Evidence-Based Medicine: Evidence-Based Medicine: What it is and what it What it is and what it isn't.isn't.

EvidenceEvidence in its broadest sense includes anything that is used to determine or demonstrate the truth of an assertion. Evidence is information, such as facts, coupled with beliefs and assumptions, that make information relevant to the proof or disproof of a hypothesis. A person’s assumptions or beliefs about the relationship between alleged facts and a hypothesis will determine if that person takes the facts as evidence. (which car is better…)

Scientific evidenceScientific evidence is an evidence which serves to either support or counter a scientific theory or hypothesis. Such evidence is expected to be empirical and properly documented in accordance with scientific method.

Scientific evidence is evidence where the dependence of the evidence on beliefs and assumptions is not conceded, enabling to examine the background beliefs or assumptions. Standards for evidence may vary according to whether the field of inquiry is among the natural sciences or social sciences. (Where is medicine…?)

Scientist can develop a theory which may be falsified or verified by testing it against evidence or known facts. Asymmetry exists that evidence can prove a theory wrong, by establishing facts that are inconsistent with the theory. In contrast, evidence cannot prove a theory correct because other evidence, yet to be discovered, may exist that is inconsistent with the theory - e.g no evidence exists for inteligent extraterestial live but it does not mean that it is scientifically proven that no E.T exists…

SScientific theory or hypothesiscientific theory or hypothesis - consists either of a suggested explanation for a phenomenon or of a reasoned proposal suggesting a possible correlation between observable events (phenomenon is any occurrence that is observable by senses or by mind). Theory or hypothesis is a trial solution to a problem - an "educated guess". Experimenters may test and reject several hypotheses before solving the problem. Researchers weighing up alternative hypotheses may take into consideration:

Testability - a hypothesis must be falsifiable, and one cannot regard a proposition or theory as scientific if it does not admit the possibility of being shown false at least in principle.

Simplicity - discouraging the postulation of excessive numbers of entities Scope - the apparent application of the hypothesis to multiple cases of phenomena Fruitfulness - the prospect that a hypothesis may explain further phenomena in the future Conservatism - the degree of "fit" with existing recognized knowledge-systems

Scientific methodScientific method is a body of techniques for investigating phenomena, acquiring new knowledge, or correcting and integrating previous knowledge. It is based on gathering observable, empirical and measurable evidence subject to specific principles of reasoning.

Ibn al-Haytham 965–1039 a pioneer of scientific method. Due to his formulation of a modern quantitative, empirical and experimental approach to physics and science, he is considered the pioneer of the modern scientific method and the originator of experimental science. Some have described him as the first scientist.

Elements of scientific methodElements of scientific method:: Define the question Gather information and resources (observe) Form hypothesis Perform experiment and collect data Analyze data Interpret data and draw conclusions that serve as a

starting point for new hypothesis Publish results Retest - frequently done by other scientists - peer

review

Is medicine a science?Is medicine a science?

Medicine is the science and "art" of maintaining and restoring human health. Our primary goal is to help a patient.

Science refers to a system of acquiring knowledge and its primary goal is to find a truth.

The modern practice of medicine occurs at the many interfaces between the art of healing and various sciences. Medicine is directly connected to the health sciences and biomedicine and is using scientific knowledge for the art of healing.

Physician is committed to promoting the health of any individual accepted as a patient’. Medical practice has an inherently moral aspect. Science is goal-directed, but its end is theoretical, not practical, and science is not committed to promoting any interest at all.

Evidence-based medicine is the conscientious, explicit and Evidence-based medicine is the conscientious, explicit and judicious use of current bestjudicious use of current best evidenceevidence in making decisions about the care of individual patients.

The practice of evidence-based medicine means integrating individual clinical expertiseindividual clinical expertise with the best available external clinical evidenceexternal clinical evidence from systematic research.

By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice.

By best available external clinical evidence we mean clinically relevant research.

Good healthcare professionals use both individual clinical expertise and the best available external evidence, and neither alone is enoughneither alone is enough.

Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient.

Without current best evidence, practice risks becoming rapidly out of date.

Evidence-based medicine is not "cook-book" medicineis not "cook-book" medicine.

Because it requires a bottom-up approach that integrates the best external evidenceevidence with individual clinical expertiseexpertise and patient-choicepatient-choice, it cannot result in slavish, cook-book approaches to individual patient care.

External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision.

Evidence-based medicine is not restricted to randomized trials and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions. It is when asking questions about therapy that we should try to avoid the non-we should try to avoid the non-experimental approachesexperimental approaches, since these routinely lead to false-positive conclusions about efficacy.

Because the randomized trial, and especially the systematic review of several randomized trials, is so much more likely to inform us and so much less likely to mislead us, it has become the “gold standard” for judging whether a treatment does more good judging whether a treatment does more good than harm.than harm.

Some questions about therapy do not require randomized trials (successful interventions for otherwise fatal conditions) or cannot wait for the trials to be conducted.

SOURCE: Oxford-Center for Evidence-Based Medicine - http://www.cebm.net AUTHORS: David L. Sackett, Professor, NHS Research and Development Centre for Evidence-Based Medicine, Oxford, William M. C. Rosenberg, Clinical Tutor in Medicine, Nuffield Department of Clinical Medicine, Oxford. J. A. Muir Gray, Director of Research and Development, Anglia and Oxford Regional Health Auhtority Milton Keynes, R. Brian Haynes, Professor of Medicine and Clinical Epidemiology, McMaster University Hamilton, Canada, W. Scott Richardson, Rochester, USA

Shortened citations from the original article, highlighted fonts and colors by J.Pazdirek SBAHC Saudi Arabia - Riyadh

What is external clinical evidenceWhat is external clinical evidence

Evidence Evidence pyramidspyramids

Meta-analysis - Meta-analysis - Analysis of analysisAnalysis of analysis In statistics, a meta-analysis combines the results of several studies that address a

set of related research hypotheses. Metaanalysis can often be concerned with trying to find the faults in a statistical

study, for instance if an inappropriate statistical test has been used to analyze the data.

A meta-analysis can be performed on studies that describe their findings in correlation coefficients which indicates the strength and direction of a linear relationship between two variables.

A weakness of the method is that sources of bias are not controlled by the method and a good meta-analysis of multiple badly designed studies will still result in bad statistics

"Don't trust any statistics you did not fake yourself“ Winston Churchill

Efficacy of continuous passive motion following total knee Efficacy of continuous passive motion following total knee arthroplasty:arthroplasty:

a metaanalysis.a metaanalysis.Brosseau L, Milne S, Wells G, Tugwell P, Robinson V, Casimiro L, Pelland L, Noel MJ, Davis J, Brosseau L, Milne S, Wells G, Tugwell P, Robinson V, Casimiro L, Pelland L, Noel MJ, Davis J, Drouin H.Drouin H.School of Rehabilitation Sciences, University of Ottawa, Ottawa, Ontario, Canada. School of Rehabilitation Sciences, University of Ottawa, Ottawa, Ontario, Canada.

OBJECTIVE:OBJECTIVE: The objective of this metaanalysis is to examine the effectiveness of The objective of this metaanalysis is to examine the effectiveness of continuous passive motion (CPM) following total knee arthroplasty (TKA). continuous passive motion (CPM) following total knee arthroplasty (TKA).

METHODS:METHODS: This metaanalysis used the methodology proposed by the Cochrane This metaanalysis used the methodology proposed by the Cochrane Collaboration.Collaboration.

