EBPfisio

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Evidence-Based Physiotherapy Practice

Contact Author:
Mary Ann OBrien MSc, BHSc(PT)
School of Rehabilitation Science
McMaster University
HSC 3H7
1200 Main Street West
Hamilton
Ont L8N 3Z5
Phone (905) 525-9140 ext 22344
Email maobrien@fhs.mcaster.ca
Table of Contents
Introduction to Evidence-Based Physiotherapy Practice
Other resources for Evidence-Based Physiotherapy
Sample clinical scenarios, searches, critical appraisal worksheets and CATs for Physiotherapy
Introduction to Evidence-Based Physiotherapy Practice
Thomson-OBrien MA, Moreland J. Evidence-based Information Circle. Physiotherapy Canada
1998;50:171:205.
Evidence-Based Practice Information Circle
Mary Ann Thomson-OBrien
1,2
Julie Moreland
1,3
McMaster University
1
, Hamilton Health Sciences Corporation
2
, St. Josephs Hospital
3
Hamilton ON L8N 3Z5
Key Words: decision-making; information processing; critical appraisal
Adapted from a presentation at the Canadian Physiotherapy Association Congress, June 1996, Victoria, British Columbia.
Abstract
Physiotherapists make decisions at many points in the care of patients or clients, yet the information upon
which we base these decisions may be of variable quality. The purpose of this paper is to present a model
to integrate the activities of information processing, critical appraisal, evidence-based practice and
continuing education into clinical decision-making. The Evidence-based Practice Information Circle model
(EPIC) is constructed of concepts with a supporting framework, assumptions and theories. At the centre of
the model are the fundamental clinical actions which occur between the client and the therapist. These
clinical actions generate information needs, which elicit a circle of events leading back to clinical action.
Several clinical problems relevant to physiotherapy are given as examples to illustrate the model. EPIC
provides a framework for continuing clinical excellence in this era of health care reform. There are
implications for undergraduate training as well as continuing education endeavours.
The primary goal of physiotherapy is to provide the highest quality of care to achieve the best outcomes for
clients in a cost-effective manner. The care process involves assessment, physical diagnosis or problem
summary, identification of client-centred goals (outcomes), selection of effective therapeutic interventions
and evaluation of progress. In order to make sound decisions throughout this process, physiotherapists
require valid information.
Some information sources may be dependable such as published reports of rigorous clinical studies and
validated theoretical models. Other conventional sources of information such as personal experience,
peers, experts and even medical textbooks may be subject to bias. For example, Antman et al
1
found that
standard medical textbooks contained some information which was out of date or even incorrect.
A paradigm shift for the processing of information for medical practice has been suggested by the
Evidence-based Working Group.
2
Evidence-based medicine is founded on the examination of findings from
sound clinical research. They propose that intuition, unsystematic clinical experience, and
pathophysiological explanations be de-emphasized for the process of clinical decision-making. In a recent
publication of the Canadian Physiotherapy Association, evidence-based practice (EBP) has been identified
as a priority.
3
The implementation of evidence-based practice may require upgrading of skills or even the
acquisition of new skills. This has implications for the design of both undergraduate and continuing
education.
One preliminary skill is the ability to examine one's practice in order to identify opportunities for
improvement. These opportunities may include utilizing the best diagnostic and assessment tools, carrying
out the most effective treatment, accurately predicting the outcome of treatment, and being knowledgeable
about etiological factors for health promotion and secondary prevention.
Given that we acknowledge that valid information is required, the busy clinician is faced with a formidable
task. To obtain the required information, therapists need skills to utilize informatic tools such as
computerized data bases for searching the literature and systems for storing relevant material. The
availability of high quality information may be hampered by physical and financial access to computerized
data bases, the large volume of available literature, the lack of user friendliness of research reports and the
inconvenience of obtaining information.
4
Once studies are located, critical appraisal skills are needed to
evaluate whether the conclusions are valid and applicable to the treatment setting. The purpose of this
paper is to provide a framework and model to help clinicians integrate EBP, critical appraisal, informatics
and continuing education.
Framework
The framework for the model builds upon the following values and assumptions.
1. Using evidence derived from sound research will result in improved quality of care.
2. Evidence should be used to assist in decision-making. Other factors which contribute to decision-making
include the client's individual problem, preferences and environment.
3. Clinical experience is valuable in the many situations where there is no evidence. However, decision-
making based solely on clinical experience may be biased. Experience is also valuable for generating
research questions.
4. Professional values include the maintenance of a knowledge base which is current and based on
research. This research should use valid methods (qualitative and quantitative) for designing and
performing studies.
