significant changes in physical capability (P = 0.021) and psychological functioning (P = 0.046). Three patients reported bruising after the acupuncture sessions.NOTE: Because these are continuous variables, we cannot calculate absolute risk reduction or relative risk reduction or number needed to treat.

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 the likely treatment benefits worth the potential harm and costs?
What is the number needed to treat (NNT) to prevent one adverse outcome or produce one positive outcome?
Is the reduction of clinical endpoints worth the increase of cost and risk of harm?

Do these patients in this study match George for age, physical conditioning, or previous treatment? Note that the mean age of patients in this study was 65 to 68 years and primarily women.

APPLY:
talk with the patient
5. Return to the patient — integrate the evidence and clinical expertise, patient preferences and apply it to practice
Think about George, your treatment recommendation for him and what you would discuss with him on his next visit. George 2

Also in this series:

1.  What is EBM

2. The Clinical Question

3. The Literature Search

4. Evaluating the Evidence

5. Testing Your Knowledge

_______________

Source: UNC

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