RESULTS:RESULTS: This review of 14 studies (952 patients) found significant improvements in This review of 14 studies (952 patients) found significant improvements in active knee flexion and analgesic use 2 weeks postoperatively with the use of CPM and active knee flexion and analgesic use 2 weeks postoperatively with the use of CPM and physiotherapy (PT) compared to PT alone. In addition, length of hospital stay and need for physiotherapy (PT) compared to PT alone. In addition, length of hospital stay and need for knee manipulations were significantly decreased in the CPM group. Not enough data were knee manipulations were significantly decreased in the CPM group. Not enough data were available to compare the degree of knee flexion applied or number of hours of application available to compare the degree of knee flexion applied or number of hours of application of CPM. However, significant results were not found for other comparisons such as short of CPM. However, significant results were not found for other comparisons such as short term CPM application versus longterm CPM application and wide treatment range versus term CPM application versus longterm CPM application and wide treatment range versus small treatment range for the outcomes of active knee flexion, passive knee flexion and small treatment range for the outcomes of active knee flexion, passive knee flexion and extension, presence of a fixed flexion deformity, use of analgesic, or total knee range of extension, presence of a fixed flexion deformity, use of analgesic, or total knee range of motion.motion.

CONCLUSION:CONCLUSION: CPM combined with PT may offer beneficial results for patients post-TKA. CPM combined with PT may offer beneficial results for patients post-TKA. However, the potential benefits will need to be carefully weighed against the However, the potential benefits will need to be carefully weighed against the inconvenience and expense of CPM. More research is necessary to assess the differences inconvenience and expense of CPM. More research is necessary to assess the differences in effectiveness with different characteristics of application such as total duration of in effectiveness with different characteristics of application such as total duration of treatment and intensity of CPM interventions.treatment and intensity of CPM interventions.

Systematic reviewSystematic review Systematic reviews are summarizing research evidence. The explosion in biomedical

publishing perhaps 20,000 journals and upwards of 2 million articles a year makes keeping up with primary research an impossible feat.

High-quality systematic reviews take great care to find all relevant studies published and unpublished, assess each study, synthesize the findings from individual studies in an unbiased way and present a balanced and impartial summary of the findings with due consideration of any flaws in the evidence.

Systematic reviews are needed whenever there is a substantive therapeutic question, several primary studies – perhaps with disparate findings – and substantial uncertainty.

Developing a systematic review requires the following steps: Defining an appropriate therapeutic question. Searching the literature. Assessing the studies. Combining the results. Placing the findings in context The findings from this aggregation of an unbiased selection of studies then need to be

discussed to put them in context. This will address such issues as the quality and heterogeneity of the included studies, the likely impact of bias and chance and the applicability of the findings.

A word of caution, however. Performing a rigorous systematic review is far from easy. It requires meticulous and laborious searching and considerable attention to methodological detail before it truly deserves the badge' systematic’. Not all published systematic reviews have been produced with meticulous care – therefore the findings may sometimes mislead.

Many high-quality reviews are available from electronic sources such as the Cochrane Library

Exercise for treating isolated anterior cruciate ligament injuries in Exercise for treating isolated anterior cruciate ligament injuries in adultsadults

Systematic review.Systematic review. AH Trees, TE Howe, J Dixon, L White AH Trees, TE Howe, J Dixon, L White Objectives:Objectives: To present the best evidence for effectiveness of exercise used in the To present the best evidence for effectiveness of exercise used in the

rehabilitation of isolated ACL injuries in adults, on return to work and pre-injury levels of rehabilitation of isolated ACL injuries in adults, on return to work and pre-injury levels of activity.activity.

Search strategy: We searched the Cochrane Bone, Joint and Muscle Trauma Group Search strategy: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PEDro - The Physiotherapy Evidence Database, CINAHL, AMED, and MEDLINE, EMBASE, PEDro - The Physiotherapy Evidence Database, CINAHL, AMED, and reference lists of articles.reference lists of articles.