Model
The model
5
(see Figure 1) of interaction between EBP, critical appraisal, informatics, and continuing
education uses the following concepts and theories.
Concepts
The following definitions are used within this model.
Informatics: The science concerned with systems and tools to gather, organize, process, store, transmit,
and present information.
6
Effective information management has become important due to the information
explosion and time constraints of busy clinicians. It is ideal to have access to relevant evidence in proximity
to the patient care setting.
Evidence: Anything that establishes a fact or gives reason for believing something.
7
The strength of the
evidence is related to the methods of obtaining it. Some methods are more subject to bias than others. For
example, the evidence derived from a case series study is weaker than that derived from a randomized
controlled trial.
8
The potential for or the presence of bias in a research project calls into question the validity
of the conclusions.
Critical Appraisal: The evaluation of research papers to determine the validity and applicability of the
conclusions. Guidelines have been published to assist readers. Separate guidelines are available for
critically appraising papers on causation, diagnosis, natural history, prognosis, and treatment.
9
Guidelines
also exist for appraising literature reviews,
10
practice guidelines,
11
clinical decision analyses,
12
and
qualitative research.
13
As a result of the critical appraisal process, a reader is able to judge how much
confidence to place in the conclusions of the study and whether the results apply to their patients/clients.
Evidence-based Practice: The process of using the results of sound research (as determined by critical
appraisal) to guide clinical care within the context of the individual client and local environment.
Continuing Education: Activities to directly or indirectly improve clinical competence so that clients may
benefit from the best quality of care. The continuing education process may be traditional or informal and
done as an individual, small or large group. Traditional activities usually include attending inservices,
conferences, courses and discussions with peers. Contemporary methods include identifying and critically
appraising relevant literature, journal clubs, and small group discussions with peers targeted at specific
patient problems.
14
Practitioners may use informatics to help educate themselves about a specific patient
problem. Regardless of the method, critical appraisal of information is important to ensure that it is founded
on valid evidence or tested theories.
Theories Underlying the Model
1. The client and physiotherapist form a fiduciary relationship within several internal and external contexts.
The major external context is the health care setting. Internal contexts for the client include: economic,
cultural, and educational background, their roles in their family and society and their vocational and
avocational interests. For the physiotherapist, these contexts also include economic, cultural and
educational background, personal beliefs, and community and administrative environments.
2. The major interactions between the client and physiotherapist involve: assessment, physical diagnosis
or problem formulation, planning (including identification of important client-centred goals and outcomes,
therapy and evaluation). These interactions define the nature of the information which physiotherapists
will require. Other factors which will shape the search for information include the experience and
expertise (novice vs expert) of the physiotherapist and the degree of uncertainty about the client's
problem.
3. Identifying information needs, locating, obtaining, critically appraising, and storing relevant information
are the informatic processes which lead to evidence-based practice.
4. There are many factors which influence the adoption of relevant information into clinical practice.
Information alone may not be adequate to change practice, however, it may serve to provide an impetus
to change. Contemporary continuing education activities need to support evidence-based practice.
These theories combine to form the Evidence-based Practice Information Circle (EPIC).
The model consists of three circles. The inner circle represents the interaction between the client and the
therapist. At any point during the assessment and treatment process, the therapist may identify the need for
further information in order to provide the best possible care. A number of questions may arise about the
management of this client or a group of clients. For example, the effectiveness of different treatments may
not be known by the therapist.
Once the information needs are specified, the middle circle represents the method which is used to obtain
and process information. Traditionally, information has been located in textbooks or journals in libraries. The
science of informatics has generated other options such as online and CD-ROM searching. MEDLINE and
CINAHL databases are commonly used to obtain relevant citations. Sometimes computer searching may
lead directly to the information which has been critically appraised as in the case of computerized journal
clubs. Another example of computer accessible material is the Cochrane Library.
15
This electronic journal is
updated regularly and contains 65 systematic reviews on topics such as pregnancy and childbirth,
schizophrenia, and stroke.
Once the relevant articles have been critically appraised, the clinician must decide whether this information
is applicable to their practice. This step provides a link back to the inner circle, the client-therapist
interaction. Continuing education is a key component in the entire process since therapists may require new
knowledge and skills at any point e.g. basic computer skills, searching, and critical appraisal skills.
Traditional inservices or conferences may not be adequate to meet these needs.
The outer circle represents the contexts which may have an impact on decision-making. Economic factors
include the ability of society to fund treatment. Personal beliefs, the community and cultural environments
may influence the type of treatment that the client may find acceptable. For the clinician, the influence of
peers may be an important factor in deciding to use newly acquired information. The educational
background (both undergraduate and continuing education) of the therapist may or may not have provided
the necessary skills to implement an evidence-based approach. The administrative environment such as
workload expectations for the number of patients seen may make access to valid information sources
difficult during the work day. Conversely, administrators and colleagues may expect therapists to provide
care based on evidence.
