Formulation of a Focused Clinical Question Using PICO University of Mary Department of Physical Therapy Michael G. Parker, PhD, PT, FACSM, Professor How do Clinical Questions Happen? Clinical questions occur during the management of a patient or during the description of a patient s care (Case Report). During patient management, you may require more information before making a clinical decision. Similarly, you may require more information about the validity of a test or the effectiveness of an intervention you are describing within the context of a Case Report. Whether you are developing a question for making a direct clinical decision or for a Case Report, your question will likely arise from one of the following evidence based practice domains shown in Table 1. Table 1. Domains of evidence-based practice and the type of evidence to look for questions within each respective area Domain Meaning of Domain Type of Evidence Diagnosis signs, symptoms, or tests diagnosing condition Diagnostic validation study Intervention/treatment Selection of effective Randomized Prognosis Causation/Etiology treatments The possible course of the impairments/functional limitations over time causes of pathology, impairments, functional limitations, and disability and how these develop Once you have determined the domain, you are ready to formulate an answerable good clinical question. How to Formulate an Answerable Clinical Question control trials Prospective cohort study Case-control or cohort study A well formulated clinical question consists of the 4 elements defined in Table 2. Those elements are Patient Population or Problem, Intervention, Comparison (if needed), and Outcome. Consequently, these elements are important because they become the key factors defining the limits of your search for the answer. For instance, in addition to the Intervention, Compare, and Outcome elements, data bases like MEDLINE/PubMed use such elements as age, gender, medical condition (Patient and Problem) to limit the electronic search of the data base. The acronym used to describe the formulation of a
question using these 4 elements is PICO (P= Patient, I= Intervention, C= Comparison, & O= Outcome). The following clinical questions are presented Table 2. The PICO method for creating an answerable clinical question Patient population or Problem What group (population) or problem do you want information about? Intervention or Exposure What physical therapy event do you need to study the the effect of or determine the validity and/or reliability of? Comparison What is the evidence that the intervention produces better results than no intervention or another kind of treatment? What is the evidence that the clinical test is as or more valid than other tests? Outcomes What is the effect of the intervention? The accuracy of a diagnostic test? as an example of the PICO method in the patient management domains of Diagnosis and Intervention. Application of the PICO Method to Formulate a Clinical Question The patient is an otherwise healthy 35 year old male with acute low back pain. You use the McKenzie symptoms of centralization and peripheralization to determine if the source of his back pain is discogenic, and question if the McKenzie method is a valid test for diagnosing disc pathology. The question will be formulated in the diagnosis domain of patient management. Your first step is to identify the 4 elements of a good clinical question. See Table 3. Table 3. Elements of the clinical question in the Diagnosis Domain of patient management Patient population or Problem otherwise healthy 35 year old male with acute low back pain Intervention or Exposure the clinical McKenzie exam (centralization and peripheralization) Comparison compare to standard imaging Outcomes diagnosing disc pathology The next step is to use the elements identified in Table 3, to write the following answerable clinical research question:
In an otherwise healthy 35 year old male with acute low back pain, how does the clinical McKenzie exam compare to standard imaging in diagnosing disc pathology? Thus, the answer to this question will assist the clinician with the decision of whether or not to use the McKenzie exam to diagnose the presence of disc pathology. Questions can also be developed to assist the clinician with decisions pertaining to the choice of interventions. The next clinical question was developed for a question relevant to the Intervention domain of patient management. The patient is a 23 year old female who is 3 months post ACL reconstruction. You are planning to use closed chain functional training for the lower extremity and question the effectiveness of this functional training program compared to a more traditional progressive resistive exercise program. Your first step is to identify the 4 elements of a good clinical question. See Table 4. Table 4. Elements of the clinical question in the Intervention Domain of patient management Patient population or Problem Otherwise healthy 23 year old female 3 months Post ACL reconstruction Intervention or Exposure closed chain functional training of the lower extremity Comparison compare to a more traditional progressive resistive exercise program Outcomes Incidence of re-injury and/or postoperative complications The next step is to use the elements identified in Table 4, to write the following answerable clinical research question: In an otherwise healthy 23 year old female who is 3 months post-acl reconstruction, how does closed chain functional training of the lower extremity affect the incidence of re-injury and post-operative complications when compared to a more traditional progressive resistive exercise program? Finding the Evidence: Searching the Data Bases After formulation of your PICO question, you can begin searching the data bases for the answers. It is recommended that you perform your search systematically; starting with the systematic review data bases like Cochrane, and if your answer is not found, searching data bases with primary sources like ProQuest/Open Door etc.
A new service provide by Medline permits you to search the Medline database using the PICO method; this new service is called AskMedline and you can find it at the following Web address: http://askmedline.nlm.nih.gov/ask/pico.php This site prompts you for Patient, Intervention, Comparison, and Outcome information prior to performing the search. In addition, you can limit the level of evidence produced, e.g., meta-analysis vs. randomized controlled trial etc below is an example of the screen prior to the search: The following page shows the result of this search:
From this screen, you can see that both articles are available full text, but may not be directly available on this data base without paying a fee. You should note that this search was done on a University of Mary computer network. Another search was performed on the effectiveness of McKenzie exercises, see next screen. You will note that I expanded the search by not specifying gender, age, comparison, or outcomes. As future searches are performed, the search could be narrowed by using more limiters.
The results of this search which specified a meta-analysis, produced the following paper. Unfortunately, full text versions of these articles may not be directly available without a charge.