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Nick Barker

Laurie Jensen

4080 Admin At

5, May 2017

PICO Question

“We need to do this research, not only to find out what works, but to find out what

interventions actually may be harmful”-Francis Collins, MD. Throughout all of the years of

medical experience for Doctors, Surgeons, Athletic Trainers, and many more people find all

different types of injuries and sicknesses with their patients. These lead to these medical

professionals wondering, and asking questions about all the different problems. The research that

has been done by these professionals is called evidence based medicine (EBM). Evidence based

medicine is The integration of the best research evidence with our clinical expertise and with our

patient’s unique values and circumstances (Jensen Power Point). Before the EBM articles though

come the research based questions called PICO questions, which are made by the medical

professionals. PICO questions are a technique that is used in an evidence based practice to frame

and answer a clinical, and or health care related question. The P in PICO stands for the problem,

the population, or the patient, which means, what are the characteristic, condition, or disease or

the patient or population. The I stands for intervention or exposure, or which main prognostic

factor. The C stands for comparison, which is the alternative to the intervention, and finally the

O stands for outcome, or what did someone do to accomplish a final goal. There are also three

types of research designs, retrospective, prospective, and compilation. Retrospective is the data

already collected or already have the condition. Prospective is the examination of the current
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condition and is followed over a certain period, and compilation is the action or process of

producing. This research paper that has been conducted has included all three different types of

EBM articles that have been found to answer two different PICO questions. Are football players

who wear prophylactic knee braces more or less likely to sustain an MCL injury compared to

football players who do not wear prophylactic knee braces? and for football players, does the use

of a glenohumeral stabilization brace reduce the future risk of anterior glenohumeral dislocations

compared to other football players without glenohumeral braces.

To start, the first PICO question that was answered is, are football players who wear

prophylactic knee braces more or less likely to sustain an MCL injury compared to football

players who do not wear prophylactic knee braces? This was a tricky question to get the answer

for based upon the number of football players who do not wear knee braces. Based upon this

PICO question three great articles were found regarding football players, MCL injuries, and the

use of prophylactic knee braces. The first article found based upon this question, but this article

had to do with the use and performance of Prophylactic knee braces vs neoprene knee sleeves.

The Article is a randomized controlled trial on the effects of Prophylactic knee braces,

and Neoprene knee sleeves on a healthy athlete’s performance The study was to see if the uses of

the two types of braces would diminish an athlete’s performance on the field during play. This

study was conducted on 31 male collegiate athletes who had to be on the active roster for the

football team, and these athletes had to have no history of knee injuries. These 31 athletes were

put into 4 groups: 1. Non braced which was the control 2. Using a neoprene knee sleeve 3. Using

a neoprene knee sleeve with 4 bilateral supports 4. Using a prophylactic knee brace. To test the

knee braces the athletes who needed to wear the braces had them placed on their dominant leg

for the exercises. All 31 of the athletes had to participate in Functional tests, and Isokinetic tests
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to get the correct performance, and results for the study. The functional tests for the athletes

consisted of a cross-over hop test, and a single leg vertical jump test. The best results of the test

for each athlete were recorded for analysis. The Isokinetic tests that the 31 athletes had to do

consisted of performing the Biodex concentric knee extension and flexion test. This step up

consisted of 3 repetitions at 60 degrees/sec, 5 repetitions at 180/ degrees, and 10 repetitions at

300 degrees/sec. After all these tests were taken the data was recorded, and studied in the lab.

The results showed that after all of the workout tests the knee braces did not show any difference

in performance compared to each other, and even compared to the Non-braced athletes. The only

difference found in all of the studies is that the Prophylactic knee brace provided more stability

during the tests, compared to the knee sleeve and the non-braced control group.

Secondly, the next article that was found based on the PICO paper is based upon of

prophylactic braces in the prevention of knee ligament injuries in collegiate football players.

This study was put together to review all different literature regarding knee braces, and to

evaluate them to see the efficacy of prophylactic knees braces protecting the knee ligaments of

college football players.