Case Scenarios
In order to illustrate the model, two examples are provided. These are based upon actual situations
encountered in two physiotherapy departments located in teaching hospitals. A physiotherapist received a
referral for an older adult aged 78 years who was beginning to have problems moving about in her home.
The client reported feeling exhausted after climbing and descending the stairs to her basement. Subjective
and objective assessment revealed that muscle weakness was the primary problem. Before discussing
possible treatments, the physiotherapist wonders how elderly individuals respond to strengthening
exercises. The therapist identifies this as a need for information and schedules some time to go to the
library.
The search for information and the critical appraisal process are represented by the middle circle. The
therapist decided to search the CINAHL and MEDLINE databases to determine if any recent clinical trials
had been published. Three randomized controlled trials were identified. The librarian assisted the therapist
in obtaining the papers. In 1989, Hagberg et al
16
conducted a trial of lower and upper body strengthening
using Nautilus machines in adults aged 70 to 79 years. Subjects were randomized to a control group, an
endurance training group and a resisted strengthening exercise group. Training sessions were done for 26
weeks, 3 times a week. The results showed that the experimental groups improved in endurance and
strength respectively and this was statistically significant in comparison to the control group. There were no
adverse effects reported. Critical appraisal of the study using criteria suggested by Guyatt et al
17,18
identified that there were few methodological flaws in the study with the exception of a potential for bias
because of lack of blinding of the therapist performing the treatments and measuring their effectiveness.
This may have resulted in a bias in favour of the treatment groups. Despite the potential for bias, this study
provides reasonably strong evidence that muscle strength improves with resisted dynamic exercises in
older adults.
Charette et al
19
reported a randomized controlled trial with women aged 64 to 86 years in which weight
training was done for the knee and hip muscle groups for 12 weeks, 3 times a week. The control group did
not receive an exercise program. The results of the study were statistically significant in that both one
repetition maximum and type II fibre area increased. One of the subjects reported experiencing discomfort
during the exercise. Critical appraisal of the study identified that the post-treatment assessment was not
blinded and the control group did not receive a placebo intervention. These factors may have potentially
biased the outcome in favour of the treatment group. Taking this into consideration, this study provides
moderately convincing evidence that resisted dynamic exercises improve strength in older women. One of
the limitations of both studies was that none measured functional outcomes.
Topp et al
20
also performed a randomized controlled trial using a weight lift machine for adults over 65
years. The experimental group received dynamic resistance strength training three times per week for 12
weeks while the control group received a placebo intervention. There were statistically significant
differences between the two groups for isokinetic strength but not for balance or gait velocity. It was unclear
whether the sample size was large enough to detect a statistically significant difference for the last two
variables. There were no adverse effects. Critical appraisal of the study revealed that there was adequate
follow-up of participants. However, the outcome assessment was not blinded and there was potential for
contamination and co-intervention which may have biased the results. Because of these factors, it is difficult
to draw practical conclusions from this study.
As a result of this information, the therapist discussed a strengthening program with the client and
suggested that it take place three times a week for 12 weeks. The therapist also informed the client that
there was a risk that some discomfort from the exercises may occur. The therapist also decided to include
functional exercises for stair climbing, since the client had indicated that this was an important activity. The
therapist monitored the response to treatment through periodic measurements of strength and stair climbing
function. Personal, economic, cultural, and educational factors (outer circle) were taken into consideration in
implementing the treatment plan.
As the second example, a group of physiotherapists who were treating individuals with stroke identified that
they needed to measure gross motor outcomes in order to determine if the clients were improving (inner
circle). One of the physiotherapists offered to search the literature for gross motor outcome measures. As a
group, they decided to search for a measure which was reliable, valid (with longitudinal construct validity to
demonstrate change) and responsive to change. From the MEDLINE and CINAHL databases and
discussions with colleagues, seven assessments were identified and a table was developed (Table 1). As a
result, the physiotherapists selected the instrument
21
which best met their inclusion criteria (middle circle).
They incorporated this instrument into their practice as a valid and feasible (outer circle) way of measuring
treatment outcomes.
