成人快手

Jordan: Welcome to the ClinEd Collective, a podcast for chiropractic clinicians, educators, and scholars. Inspired by the triple threat model of integrating clinical care, clinical education, and research and scholarship, we aim to share practical insights and explore topics that help chiropractors advance patient care, enhance teaching, and engage more meaningfully with evidence and scholarship.

The ClinEd Collective is part of the Froedtert and 成人快手 Spine Care Programming and the Wisconsin Institute of Neuroscience, a partnership of Children's Wisconsin, the Froedtert and 成人快手 Health Network, the 成人快手, and the Clement J. Zablocki Veterans Administration Medical Center. The hosts of the ClinEd Collective are Jordan Gliedt and Pat Battaglia.

I'm Jordan Gliedt, a chiropractor at the Froedtert and 成人快手 Spine Care Clinics and an associate professor in the Department of Neurosurgery at the 成人快手. I serve as program director for both the Doctor of Chiropractic Residency program and the Chiropractic Student Preceptorship program. My work focuses on advancing patient-centered collaborative clinical care while contributing to transformative clinical education and scholarship across musculoskeletal health and health professions education.

Pat: And I'm Pat Battaglia, the associate vice president for community-based clinical education at the University of Western States in Portland, Oregon. I'm a board-certified chiropractic radiologist, and before moving into full-time academic leadership, I spent several years practicing within integrated health systems. My work is guided by the triple threat, bringing together clinical care, clinical education, and scholarship. And really at the heart of what I do is building real-world, diverse, and rigorous clinical training experiences that prepare chiropractic learners to thrive in modern team-based healthcare environments.

Jordan: Thank you for joining us on the ClinEd Collective. Let's begin.

Pat: In this rapid review, we're discussing PICO. By the end of this episode, listeners will be able to formulate a well-structured PICO question from a clinical uncertainty, identify reliable sources of evidence to address PICO questions, demonstrate how to teach the PICO framework to learners, and lastly, apply the PICO framework to develop meaningful research questions.

Jordan: Thanks, Pat. So, let's just jump right in it. What is PICO? PICO really is just a framework in how you can define a research question or a clinical question and bring that into the research realm and gain more understanding. So, P in PICO stands for patient or the population that you're interested in. I stands for the intervention that you're interested in. C is the comparator, so what are you comparing the intervention with? And then O is for outcome.

Pat: So, Jordan, I thought maybe an example would help crystallize this. Let's imagine a scenario where a patient presents with acute lumbar radiculopathy. Common clinical scenario, painful condition, and oftentimes the clinician's faced with a lot of questions from the patient as far as what treatment is gonna help me feel better and restore my function. And there's a lot of nuance to this but in general, when patients see chiropractors for this condition, in part they're wondering, is an adjustment gonna help? Should I go see a medical doctor and get some medicine or an injection? These sorts of things. So, I thought I'd provide you with a PICO question that might help answer this, and curious what you think. So, here's my question. In adults with acute lumbar radiculopathy, how does spinal manipulation therapy compared with epidural steroid injection affect pain reduction and functional improvement?

What do you think?

Jordan: I think that's good. You've really hit all the elements of PICO. The population is adults with acute lumbar radiculopathy. The intervention you're looking at is spinal manipulation compared with epidural steroid injection, and you defined quite well your outcome, which is pain reduction and functional improvement.

So, one thing that I do wanna caution is that it will yield results that are consistent with comparing spinal manipulation within this very specific population with lumbar epidural injection. So, you have to understand the scope of what the information you're gonna get, and you're not necessarily gonna be able to compare it outside of that to, let's say, acupuncture or exercise or usual medical care.

So now that we've formulated a PICO question, it's really important to discuss, what do you do next? How do you find this information. I wanna Define a couple of pathways that our listeners can see as more reliable peer-reviewed databases with information. That can include PubMed, UpToDate or Open Evidence. These are good databases with peer-reviewed information

Pat: So many of our listeners, Jordan, are not just practicing clinicians. They also have a dual role of providing mentorship to learners. They have students or residents in the clinic alongside with them. So, I want to take us into a clinical learning environment and talk a little bit about how we can adapt this process of PICO and really model it for our learners.

