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How can athletic trainers ask a clinically relevant question using PICO?

This is an excerpt from Evidence-Based Practice in Athletic Training 2nd Edition With HKPropel Access by Scot Raab,Naoko Giblin.

Step 1: Create a Clinically Relevant and Searchable Question Concerning Your Patient

Creating a clinically relevant question is often more complex than it seems. A searchable question has three or four components as expressed in the acronym PICO: the population or problem (or both), the intervention (treatment), the comparison intervention (the treatment you are curious about) or population, and the outcome measure by which the intervention is appraised. Some questions may have only one intervention or comparison component.

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Foundations of Evidence: Components of a Searchable Question

1. Patient or problem (or both)
2. Intervention or treatment
3. Comparison intervention or population
4. Outcome

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To begin the process, consider your current clinical work with patients. If a particular case you are working with is complex or difficult, consider using it for your question. If you are not working clinically, consider an injury, illness, or treatment you would like to learn more about. If you are having a hard time coming up with something, here are a few scenarios to consider:

• Scenario A: A young female soccer player is returning to play after a six-month rehab program following an ACL tear. She had a bone-patellar tendon-bone (BPTB) graft to reconstruct the ACL, which is creating some minor residual anterior pain. In the first game back, she suffers an ACL tear in the opposite knee. Given the residual pain from the first ACL surgery, she asks you whether an allograft is a better option for the second knee reconstruction. You decide to do an EBP search to address her question.
• Scenario B: A young male basketball player has been battling chronic Achilles tendinopathy for 10 months and is getting frustrated. A colleague shared a similar case with you and suggested adding eccentric exercises to the rehab plan. You decide to do an EBP search to determine whether there is any increased risk of rupture when adding eccentric exercises for a patient with a chronic Achilles tendon injury.
• Scenario C: You walk out to track practice one day and are alarmed that a quarter of your athletes have applied kinesiology tape in various places on their legs. Some of your colleagues have reported gains from the use of kinesiology tape, whereas others claim that it is a money-making scheme and doesn’t work beyond the placebo effect. You decide to do an EBP search to find out whether kinesiology tape is proven to reduce injury symptoms.

To structure your EBP question, you need to put it into the PICO format:

P: Patient (or athlete) and problem (or injury)

I: Intervention currently in place

C: Comparison intervention

O: Outcome to measure to determine which intervention is best for the athlete

Defining P is the easy step. This is your patient and their injury, illness, or ­condition. Avoid being too detailed initially. For example, you may want to avoid limiting age beyond, say, youth or geriatric. However, you should state the exact injury or condition (e.g., patellar tendinitis rather than knee injury). The latter would garner thousands of articles. For scenario A, the P would be female soccer athletes with ACL tears. You would not want to enter collegiate because doing so may limit the results and this categorization is less important. However, the word female is an important one to include, given the disparities between male and female ACL injury rates. Now consider the scenario from your clinical practice and write down your patient and problem.

The next component, the intervention, is most commonly what is already present—a current treatment, the surgery that has been chosen, diagnostic testing performed, or similar elements. If the intervention is a regular rehabilitation protocol, you may compare it with the comparison intervention that, for example, uses the same regular rehabilitation protocol but also employs iontophoresis. The intervention would be the treatment you are currently providing or the surgery commonly performed. In the research studies you find in your search, this intervention group may be the control group, meaning the group that underwent the traditional treatment or surgery. For scenario A, the intervention would be autograft ACL surgery. You may want to define the type of graft, such as bone-patellar tendon-bone (BPTB) or hamstring. In many scenarios, the intervention may be a standard treatment—nothing new. For example, for acute patellar tendinitis, the intervention may be providing a standard treatment and not stretching the quadriceps. In contrast, the comparison intervention may be to offer a standard treatment and add an aggressive quad stretching component. For scenario C, the intervention would be providing a standard treatment and not applying kinesiology tape. Now consider the scenario from your clinical practice and write down your intervention.

To define comparison, consider the new comparison intervention that you are wondering about. This is most commonly the real point of your EBP question—that is, is there something better out there than what you are doing or intend to do? In most of the research articles you will find in your search, this group will be the experimental group, meaning the group that received the extra treatment, new surgery, or the like. For scenario A, the comparison would be allograft ACL surgery. For scenario C, the comparison intervention would be applying the kinesiology tape in addition to doing the normal rehabilitation for any injuries. Now consider the scenario from your clinical practice and write down your comparison.