Table 1 Summary of Gross Motor Assessments
Measure Content
Validity
Test-retest Reliability
(ICC or Kappa > .80)
Construct/Criterion
Longitudinal Validity
Responsiveness
Chedoke-McMaster
Gross Motor
Function and
Walking (GMF)
Inventory
21
Yes Yes, rehab unit stroke
patients
Yes, rehab unit stroke
patients
Yes, rehab unit
stroke patients
Motor Assessment
Scale (MAS)
22
Not
reported
Yes, patients who had
reached a plateau,
patients were > 5
months post-stroke
Yes, rehab unit stroke
patients
Not reported
Clinical Outcome
Variables Scale
23
Not
reported
Yes, rehab unit
patients, 5 patient
programs
Not reported Not reported
Modified Chart for
Motor Capacity
Assessment
24
Not
reported
Not reported Not reported Not reported
Functional Mobility
Assessment Tool
25
Yes,
professional
consensus
Rivermead Stroke
Assessment
26
Not
reported
Not reported, Pearson
cor. of .66 for gross
motor function
Not reported Not reported
Ashburn Physical
Assessment for
Stroke Patients
27
Not
reported
Discussion
Two of the major assumptions of the framework is that high quality evidence exists and that evidence-based
practice improves quality of care. In many areas of physiotherapy, evidence does not exist. Many of the
orthopaedic joint mobilization techniques have not been evaluated. Since mobilizations are dependent upon
individual patient findings, they are difficult to study using traditional group designs. N of 1 studies may be
helpful in this area. Some authors suggest that grey areas of practice where evidence is incomplete or
conflicting will always exist.
28,29
Other barriers to incorporating evidence into practice may include problems with the research methods and
applicability of the studies. Examples of problems with the study methods include failure of the
randomization process and loss of patients to follow-up. For example, Inaba et al
30
studied progressive
resisted exercises in patients undergoing rehabilitation following a stroke. The results were positive at one
month; however, at two months, the results were not significant. Since 56% of the patients were not
available for testing, this loss to follow-up may have resulted in a systematic bias which may have
strengthened or weakened the conclusion. The reader cannot tell if patients were not available because
they were worse off or because they improved. This presents the clinician with a dilemma. In light of
insufficient evidence, the clinician may need to rely on the following sources of information in decreasing
order of rigour: substantiated theory, unsubstantiated theory, expert opinion, and clinical experience. In
these cases, it is paramount for clinicians to objectively document their treatments and outcomes. This type
of documentation provides a clear indication of the client's response to treatment and these data may
suggest research questions.
Another problem may be the limited applicability of the findings. For example, the sample may be very
narrowly defined. Przybylski et al
31
found that decreasing the ratios of nursing home residents to
physiotherapists from 200:1 to 50:1 resulted in improved function. Generalization of this finding to patients
on maintenance programs in acute hospitals would be questionable if the patients in nursing homes are
substantially different from those in acute hospitals.
The implementation of evidenced-based practice has not been evaluated in physiotherapy. It is not clear
that using evidence to make decisions will result in improved quality of care for patients although this is a
logical assumption. Practice guidelines which are systematically developed approaches to guide clinicians
and clients health care choices for specific problems have been studied in physicians. Grimshaw and
Russell
32
conducted a systematic review of the effect of clinical guidelines on medical practice. They
reported that 55 of 59 studies detected significant improvements in the process of care while nine of 11
studies demonstrated significant improvement in patient outcomes. Browman et al 1995
33
have provided a
framework to assist clinicians to develop guidelines based on evidence from clinical studies.
It may not be reasonable to expect the busy clinician to have the skills or time necessary to search, obtain,
and critically appraise relevant articles. What processes would assist us to use evidence as a basis for our
practice? The availability of systematic research reviews and meta-analyses, evidence-based practice
guidelines, journal clubs in which members critically appraise papers or topics may facilitate this process.
There may be a place for consensus conferences in the development of practice guidelines but unless they
are based on evidence, they may be biased. Further, consensus conferences have been ineffective in
changing the practice of physicians.
34
Newer technologies such as electronic textbooks, reference
management software and clinical informatics networks may prove useful. Perhaps the most promising
method of implementing evidence-based practice is to assist undergraduate students to acquire skills as
information consumers. Obviously, there would be a lengthy lead-in time before a sufficient number of
physiotherapists graduate and percolate into the health care system. Other promising methods include
better linkage between academic programs in physiotherapy and the clinical communities.
Conclusion
Physiotherapists face a great challenge in trying to integrate sound research findings into their clinical
practice. Barriers include the amount of new information, as well as a lack of skills in accessing and
appraising relevant studies. The EPIC Model provides a framework for continuing clinical excellence by
linking clinical decision-making and relevant research. Future directions include exploring the relationship
between implementation of evidence-based practice and quality of care. In addition, we need to develop
strategies to cope with situations where evidence does not exist or is conflicting. Those responsible for
undergraduate curriculum development and continuing education endeavours have a key role in facilitating
the process of implementing valid research findings in clinical practice.