Selection criteria:Selection criteria: Randomized controlled trials and quasi-randomized trials testing Randomized controlled trials and quasi-randomized trials testing exercise programmes designed to rehabilitate adults with isolated ACL injuries. Trials exercise programmes designed to rehabilitate adults with isolated ACL injuries. Trials where participants were randomized to receive any combination of the following: no where participants were randomized to receive any combination of the following: no care, usual care, a single-exercise intervention, and multiple-exercise interventions. The care, usual care, a single-exercise intervention, and multiple-exercise interventions. The primary outcome measures of interest were returning to work and return to pre-injury primary outcome measures of interest were returning to work and return to pre-injury level of activity post treatment, at six months and one year.level of activity post treatment, at six months and one year.

Data collection and analysis:Data collection and analysis: All trials judged to have met the inclusion criteria were All trials judged to have met the inclusion criteria were independently assessed for methodological quality by use of a 15 point checklist. Pairs of independently assessed for methodological quality by use of a 15 point checklist. Pairs of authors independently extracted data. For each study, relative risk and 95% confidence authors independently extracted data. For each study, relative risk and 95% confidence intervals were calculated for dichotomous outcomes and mean differences and 95% intervals were calculated for dichotomous outcomes and mean differences and 95% confidence intervals calculated for continuous outcomes.confidence intervals calculated for continuous outcomes.

Main results:Main results: Nine trials, involving 391 participants met the inclusion criteria of the Nine trials, involving 391 participants met the inclusion criteria of the review. Only two trials, involving 76 participants, reported conservative rehabilitation and review. Only two trials, involving 76 participants, reported conservative rehabilitation and seven trials, involving 315 participants, evaluated rehabilitation following ACL seven trials, involving 315 participants, evaluated rehabilitation following ACL reconstruction. Methodological quality scores varied considerably across the trials, with reconstruction. Methodological quality scores varied considerably across the trials, with the nature of participant and assessor blinding poorly reported. Trial comparisons fell into the nature of participant and assessor blinding poorly reported. Trial comparisons fell into six categories. Pooling of data was rarely possible due to lack of appropriate data as well six categories. Pooling of data was rarely possible due to lack of appropriate data as well as the wide variety in outcome measures and time points reported. Insufficient evidence as the wide variety in outcome measures and time points reported. Insufficient evidence was found to support the efficacy of one exercise intervention over another.was found to support the efficacy of one exercise intervention over another.

Authors' conclusions:Authors' conclusions: This review has demonstrated an This review has demonstrated an absence of evidence to absence of evidence to support one form of exercise intervention against anothersupport one form of exercise intervention against another and the use of and the use of supplementary exercises in the management of isolated ACL injuries. Further research in supplementary exercises in the management of isolated ACL injuries. Further research in the form of large scale well designed randomized controlled trials with suitable outcome the form of large scale well designed randomized controlled trials with suitable outcome measures and surveillance periods, using standardized reporting should be considered.measures and surveillance periods, using standardized reporting should be considered.

Randomized controlled trialRandomized controlled trial Randomized controlled trials is experimental study of population used to compare treatments

between individual subjects. Experimental investigations tend to be time consuming and expensive. (Who is paying for the study is also an important information).They should not, therefore, be undertaken without good reason. They do provide the most compelling evidence of cause and effect. They are often used for comparison of two treatments.

Criteria for entry to the study sample must be specified (for example, in terms of age, sex, diagnosis, etc). The subjects studied should be representative of the target population in whom it is hoped to apply the results. Subjects who satisfy the entry criteria are asked to consent to participation. As far as possible, the criteria for withdrawing a patient from treatment should be specified in advance.

Those subjects who agree to participate are then randomized to the treatments under comparison. This can be achieved with random numbers generated by computer.

When outcome is influenced by other aspects of a patient's management, as well as by the treatments under comparison, it may be desirable for those responsible for management to be "blinded" to which treatment has been allocated.

Bias in the evaluation of subjective outcomes can be avoided by blinding the assessor to the treatment given.

Similarly, if the end point is a subjective physical sign then the examiner is best kept ignorant about which patient received which treatment.

It is important to measure not only the outcomes that the treatments are intended to improve, but also possible adverse effects.

The statistical analysis of randomized controlled trials is complex. Whatever analytical technique is adopted, it is important always to compare subjects according to the treatment to which they were randomized, even if this treatment was not completed.