The methods used for this study included gathering articles about prophylactic knee

braces from 1970 through November 2006. From there the 725 articles were cut down to

prophylactic knee braces and college football players. After all the articles were reviewed only 7

of them made the cut. In those 7 studies they all included what players were wearing knee

braces, and what athletes were not. After all the data from the studies were plugged in, and the

non-braced/braced injury rate was found the experts plugged the numbers into multiple

equations. Once the data was found it showed that in 3 of the studies 42, 32, and 17 players who

were numbers needed to treat to benefit from knee injuries, would need to have a brace on for
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one season to prevent a knee injury. But from the other side (numbers needed to treat to harm) 4

studies were given back showing that 32, 26, and 32 players who were wearing a knee brace

because of an injury for one season, were more likely to have one more knee injury occur. Based

on the evidence of the study being different the specialists cannot conclusively advocate or

discourage the use of a prophylactic knee brace for a collegiate football player to prevent a knee

ligament injury. Reasons why there was not a solid conclusion on the study is because of some

certain factors. These factors that changed the study include the studies were not randomized,

different braces were used within the study, and only one group excluded people with existing

knee injuries.

Lastly, he third and final article that was found is a big one. The article that has chosen is

a prospective, analysis of medial collateral ligament sprains in Big Ten Conference college

football players over a three-year period. This analysis covered over every team in the Big Ten

conference for over three football seasons, but the athlete had to meet some certain criteria just to

be able to participate in the study. If the athlete participated in the study they had to mark down

if they wear knee braces already or if they do not to see whether they hurt the leg in the brace, or

the leg that is not covered by the brace. All together over the three football seasons 98 members

per team were able to contribute to the study which in total combined to 987 Big Ten Football

players. These 987 football players experienced in three years 292,430 injury exposures based on

what the teams did per season. Each player per year experienced 93 regular practices, 4

scrimmages, and only 53 members of the teams got to play in 12 games which also caused an

extra 106 knee exposures per game. Each athlete had a variable which would either increase their

chance for a knee injury, or not. These variables depended on position, and whether they were a

starter, back-up, or not even considered on the team (Walk-on). Over the three years 475 knee
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injuries were recorded out of 2,608 injuries, 43 percent of those knee injuries involved the MCL.

In the position stand point 47 of the MCL injuries came from offensive linemen, while 30 of the

athletes were defensive lineman and another two were kickers. Furthermore, for the whole study

group 50 percent of knee exposures were when a player was wearing a prophylactic knee brace,

while 49. 3 percent of exposures happened when players were not wearing a knee brace.

Along with this article, is the second part which also goes more in depth with all of the

information on the studies. Part two of this article states all of the concluding results from the

study, and more results that came from each position group. Out of all 987 athletes only 76

according to all the participation variables, and daily records on them have truly completed the 3-

year period without incurring a knee injury. That is only 7.7 percent of the athletes that

completed finished the study, kept up with every record. In total throughout the three years 22 of

the 48 game related knee injuries occurred to players who were wearing braces, while the other

26 game related occurred to the players who did not wear knee braces just like stated above. This

second article also stated that over the 3 years the starters account for 49 of the injuries,

substitutes accounted for 20, and non-players accounted for 31. Also, in contact practices 52

injuries were recorded, and 48 injuries were recorded during game situations. The final

conclusion of this article states that even when a player, no matter the position, does or does not

wear a knee brace that there is a “consistent but not statistically significant tendency for the

players wearing preventive knee braces to experience a lower injury rate than their unbraced

teammates.

In conclusion, based upon all the research that has been offered for this question it is still

unanswered today. Sports scientists, and doctors everywhere have been trying to figure out what

better for football players knee braces or not? Even after all the information that has been given,
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and even all the info that is still out there this question remains unsolvable for now. To find these

articles that were used in this research paper they had to go through certain reviews, and they had

to be over looked multiple times. This process is called the Critical Appraisal Skills Programme.

The CAST system is a series of ten questions that you look over and try to find it in an article. If

you go over the article and its missing something that means it is not a valid source. There are

also three main pillars to the CAST system and they are, Reliability, Validity, and Prevalence.

Finally, the last PICO question that this research paper covers with evidence-based

medicine is. For football players, does the use of glenohumeral-joint stability braces reduce the

future risk of shoulder dislocation compared with players who do not wear glenohumeral-joint

stability braces. The first article that goes with the PICO is about the effectiveness of

Glenohumeral- Joint stability in limiting active and passive shoulder range of motion in college

football players.