References
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control trials and recommendations of clinical experts: treatments for myocardial infarction. JAMA 1992:268:240-248.
2 Evidence Based Medicine Working Group. Evidence Based Medicine: a new approach to teaching the practice of
medicine. JAMA. 1992:268:2420-2425.
3 Contact, Official Newsletter of the Canadian Physiotherapy Association. 1995:December 1994/January:2.
4 Bohannon RW, LeVeau BF. Clinicians' use of research findings: a review of literature with implications for physical
therapists. Phys Ther 1986:66:45-50.
5 Moreland J, Thomson MA. The relationship of evidence-based practice, critical appraisal of the literature, and CLINT.
unpublished. School of Occupational Therapy and Physiotherapy, McMaster University, December 1994.
6 Van Nostrant/Reinholt Dictionary of Information Technology, Third Edition 1989.
7 The Oxford Paperback Dictionary, Oxford University Press, Oxford 1979.
8 Sackett DL. Rules of evidence and clinical recommendations on the use of antithrombotic agents. Chest 1992:102:305S-
311S
9 Oxman AD, Sackett DL, Guyatt GH, et al. Users' guides to the medical literature. How to get started. JAMA
1993:270:2093-2095.
10 Oxman AD, Cook DJ, Guyatt GH. Users' guides to the medical literature. VI. How to use an overview. JAMA
1994:272:1367-71.
11 Hayward RS, Wilson MC, Tunis SR, Bass EB, Guyatt G. Users' guides to the medical literature. VIII. How to use clinical
practice guidelines. A Are the recommendations valid? JAMA 1995:274:570-4.
12 Richardson WS, Detsky AS. Users' guides to the medical literature. VII How to use a clinical decision analysis. A Are the
results of the study valid? JAMA 1995:273:1292-5.
13 Morse JM. Evaluating qualitative research. Qualitative Health Research. 1991:1:283-286.
14 Evidence-Based Care Resource Group. Evidence-based care: improving performance: how can we improve the way we
manage this problem. Can Med Assoc J 1994:150:1793-1796.
15 Cochrane Library, BMJ Publishing Group and Update Software, London, England, 1995.
16 Hagberg JM, Graves JE, Limacher M, et al. Cardiovascular responses of 70-to 79-yr-old men and women to exercise
training. J Appl Physiol 1989:66:2589-2594.
17 Guyatt GH, Sackett DL, Cook DJ, et al. Users' guides to the medical literature. II. how to use an article about therapy or
prevention. A. Are the results of the study valid? JAMA 1993:270:2598-2601.
18 Guyatt GH, Sackett DL, Cook DJ, et al. Users' guides to the medical literature. II. how to use an article about therapy or
prevention. B. What were the results and will they help me in caring for my patients? JAMA 1994:271:59-63.
19 Charette SL, McEvoy L, Pyka G, et al. Muscle hypertrophy response to resistance training in older women. J Appl
Physiol. 1991:70:1912-1916.
20 Topp R, Michesky A, Wigglesworth J, et al. The effect of a 12-week dynamic resistance strength training program on gait
velocity and balance of older adults. The Gerontologist 1993:33:501-506.
21 Gowland C, Stratford P, Ward M, et al. Measuring physical impairment and disability with the Chedoke-McMaster Stroke
Assessment. Stroke 1993:24:58-63.
22 Carr JH, Shepherd RB, Nordholm L, Lynne D. Investigation of a new motor assessment scale for stroke patients.
Physical Therapy 1985:65:175-180.
23 Poole JL, Whitney SL. Motor assessment scale for stroke patients: concurrent validity and interrater reliability. Arch Phys
Med Rehabil 1988:69:195-197.
24 Seaby L, Torrance G. Reliability of a physiotherapy functional assessment used in a rehabilitation setting.
Physiotherapy Canada 1989:41:264-271.
25 Badke MB, DiFabio RP, Leonard E et al. Reliability of a functional mobility assessment tool with application to
neurologically impaired patients: a preliminary report. Physiother Can 1993:45:15-20.
26 Lincoln N, Leadbitter D. Assessment of motor function in stroke patients. Physiotherapy 1979:65:48-51.
27 Ashburn A. A physical assessment for stroke patients. Physiotherapy 1982:68:109-113.
28 Naylor CD. Grey zones of clinical practice: some limits to evidence-based medicine. The Lancet 1995:345:840-842.
29 Rees J. Where medical science and human behaviour meet. BMJ 1995:310:850-853.
30 Inaba M, Edberg E, Montgomery J, et al. Effectiveness of functional training, active exercise and resistive exercise for
patients with hemiplegia. Phys Ther 1973:53:28-30.