A randomised controlled trial on the efficacy of hydroelectrophoresis in A randomised controlled trial on the efficacy of hydroelectrophoresis in acute recurrences in chronic low back pain patients.acute recurrences in chronic low back pain patients.Brizzi A, Giusti A, Giacchetti P, Stefanelli S, Provinciali L, Ceravolo MG.Brizzi A, Giusti A, Giacchetti P, Stefanelli S, Provinciali L, Ceravolo MG.Department of Neuroscience, Azienda Ospedali Riuniti di Ancona, Polytechnic University of Department of Neuroscience, Azienda Ospedali Riuniti di Ancona, Polytechnic University of Marche, Italy.Marche, Italy.

AIM:AIM: Physical therapy efficacy in the treatment of low back pain (LBP) has been widely Physical therapy efficacy in the treatment of low back pain (LBP) has been widely debated and is far from achieving high levels of evidence. Hydroelectrophoresis (Hydrofor) is debated and is far from achieving high levels of evidence. Hydroelectrophoresis (Hydrofor) is a novel method of driving drugs through the dermal tissue, which has been proposed for a novel method of driving drugs through the dermal tissue, which has been proposed for muscle pain treatment. Aim of this randomised placebo-controlled study was to ascertain the muscle pain treatment. Aim of this randomised placebo-controlled study was to ascertain the efficacy of Hydrofor treatment on acute relapsing episodes of pain in chronic LBP subjects.efficacy of Hydrofor treatment on acute relapsing episodes of pain in chronic LBP subjects.

METHODS:METHODS: Eighteen under-50 adults (M/F: 7/11; age 35+/-8 years) suffering from chronic Eighteen under-50 adults (M/F: 7/11; age 35+/-8 years) suffering from chronic LBP were enrolled within 3 to 4 days of back pain relapse. After a complete clinical and LBP were enrolled within 3 to 4 days of back pain relapse. After a complete clinical and functional assessment patients were randomly divided into 2 equal groups. Group A received functional assessment patients were randomly divided into 2 equal groups. Group A received 3 Hydrofor applications of a mixture containing both NSAIDs and muscle relaxants, whereas 3 Hydrofor applications of a mixture containing both NSAIDs and muscle relaxants, whereas Group B received 3 Hydrofor applications of a drug-free solution. Afterwards, both groups Group B received 3 Hydrofor applications of a drug-free solution. Afterwards, both groups performed the same rehabilitation treatment consisting of 7 group sessions of standard performed the same rehabilitation treatment consisting of 7 group sessions of standard physiotherapy, including stretching, range of motion and extension exercises. The Oswestry physiotherapy, including stretching, range of motion and extension exercises. The Oswestry disability index (ODI), the Million instrument scale and a visual analogue scale (VAS) were disability index (ODI), the Million instrument scale and a visual analogue scale (VAS) were chosen as outcome measures and applied at baseline, after Hydrofor/placebo applications, chosen as outcome measures and applied at baseline, after Hydrofor/placebo applications, after completion of rehabilitation sessions and, at last, 2 months later. The two-way Friedman after completion of rehabilitation sessions and, at last, 2 months later. The two-way Friedman test was used to analyse within-group (time effect) and between-group (time x group effect) test was used to analyse within-group (time effect) and between-group (time x group effect) differences.differences.

