Ask, Acquire, Appraise, Apply, Assess-Adjust

Evidence Based Practice

Five Stage Cycle of EBP

  • Formulate the clinical question ASK
  • Search and gain access to research articles ACQUIRE
  • Critically appraise the evidence APPRAISE THE EVIDENCE
  • Apply the evidence into practice APPLY
  • Evaluate the process of EBP ASSESS-ADJUST


ASK - Covert Clinical Scenarios Into A Structured And Answerable Clinical Question

Developing a well-constructed clinical question, derived from practice, is the first important step in Evidence based practice.

Anatomy of a good clinical question: PICO

PICO is a mnemonic that helps one remember the key components of a well-focused question. The question needs to identify the key problem of the patient, what treatment or tests you are considering for the patient, what alternative treatment or tests are being considered (if any) and what is the desired outcome to promote or avoid.

P= Patient Problem:

How would you describe a group of patients similar to yours? What are the most important characteristics of the patient? This may include the primary problem, disease, or co-existing conditions. Sometimes the gender, age or race of a patient might be relevant to the diagnosis or treatment of a disease.

I= Intervention, prognostic factor or exposure:

Which main intervention, prognostic factor, or exposure are you considering? What do you want to do for the patient? Prescribe a drug? Order a test? Order surgery? Or what factor may influence the prognosis of the patient - age, co-existing problems, or previous exposure?

C= Comparison:

What is the main alternative to compare with the intervention? Are you trying to decide between two drugs, a drug and no medication or placebo, or two diagnostic tests? Your clinical question may not always have a specific comparison.

O= Outcome:

What can you hope to accomplish, measure, improve or affect? What are you trying to do for the patient? Relieve or eliminate the symptoms? Reduce the number of adverse events? Improve function or test scores?


ACQUIRE - Search for the Research

The free search engines below can be used to locate and access primary research articles related to physiotherapy and rehabilitation.

  • PubMed Central (PMC) - The U.S. National Institutes of Health (NIH) digital archive of biomedical and life sciences journal literature. PMC is a free electronic archive of full-text journal articles. PMC contains more than 3 million full-text articles.
  • Google Scholar - Indexes research articles and abstracts from most major academic publishers and repositories worldwide, including both free and subscription sources.
  • Cochrane Library - The Cochrane Library is a collection of databases in medicine and other healthcare specialties. At its core is the collection of Cochrane Reviews, a database of systematic reviews and meta-analysis which summarize and interprets the results of medical research.
  • Pedro - PEDro is the Physiotherapy Evidence Database. PEDro is a free database of over 37,000 randomised trials, systematic reviews and clinical practice guidelines in physiotherapy.
  • OMICS - OMICS International is an organization that amalgamates open access publications and International science events for the benefit of the global scientific community. OMICS houses a repository of Physiotherapy and Rehabilitation open access journals.
  • Trip Database - A medical search engine with emphasis on evidence based medicine & clinical guidelines and queries. You can search by key word (e.g. asthma) which will suggest subheadings (e.g. asthma children). You can read about evidence by quality, relevance and timeline. Clinicians are also able to search across other content types including images, videos, patient information leaflets and educational courses.
  • The National Guideline Clearinghouse (NGC) (USA) - A publicly available database of evidence-based clinical practice guidelines and related documents. Updated weekly with new content, the NGC provides physicians and other health professionals with an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines and to further their dissemination, implementation, and use.
  • NICE Evidence - An online search engine that identifies relevant clinical, public health and social care guidance. As part of the service, NICE also provides access to information content purchased on behalf of the NHS. This includes access to a range of bibliographic databases such as Medline and professional journals.
Other Ways to Access Research

PNZ members working at DHBs can access medical research databases through the DHB's library. Most DHBs subscribe to Medline, Cinahl and other popular research databases.

If the article you require is not open access and you keep hitting a paywall, then don't fear!

PNZ will order an inter-library loan on your behalf.

Simply complete the electronic form by clicking here and once fully completed press 'done'. Your request will be automatically saved onto the PNZ system and fulfilled within 24-48 hours (on working days). Please check a pdf of the full text article is not available using a Google Scholar search before making a request through the PNZ Library.

Physiotherapy members working at DHBs or academic institutions should check their organisational database subscriptions prior to ordering articles through Physiotherapy New Zealand. Physiotherapy New Zealand incurs a cost for each item inter-loaned.


APPRAISE the Evidence

Read and appraise papers, grading the strength of the evidence by using CASP Checklists

Review basic information on How to critically analyse a research article

More detailed or specific information on research appraisal can be obtained from Jamas Users Guides to the Medical Literature


APPLY the Results of the Research to Clinical Practice

There are several questions to ask yourself when considering applying the findings of research to patients. These questions are as follows:
  • 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 potential harms of the surgery or the cost of surgery?

Take this information back to your patient and discuss the issues with them and help them decide on a plan of action.


ASSESS-ADJUST to Evaluate your Performance

  • Did you ask a relevant, well-focused question?
  • Did you know how to access the relevant information?
  • Was your search extensive?
  • Did you manage to integrate findings from research with your clinical experience and the patient's preference?
  • What was the efficacy of the intervention on outcomes?
  • How may you improve the process next time?

Reflecting is the final step in the evidence-based practice cycle. For relevant self-evaluation questions see further details click here