31 Przybylski B, See D, Watkins M. A study of the outcomes of enhanced physical therapy and occupational therapy hours
of service to long term care residents in a nursing home setting. A project submitted to the Long Term Care Branch,
Alberta Health, Sept. 1993, Alberta, Canada.
32. Grimshaw J, Russell I. The effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations.
Lancet.1993:342:1317-22.
33. Browman GP, Levine MN, Mohide EA, Hayward RSA, Pritchard KI, Gafni A, Laupacis A. The practice guidelines
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effect of a consensus statement on the practice of physicians. N Engl J Med 1989:321:1306-11.
Other sources of Evidence-Based Physiotherapy
Cochrane Rehabilitation and Related Therapies Field
Contact Dr. Henrica (Riekie) de Vet
Department of Epidemiology
University of Limburg
Email: hcw.devet@epid.rulimburg.nl
Orthopaedic Division Review
Orthopaedic Division of the Canadian Physiotherapy Association
September/October 1998 Issue
Evidence-Based Practice
Email: aberk@sumhab.com
Note: The entire issue was devoted to different aspects of evidence-based physiotherapy practice in
orthopaedics including selecting the best clinical diagnostic tests and measurement of functional status,
progress, and outcome.
Sample scenarios, searches, completed worksheets and CATs for Physiotherapy
A. Diagnosis
Section Authors:
Anita Gross, Ted Haines, Diane Hartley.
Contact Details: Anita Gross fax (905) 521-5090
Clinical Scenario
A 24 year old woman with a gradual onset of left temporomandibular joint (TMJ) pain after yawning 10 days
ago, reports severe worsening over the past 5 days resulting in a change to a soft diet. Her past history
reveals recurrent episodes of jaw joint locking. Clinical findings are reduced mouth opening (maximum
active opening 35mm, passive opening 36 mm), right laterotrusion (5mm) and a reproducible reciprocal
click (early on opening and late on closing). There is no crepitus. Some local muscle tenderness exists
(masseter, medial pterygoid). There is reduced joint play. Tomography results in the medical record
demonstrated diminished anterior translation of both condyles. No osseous changes were noted. The
clinical impression is internal derangement. You wonder if your diagnosis is correct, so you develop the
following question and make plans to search MEDLINE:
Is your clinical impression of temporomandibular joint disorder (internal derangement) correct for your
patient with the following clinical [history of locking, preauricular pain, reproducible and reciprocal click, local
muscle tenderness, reduced joint play, reduced mouth opening (35 mm)] plus tomography findings
(diminished anterior translation of both condyles, no osseous changes)? Is this diagnostic impression
important for clinical management?
You do a MEDLINE search (1988 - 1998) using the MESH heading temporomandibular joint disorders and
find one article assessing a cluster of clinical tests and tomography:
Citation
Schiffman EL, Anderson GC, Fricton JR, Burton K, Schellhas KP. Diagnostic criteria for intrarticular
temporomandibular disorders. Community Dent Oral Epidemiol 1989;17:252-257.
Read this article and decide:
1. Is the evidence from this study valid for the clinical diagnosis?
2. If valid, is this evidence important?
3. If valid and important, and if your patient was shown to have internal derangement can you apply this
evidence in caring for your patient?
DIAGNOSTIC WORKSHEET
Citation:
temporomandibular disorders. Community Dent Oral Epidemiol 1989; 17:252-257.
Are the results of this diagnostic study valid?
Schiffman et al 1989
1. Was there an independent, blind
comparison with a reference (gold)
standard of diagnosis?
A blind comparison was made. However, it
is not clear if the reference test
(arthrotomography) was performed
independent of the clinical tests.
The validity of the reference standard is
not specified. No convincing evidence was
provided in the article to support that this
test is the best reference or gold standard.
There is some evidence that MRI is the best
reference standard.
2. Was the diagnostic test evaluated in
an appropriate spectrum of patients
(like those in whom it would be used in
practice)?
A representative mix of cases appears to be
present.
3. Was the reference standard applied
regardless of the diagnostic test
result?
Yes
Are the valid results of this diagnostic study important?
YOUR CALCULATIONS:
Study Setting: tertiary care
Target disorder: internal derangement
Reference standard: arthrotomography
Diagnostic test: diagnostic criteria for intraarticular TM disorder (Table 3 of the paper) included positive
history of mandibular limitation, no reciprocal click, no coarse crepitus, maximum opening less than or equal
to 35 mm, passive opening stretch less than 40 mm, contralateral movement less than 7 mm, no S-curve
deviation and tomography findings of decreased translation of the ipsilateral condyle.