RESULTS:RESULTS: All subjects declared a significant pain reduction since the first Hydrofor All subjects declared a significant pain reduction since the first Hydrofor application. Pain evolution overlapped in the 2 groups until the 3rd session, after which Group application. Pain evolution overlapped in the 2 groups until the 3rd session, after which Group A significantly diverged from Group B, as they affirmed a greater symptom reduction than A significantly diverged from Group B, as they affirmed a greater symptom reduction than controls (time x group effect: VAS: F = 7.4, p <0.01). Such difference disappeared after the controls (time x group effect: VAS: F = 7.4, p <0.01). Such difference disappeared after the physiotherapy sessions as well as 2 months later (time x group effect: VAS: F = 2.1, p =0.08). physiotherapy sessions as well as 2 months later (time x group effect: VAS: F = 2.1, p =0.08). Pain-related disability showed a greater reduction in Group A than B immediately after Pain-related disability showed a greater reduction in Group A than B immediately after Hydrofor application (time x group effect: ODI: F=3.9 p <0.05; Million: F=4.1 p<0.05), but the Hydrofor application (time x group effect: ODI: F=3.9 p <0.05; Million: F=4.1 p<0.05), but the mean scores almost overlapped at the 2 month follow-up (time x group effect: ODI: F=2.3 p mean scores almost overlapped at the 2 month follow-up (time x group effect: ODI: F=2.3 p =0.08; Million: F=1.3 p=0.26).=0.08; Million: F=1.3 p=0.26).

CONCLUSIONS:CONCLUSIONS: Hydrofor treatment relieves relapsing LBP and could be recommended to Hydrofor treatment relieves relapsing LBP and could be recommended to active adults as a safe technique shortening the time needed to achieve functional active adults as a safe technique shortening the time needed to achieve functional restoration.restoration.

Case-control studiesCase-control studies

Case-control studies often referred to as a Retrospective Studies are less expensive and often used type of epidemiological studies.

In a case-control study patients who have developed a disease are identified and their past exposure to suspected etiological factors is compared with that of controls or referents who do not have the disease. The great triumph of the case-control study was the discovery of the link between tobacco smoking and lung cancer.

Randomized controlled trials cannot be used to evaluate the effects of toxic substances. Case definition and selection of cases: The case-control study begins with the identification

by researchers of an outcome or effect and a number of potential causative factors. Using medical records or interviews researchers record the variables identified as risk factors plus other non-risk variables which can then be used to select matching controls.

Selection of controls: A number of Control subjects are then chosen who do not exhibit the outcome or effect under investigation. These controls should match the cases as closely as possible.

Ascertainment of exposure: The case and control groups are then compared on the proposed causal factors.

Statistical analysis is used to estimate the strength of association of each factor with the studied outcome.

Limitation of motion following anterior cruciate ligament Limitation of motion following anterior cruciate ligament reconstruction. A case-control studyreconstruction. A case-control study

NG Mohtadi, S Webster-Bogaert and PJ Fowler NG Mohtadi, S Webster-Bogaert and PJ Fowler Division of Orthopaedics, University Hospital, London, Ontario, Canada.Division of Orthopaedics, University Hospital, London, Ontario, Canada.

Limitation of motion following ACL reconstructionLimitation of motion following ACL reconstruction is a well-recognized and is a well-recognized and

disturbing complication. disturbing complication. The purposesThe purposes of this study were to identify and characterize those patients who of this study were to identify and characterize those patients who

developed this complication from a series of 527 ACL reconstructions, determine developed this complication from a series of 527 ACL reconstructions, determine etiologic factors, and make recommendations regarding prevention and etiologic factors, and make recommendations regarding prevention and management.management.

The case groupThe case group included 37 patients who required a manipulation under anesthesia included 37 patients who required a manipulation under anesthesia because of failure to gain a satisfactory range of motion after an ACL reconstruction. because of failure to gain a satisfactory range of motion after an ACL reconstruction. Unsatisfactory motion was defined as a Unsatisfactory motion was defined as a flexion deformity of 10 degrees or moreflexion deformity of 10 degrees or more and/or limitation of flexion to less than 120 degrees by 3 months following ACL and/or limitation of flexion to less than 120 degrees by 3 months following ACL reconstruction. reconstruction.

The control groupThe control group of patients were selected randomly from the overall series and of patients were selected randomly from the overall series and all had a satisfactory range of motion. all had a satisfactory range of motion.