The last step in creating a searchable question is defining the outcome measure (O), or what you intend to examine to determine which intervention or comparison intervention is best for your patient. Many times in athletic training, the outcome may be the time to return to play or the reinjury rate. Other common outcome measures are pain level, symptom reduction, and range of motion. At times, you may need to delve into the research studies to find out what is most commonly used as the outcome measure for the issue you are investigating. For example, if you are wondering whether acromioclavicular surgery is as effective as conservative, nonsurgical rehabilitation treatment, your outcome variable could be how quickly people return to play or how often people in each group become reinjured. The determination of which outcome measure to use in your search may be dictated by your patient’s values or priorities or by whatever you find in your search. Is your patient more concerned with getting back to play quickly or getting back to play safely with little chance of reinjury? For scenario A (ACL graft options), the outcome measure needs to consider the patient’s primary concern—specifically, the amount of residual pain the patient had after her first BPTB autograft surgery. For that search, the outcome would be the post-surgery pain level. For scenario C (kinesiology tape), the outcome would be a reduction in symptoms. Now consider the scenario from your clinical practice and write down your outcome.

Now it’s time to put your PICO question together from the components you wrote down. Be sure to read variations of the question out loud to hear what arrangement of the PICO sounds most appropriate. For scenario A with the ACL, the question may be stated like this: For female soccer players with ACL tears, does a BPTB autograft or an allograft create less postsurgical pain through RTP (return to play)? For scenario B with the Achilles tendon, the question may be stated in this way: For male basketball players with chronic Achilles tendon injuries, is the risk of rupture increased when adding eccentrics to the rehabilitation program? And for scenario C with the kinesiology tape, the question may be stated in this way: For running athletes with orthopedic injuries, does the application of kinesiology tape create a more rapid reduction of symptoms than not using the tape?

Now that you have created your PICO question, you are ready to begin your search. If you are missing components of PICO, you may have created a nonsearchable EBP question. Also, a question that asks simple demographic or statistical questions may be nonsearchable. For example, whether rugby players or American football players get more concussions is simply an epidemiological statistic and not a question that involves interventions. Finally, if your outcome measure is not quantifiable, you must refine it. For example, if your PICO is comparing two surgeries to determine which is “better” as the outcome measure, you will likely find no articles because no research articles use the undefined term better as the outcome. See the sidebar Examples of Searchable and Nonsearchable EBP Questions.

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Examples of Searchable and Nonsearchable EBP Questions

Searchable Questions

Patient and problem: Track sprinters with medial tibial stress ­syndrome (MTSS)

Intervention: Rehabilitation and rest

Comparison: Rehabilitation and kinesiology tape

Outcome: Pain reduction

Question: Do track sprinters with MTSS have greater pain reduction with rehabilitation and rest or with rehabilitation and kinesiology tape?

Patient and problem: Female soccer players

Intervention: Core stability ACL injury prevention program

Comparison: Jump landing ACL injury prevention program

Outcome: Occurrences of ACL tears

Question: In female soccer players, is there a reduced ­incidence of ACL tears for those performing core stability programs compared with those performing jump landing programs?

Nonsearchable Questions

Patient and problem: Athletes with MTSS

Intervention: None

Comparison: None

Outcome: Ability to complete the season

Question: Are athletes with MTSS able to complete the season?

Doing an EBP search for this question is not possible or very difficult because there is no clear outcome that defines “the ability to complete the season.” Without intervention or comparison, you are simply trying to ­determine if no treatment would allow the athlete to return to activity. This is neither ethical nor a standard of care. The patient population may be too broad. 

Patient and problem: Soccer players

Intervention: Core strengthening programs

Comparison: Cardiovascular training programs

Outcome: None

Question: How is a core strengthening program compared to a cardiovascular training program among soccer players? 

This question is not searchable because it lacks an outcome. Without knowing what outcome(s) should be investigated, your EBP search will be extremely difficult. While missing a component or two in the PICO ­questions like in these two examples is not too uncommon, a clinical EBP search will be more effective and efficient if all four components are ­provided.

More Excerpts From Evidence-Based Practice in Athletic Training 2nd Edition With HKPropel Access

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