This article was made to help determine the effectiveness of glenohumeral-joint stability

in limiting active and passive shoulder abduction so no anterior glenohumeral dislocations will

happen to college football players. This study was conducted on 15 Temple university football

players after their 5-week spring season was completed. After the 5-week practice period the 15

athletes were fitted with either Denison and Duke Wyre harness, or the Sawa shoulder brace. The

athletes were instructed to do multiple motions inside of the brace which included abducting the

shoulder, and internal rotation. The athletes were then instructed to do this trail three times with

five seconds of rest in-between each lift. The results of this study showed that with the Denison

and Duke Wyre harness active shoulder abduction resulted in an average increase of 23 degrees,

and an increase of 11.8 degrees with the Sawa. On the other hand, passive shoulder abduction

was an average increase of 28 degrees for the Denison and Duke Wrye harness, and an increase
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of 14.6 degrees for the Sawa. This study showed that neither brace maintained the correct arm

position of 45 degrees during active or passive shoulder abduction.

The next article that tries to answer the PICO question is about the effect of a Neoprene

shoulder stabilizer on active joint reposition in subjects with stable and unstable shoulders. The

study consisted of forty subjects broken up into two groups. Group one was made up of twenty

students from the university, while group two was made up of 20 divisions 1 athletes who had a

history of anterior glenohumeral dislocations. For the test the effected group was given a sully

based upon their past history, and instability tests. To test the assessment of active joint-

reposition the effected arm of group two was being used, and the dominant arm of group one is

also being used. Each person was told to move their shoulder slowly from neutral rotation to one

of the three target areas which was projected by a target. The other thing the study tested was a

range of motion assessment. To test range of motion, maximum external rotation of both groups

were taken and compared against each other. Based on the results of this study it shows that the

unstable group showed improvement while wearing the sully throughout all of the tests.

In conclusion, the tests in both of these studies seemed to be very different from each

other’s point. Just like the first PICO question this one could not be answered to the fullest

extent. To wrap it all up, this paper serves a great deal in showing the real importance of

evidence-based medicine. It shows that when doctors, surgeons, or any other healthcare

professionals have questions they can get the correct answer based on facts. Without evidence

based medicine people would not have an intelligence regarding any type of medicine, or drug.

Not only for the people in the world but EBM is also for the other doctors who may have just

heard about other random studies going on that he/she wants to learn about. All together EBM is
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a great and interesting process that has been here for some time. Without EBM the medical

world might not be what it is today.


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Works Cited

Albright, John; Powell, John; Smith, Walter; Martindale, Al; Crowley, Edward; Monroe, Jeff;
Miller, Russ; Connolly, John; Hill, Billy; Miller, Dennis; Helwig, Dennis; Marshall, Jim (1994).
"Medial Collateral Ligament Knee Sprains in College Football." The American Journal of Sports
Medicine 22(1): 12-18. <http://hdl.handle.net/2027.42/67097>

Chu, Jennifer C. et al. “The Effect of a Neoprene Shoulder Stabilizer on Active Joint-Reposition
Sense in Subjects With Stable and Unstable Shoulders.” Journal of Athletic Training 37.2
(2002): 141–145. Print.

Jensen, Laurie. “Evidence based medicine” Administration in Athletic Training, 5 May 2017,

Tarble Arena Recreational Center, Kenosha, WI. Lecture.

Mortaza N, Ebrahimi I, Jamshidi AA, Abdollah V, Kamali M, et al. (2012) The Effects of a
Prophylactic Knee Brace and Two Neoprene Knee Sleeves on the Performance of Healthy
Athletes: A Crossover Randomized Controlled Trial. PLoS ONE 7(11): e50110.
doi:10.1371/journal.pone.0050110

Pietrosimone, Brian G et al. “A Systematic Review of Prophylactic Braces in the Prevention of


Knee Ligament Injuries in Collegiate Football Players.” Journal of Athletic Training 43.4
(2008): 409–415. Print.

Weise, Keon et al. “Effectiveness of Glenohumeral-Joint Stability Braces in Limiting Active and
Passive Shoulder Range of Motion in Collegiate Football Players.” Journal of Athletic
Training 39.2 (2004): 151–155. Print.