Jordan: I think it's always great to talk about, how do you actually implement it when you're in a clinical room with learners? How do you do that live?

Pat: First, it's important to understand this process really shouldn't be any different when deployed by a student or a resident versus a clinical attending. It's the same thing. You're learning how to ask answerable questions that are important to the patient you're working with. I think that's really important to understand. There are some tactics that can help, and as a overarching theme, I think it's really about being intentional in how you go about this. So, the first would be blocking time, whether it's during a day or once a week or maybe even once a month. Finding some time, protecting some time to walk through methodically this process with the learner can be very helpful.

Assigning homework is great. A PICO question lends itself to a good homework exercise, whether it's having a learner generate the question and then bringing it back for critique or using the resources you provided, having a learner go to the literature and answer these questions and then circling back for a debrief.

And then being intentional about verbalizing this. This is the think out loud method. Being intentional about verbalizing how you're thinking about framing the clinical scenario in front of you as a PICO question. The more you verbalize it, the more learners are gonna start to think that way as well, and it just becomes second nature, which is really important when you're in a busy clinical workday.

And then lastly, something just to be mindful of, there are going to be a lot of examples where the output of a PICO search doesn't yield what you might be looking for. You might not get much, if any information as far as what's available evidence to use in this case. So, I'll bring us back to the principles of evidence-based and evidence-informed practice outside of the scope of today's rapid review. But it's something to keep in mind and address proactively with your learners that, hey, maybe we might not get all the answers we're looking for here. We're gonna start with the best evidence and good practices to care for this patient, but I'll also come back to my experiences, patient's preferences, values, and so on.

Jordan: That's a great explanation, Pat. I really wanna highlight one thing. PICO just isn't an exercise. It's really ingraining lifelong professional skills. In how to acquire that information. Just having that as an ingrained part of your professional life I think is really important.

So, I'll transition us to how do you utilize PICO from a research standpoint? This is a way in which we can identify how to acquire information. Once you consume that information, it's really a nice way to identify gaps. So, if you identify a gap in the body of knowledge, you set yourself up to executing a research study that narrows the gap.

Pat: So, Jordan, what I'm hearing is ask clinical questions framed through PICO, and if you don't identify much or any high-quality literature to answer those questions, maybe that's an opportunity to conduct some of it on your own.

Jordan: That's an excellent way to view it, and that's a really nice simplistic way in which you can identify meaningful areas of research.

Pat: In this rapid review, we discussed PICO. After listening, we hope you feel more prepared to formulate a well-structured PICO question from a clinical uncertainty, identify reliable sources of evidence to address PICO questions, demonstrate how to teach the PICO framework to learners, and lastly, apply the PICO framework to develop meaningful research questions.

Jordan: As a reminder, please visit the show notes for more detailed information and resources on this topic. The ClinEd Collective is a podcast that is part of the Froedtert and the 成人快手 Spine Care Programming and the Wisconsin Institute of Neuroscience.

PICO is a practical framework for translating a clinical uncertainty into a focused, answerable question:

• P 鈥� Patient, population, or problem
• I 鈥� Intervention
• C 鈥� Comparator
• O 鈥� Outcome

PICO can help clinicians identify useful search concepts, teach evidence-seeking skills, and recognize unanswered questions that may warrant further research.

Using PubMed in Evidence-Based Practice 鈥� National Library of Medicine
This explains how to formulate a PICO question, identify search terms, search PubMed, locate full-text articles, and save searches. It includes practice exercises suitable for clinicians and learners.

