MSc in EBHC: A “breakthrough” in evidence appraisal

December 13, 2018

“We all benefitted enormously from this study appraisal process – both within the small groups and by developing our own confidence and understanding of “evidence””

We are Daniel and Dor, a Registered Nurse and NHS manager from Cornwall, UK and a Physiotherapist specialising in stroke from Rehovot, Israel. We were both students on the Practice of Evidence-Based Health Care module (PEBHC) – our first module of the MSc in Evidence-Based Health Care (EBHC).

During the face-to-face “Oxford week” we were set the task of completing a small group appraisal and presentation of evidence for an important question of our choice. Our steep learning curves had already begun on Monday and by mid-week we were feeling (slightly!) more confident about putting all of that intense study into practice.

Our group chose a study published in the NEJM a couple of weeks earlier entitled “Recovery of Overground Walking after Chronic Motor Complete Spinal Cord Injury”. The study also made headlines in the newspapers, TV and internet news. At first sight it looked like one of those “breakthrough” studies about which we had been advised to be skeptical. The study was suggested by Dor, and the rest of us in the group (a physio, a midwife, a social care manager and a nurse) set about working out just what type of study this actually was… and much analysis, debate and coffee ensued.

Four participants were involved in the study – three male and one female, all aged between 22 and 32 years. Two of the participants had AIS-A injury (complete loss of both sensory and motor function below the level of spinal injury) and two had AIS-B injury (complete loss of motor function but with some sensation). The four participants had been selected from around 2,000 possible candidates because of their baseline physiological characteristics and their potential to carry out as many as 278 training sessions over an 85-week period.

As taught on day one (and reinforced throughout the week), we started with the clinical question being answered using PICO (population/participants, intervention, comparison, outcome). We defined the clinical question as “Can patients with complete spinal cord injury regain upright posture and mobility through the incorporation of epidural spinal cord stimulation in their rehabilitation program?” based on the following PICO:

Participants: Adult with AIS-A injury and AIS-B injury
Intervention: Epidural spinal cord stimulation alongside rehabilitation
Comparison: none
Outcome: Ability to either stand unaided, complete upper body trunk exercises whilst sitting, or walk using bars or a frame.

We then appraised the study methods. The first thing we discussed was the type of study design used. Was it a non-randomised, non-controlled experimental trial or were we making things too complicated? We decided after much debate (and may be a little help from our tutor Dr. David Nunan) that this was a case series involving exactly the study design we arrived at.

We identified some other issues too. Sample size was only four people (we didn’t need the amazing statistics lesson we had to tell us this was a small sample). We considered recruitment and selection bias were high, as the participants were chosen so carefully external validity was compromised. In addition, performance bias was high with no blinding provided to the participants or the assessors. We judged reporting bias also to be high as measuring the ability to stand and make “a few steps” can be very subjective.

However, we knew that despite the limitations, the outcomes still made this an important study with landmark findings. The study is the first to report improved outcomes for independent limb control, active standing and even walking, with the use of an active intra-spinal transmitter. For the first time, the outcome for patients with this severely debilitating spinal injury could actually be different.

We had an amazing week of teaching by EBHC experts and learning from each other’s experiences and thoughts. We all benefitted enormously from this study appraisal process – both within the small groups and by developing our own confidence and understanding of “evidence”. The impact of this study, and the module, will certainly stay with us for many reasons, as we look forward to our next “evidence-based” challenge!


Daniel is a Registered Nurse working in NHS management in Cornwall, UK. He has so far completed the PEBHC module and is currently on the second compulsory module in Study Design and Research Methods. He will be starting his thesis at the end of 2019, potentially researching how Personal Health Budgets in the NHS can deliver better health outcomes for people.




Dor is a physical therapy doctor, owner and manager of a privet outpatient rehabilitation center in Rehovot, Israel. He has completed the PEBHC module so far and will hopefully starting his thesis in 2019, researching the gap between post stroke patients and their physical therapist’s expectation toward therapy process.



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