Internal Derangement of TMJ
Present Absent
Positive 43 a b 2 a+b Diagnostic
Criteria
(Sample A)
Negative 7 c d 8 c+d
Totals 50 a+c b+d 10 a+b+c+d
Schiffman et al 1989
(Sample A)
Sensitivity
*
= a/(a+c) 0.86
Specificity
*
= d/(b+d) 0.80
Likelihood ratio for a positive test = LR+ = sens/(1-
spec)
4.30
Likelihood Ratio for a negative test = LR- = (1-
sens)/spec
0.18
Positive Predictive Value = a/(a+b) 0.96
Pre-test Probability (prevalence) = (a+c)/(a+b+c+d) 0.83 0.50 0.20
Pre-test odds = prevalence/(1-prevalence) 4.88 1.00 0.25
Post-test odds (+ test) = Pre-test odds x LR+ 20.99 4.3 1.08
Post-test odds (- test) = Pre-test odds x LR- 0.86 0.18 0.05
Post-test Probability (+ test)
= Post-test odds/(post-test odds +1)
0.95 0.81 0.52
Post-test Probability (- test)
= Post-test odds/(post-test odds +1)
0.46 0.15 0.05
* Sensitivity and specificity are reported in the text and the marginal total for a+c and b+d were reported in table 2. No
further data were available to allow for extraction of the 2x2 table (cells a, b, c, d). The highlighted segments of the above
table reflect the Schiffman et al 1989 sample A results. To assist the reader in applying these clinical findings, the
additional calculations present calculations for a low (e.g. 0.20) and intermediate (e.g. 0.50) pre-test probability /
prevalence.
Can you apply this valid, important evidence about a diagnostic test in caring for your patient?
Is the diagnostic test available,
affordable, accurate, and precise in
your setting?
Yes. History, clinical evaluation and
tomography are commonly available,
affordable, done accurately (the imaging
protocol would need to be determined per
site) and precisely in our community.
Can you generate a clinically
sensible estimate of your patients
pre-test probability (from practice
data, from personal experience, from
the report itself, or from clinical
speculation)?
This is dependent on the readers data
management system available in the practice
setting. The prevalence in the study sample
was 0.83.
Will the resulting post-test
probabilities affect your management
and help your patient? (Could it move
you across a test-treatment
threshold? Would your patient be a
willing partner in carrying it out?)
Yes. If the pretest probability is a toss-up (e.g.
0.50) the post-test probability for positive test
results firms up to 81%. However, if the
pretest probability is low (e.g. 0.20), neither a
positive nor a negative test result brings the
post-test probability into a range where
intervention would likely change (0.05, 0.52
respectively). Similarly, for the high pretest
probability (e.g. 0.83, as in Schiffman et al
1989) a negative test result does not exclude
internal derangement (post-test probability =
0.46) and a positive result further confirms
your previous strong clinical impression. The
tests are of minimal risk to the patient and
therefore one should be willing to carry them
out.
Would the consequences of the test
help your patient?
Marginally to definitely Yes depending on the
prevalence of ID in your practice setting. The
treatment for internal derangement differs to
some extent in physiotherapy management
from other TMD. It would be more informative
if the LR+ for each subgroup (for example:
internal derangement with reduction and
without reduction) were reported.
Comments and Additional Notes:
1. In Schiffman et al 1989, the assumption is made that there were no missing data. Table 4 notes that
10% of the normals of sample A and 27% with the disorder were not classifiable. This is contrary to table
2 where the sample number are noted to be as follows: target disorder present n = 50, target disorder
absent n =10.
2. see also Schiffman E, Haley D. Sensitivity and specificity of diagnostic criteria for temporomandibular
internal derangements. J Dent Res 1994;73(1 NSI):440.
TEMPOROMANDIBULAR JOINT DISORDERS: CLINICAL EXAM MAY BE HELPFUL IN THE
DIAGNOSIS
Clinical Bottom Line: If the pre-test probability is intermediate (e.g. 50%), the post-test probability for
positive test results increases to 81%. The validity of the reference standard was not specified in the article;
there is evidence that MRI may be the best reference standard.
Citation:
temporomandibular disorders. Community Dent Oral Epidemiol 1989; 17:252-257
Clinical question:
Is your clinical diagnosis of: internal derangement correct when presented with a patient with the following
clinical [history of locking, preauricular pain, reproducible and reciprocal click, reduced mouth opening (35
mm), local muscle tenderness, reduced joint play] and tomography findings (diminished anterior translation
of both condyles, no osseous changes)?
Search terms:
You do a MEDLINE search (1988 - 1998) using the MESH heading temporomandibular joint disorders you
find one article assessing a cluster of clinical tests and tomography.