Using PICO to Improve PubMed Searches
In this pilot randomized study, Schardt, et al. examined whether organizing clinical questions using the PICO framework could improve the relevance of literature searches conducted in PubMed. The article provides a practical illustration of how PICO can help clinicians identify key search concepts while also highlighting common search challenges involving terminology, Medical Subject Headings, publication types, and search filters.
Schardt C, Adams MB, Owens T, Keitz S, Fontelo P. Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Med Inform Decis Mak. 2007 Jun 15;7:16. doi: 10.1186/1472-6947-7-16. PMID: 17573961; PMCID: PMC1904193.

Cochrane Handbook: Defining the Criteria for Including Studies: PICO
This explains how population, intervention, comparator, and outcome definitions shape a systematic review鈥檚 scope, eligibility criteria, and interpretation.

Finding Evidence
Different resources serve different purposes:

• PubMed is a bibliographic platform for locating biomedical literature. Finding an article in PubMed does not establish that the study is high quality or applicable to a particular patient.
• The Cochrane Library provides systematic reviews and other synthesized evidence.
• UpToDate provides expert-authored, peer-reviewed clinical decision-support summaries and graded recommendations. Access may depend on an institutional or personal subscription.
• OpenEvidence is an AI-assisted medical information platform that provides citation-linked answers grounded in clinical literature and other evidence resources. Users should review the underlying sources rather than relying only on the generated response.

Do not enter identifiable patient information into a search or AI-assisted platform unless its use has been approved by your institution.

Search Tip
PICO should guide the search, but every PICO component does not necessarily need to appear in the initial search query. Begin with the most important concepts鈥攐ften the patient/problem and intervention鈥攁nd add the comparator, outcome, or other limits only when needed.

Overly specific searches may miss relevant evidence. Search iteratively and consider consulting a health sciences librarian when the question is complex.

Worked Example From the Episode
Clinical question
In adults with acute lumbar radiculopathy, how does spinal manipulation therapy compared with epidural steroid injection affect pain reduction and functional improvement?

PICO elements

• Population: Adults with acute lumbar radiculopathy
• Intervention: Spinal manipulation therapy
• Comparator: Epidural steroid injection
• Outcomes: Pain reduction and functional improvement

Possible initial search
(鈥渓umbar radiculopathy鈥� OR sciatica OR 鈥渓umbar disc herniation鈥�) AND (鈥渟pinal manipulation鈥� OR 鈥渟pinal manipulative therapy鈥�) AND (鈥渆pidural steroid injection鈥� OR 鈥渆pidural corticosteroid injection鈥�)

A direct search may identify little or no head-to-head evidence. When this occurs, search the interventions separately, identify systematic reviews and clinical guidelines, and carefully evaluate whether indirect evidence applies to the patient in question.

Teaching PICO
A simple clinical-learning exercise is to ask a learner to:

1. Identify one uncertainty arising from a patient encounter.
2. Formulate a PICO question.
3. Identify the most important search concepts.
4. Search an appropriate evidence resource.
5. Select and critically examine the most relevant evidence.
6. Return for a short debrief about the search process, findings, limitations, and application to the patient.

From Clinical Question to Research Question
An unanswered PICO question may identify a potential research opportunity, but absence of a direct answer does not automatically establish a meaningful research gap. It is important to first verify the gap through a sufficiently comprehensive search and evaluate the proposed question. The use of the FINER criteria can help to evaluate the proposed question:

• Feasible
• Interesting
• Novel
• Ethical
• Relevant

Farrugia and colleagues provide a practical introduction to developing research questions, hypotheses, and objectives.

Apply It to Your Practice
Consider the following questions:

1. What clinical uncertainty have I encountered recently?
2. Can I translate it into a focused PICO question?
3. Are my selected outcomes meaningful to the patient?
4. Which PICO concepts should be included in my initial search?
5. Does the evidence apply to this patient and clinical context?
6. How do patient preferences, risks, costs, and access affect the decision?
7. How will I respond if the available evidence is indirect or uncertain?
8. Could an unanswered question represent a feasible and important research opportunity?