The cases and controls were The cases and controls were then compared by analyzing these variablesthen compared by analyzing these variables: age, : age, sex, knee, time from injury to reconstruction, type of tissue used, meniscal sex, knee, time from injury to reconstruction, type of tissue used, meniscal abnormalities or surgery, repair of the medical collateral ligament, and postoperative abnormalities or surgery, repair of the medical collateral ligament, and postoperative immobilization and rehabilitation. The cases were followed up to assess the range of immobilization and rehabilitation. The cases were followed up to assess the range of motion compared to the opposite knee at an average of 26 months post motion compared to the opposite knee at an average of 26 months post manipulation. Thirty-seven patients (7%) underwent a manipulation under manipulation. Thirty-seven patients (7%) underwent a manipulation under anesthesia, 9 of these (24.3%) also had an arthroscopic arthrolysis.anesthesia, 9 of these (24.3%) also had an arthroscopic arthrolysis.

Reconstructions done Reconstructions done less than 2 weeksless than 2 weeks post injury showed a statistically post injury showed a statistically significant higher rate of knee stiffness. The same trend was also present for those significant higher rate of knee stiffness. The same trend was also present for those reconstructed reconstructed 2 to 6 weeks2 to 6 weeks post injury. All other variables failed to show a post injury. All other variables failed to show a significant statistical difference. At followup, the average loss of extension was 4 significant statistical difference. At followup, the average loss of extension was 4 degrees and loss of flexion 5 degreesdegrees and loss of flexion 5 degrees

Longitudinal studiesLongitudinal studies In a longitudinal study subjects are followed over time with continuous or repeated

monitoring of risk factors or health outcomes, or both. A cohort studyA cohort study is a form of longitudinal study. A cohort is a group of people who

share a common characteristic or experience within a defined time period. The main characteristic is that the study proceeds from cause to effect. Some of these studies

have continued for decades. The cohorts are identified prior to the appearance of the disease under investigation. The study

groups, so defined, are observed over a period of time to determine the frequency of disease among them.

The comparison group may be the general population from which the cohort is drawn, or it may be another cohort of persons thought to have had little or no exposure to the substance under investigation, but otherwise similar.

Clinical follow up studiesClinical follow up studies Clinical follow up studies - longitudinal studies in which patients with a disease are

monitored systematically to establish how their illness progresses and what influences the prognosis. To measure outcome over longer periods, survival rates are used.

Case Report andCase Report and Case Series Case Series A case report is a descriptive study of a single individual (case report) or small group (case

series) in which the study of an association between an observed effect and a specific environmental exposure is based on detailed clinical evaluations and histories of the individual(s). No control group is involved.

A Case Report tells a clinical story that has unique value to the field of practice. In a case report, the clinical case presentation is examined in the context of current scientific

knowledge and is shared for the purpose of educating others or stimulating further scientific inquiry and the development of a new understanding or knowledge.

Some cases are published because they support findings of previously published cases or because they illustrate an important point in the care of a patient.

Case reports serve as foundational elements for more sophisticated scientific endeavors. Following types of cases as worth reporting: Uncommon observations A new theory Questions regarding a new theory Unusual combination of conditions or events that cause confusion Adverse responses to therapies Personal Impact Unique aspects of the practice Very common observations or practices that have not been documented previously

Expert opinionExpert opinion

An expert is someone widely recognized as a reliable source of knowledge, technique, or skill whose judgment is accorded authority and status by the public or their peers. Experts have prolonged or intense experience through practice and education in a particular field.

In specific fields, the definition of expert is well established by consensus and therefore it is not necessary for an individual to have a professional or academic qualification for them to be accepted as an expert. In this respect, a shepherd with 50 years of experience tending flocks would be widely recognized as having complete expertise in the use and training of sheep dogs and the care of sheep.

The term is widely used informally, with people being described as 'experts' in order to bolster the relative value of their opinion, when no objective criteria for their expertise are available.

Academic elitism arises when experts become convinced that only their opinion is useful, sometimes on matters beyond their personal expertise.

SciencScience is e is NOT NOT the the only only way way

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