The Study:
1. Gold Standard A reference test (arthrotomography) was used. A blind comparison was made. However,
it was not clear if the reference test was performed independently of the clinical tests. The validity of the
reference standard was not specified.
2. Study Setting - tertiary care
3. The Evidence
Diagnostic
Criteria
Internal
Derangement
No Internal
Derangement
Likelihood Ratio
Present 43/50 2/10 4.30
Absent 7/50 8/10 0.18
50 10
If the pre-test probability is intermediate (e.g. 50%) then a positive clinical test would be helpful, yielding a
post-test probability of 81%.
If the pre-test probability is low (e.g. 20 %) then the clinical test is not useful (post-test probability = 52%).
Comments
1. Diagnostic test: diagnostic criteria for intraarticular TM disorder (Table 3 of the paper) included positive
history of mandibular limitation, no reciprocal click, no coarse crepitus, maximum opening less than or
equal to 35 mm, passive opening stretch less than 40 mm, contralateral movement less than 7 mm, no
S-curve deviation and tomography findings of decreased translation of the ipsilateral condyle.
2. Uncertain if the reference standard that was used was the best available
3. Unclear if the reference standard performed independently of the clinical tests
Appraised by: Anita Gross; February 16, 1999. Expiry date: 2001
B. Prognosis
Section Authors: Bert Chesworth, Mary Ann O'Brien
Clinical Scenario
You are a newly graduated physiotherapist working in an out-patient clinic. Your client, a 22 year old male
university student, had an open surgical repair of his torn left anterior cruciate ligament 8 weeks ago. In
your discussion of treatment goals, he tells you he hopes to be able to return to intramural basketball. You
decide that you need more information so you plan to search MEDLINE on-line at the end of the day. Prior
to searching, you form the following question: In people who have had an open surgical repair to the
anterior cruciate ligament, what are the chances of returning to strenuous sport?
Search Terms
Knee injuries (MeSH), anterior cruciate ligament repair (text word) combined with randomized controlled
trials (MeSH), random allocation (MeSH) searched from 1988-1998
Citation
Andersson C, Gillquist J. Treatment of acute isolated and combined ruptures of the anterior cruciate
ligament. Am J Sport Med 1992;20:7-12.
1. Is the evidence about prognosis valid?
2. Is this valid evidence about prognosis important?
3. Can you apply this valid and important evidence about prognosis in caring for your client?
PROGNOSIS WORKSHEET: page 1 of 2
Are the results of this prognosis study valid?
1. Was a defined, representative
sample of patients assembled at a
common (usually early) point in the
course of their disease?
Yes
2. Was patient follow-up sufficiently
long and complete?
Yes up to 52 months
3. Were objective outcome criteria
applied in a blind fashion?
No
4. If subgroups with different
prognoses are identified, was there
adjustment for important prognostic
factors?
Looked at patients with isolated
anterior cruciate injuries as well
as those with combined injuries
e.g. meniscal tears
5. Was there validation in an
independent group (test-set) of
patients?
No
PROGNOSIS WORKSHEET: page 2 of 2
Are the valid results of this prognosis study important?
1. How likely are the outcomes over
time?
13/23 (57%) at a mean follow-up
time of 52 months
2. How precise are the prognostic
estimates?
95% confidence interval: 37% to
77%
If you want to calculate a Confidence Interval around the measure of Prognosis:
Clinical Measure Standard Error (SE) Typical calculation of CI
Proportion (as in the rate of
some prognostic event, etc)
where:
the number of patients = n
the proportion of these
patients who experience
the event = p
{p x (1-p) / n}
where p is proportion and n
is number of patients
If p = 13/23 = 0.57 (or 57%)
& n=23
SE= {0.57 x (1-0.57) / 23}
= 0.103 (or 10.3%)
95% CI is 57% +/- 1.96 x
10.3% or 36.8% to 77%
Can you apply this valid, important evidence about prognosis in caring
for your patient?
1. Were the study patients similar to
your own?
Not Clear
2. Will this evidence make a clinically
important impact on your
conclusions about what to offer or
tell your patient?
This evidence will provide long
term guidance but isnt helpful in
the short term.
Additional Notes:
OPEN ACL REPAIR: CHANCE OF RETURNING TO SPORT AFTER SURGERY
Clinical Bottom Line
57% (95% CI 37 to 77%) chance of returning to sport 4 years after surgical repair of an isolated tear of the
anterior cruciate
Citation:
Clinical question:
In people who have had an open surgical repair to the anterior cruciate ligament, what are the chances of
returning to strenuous sport?
Search Terms
Knee injuries (MeSH), anterior cruciate ligament repair (text word) combined with randomised controlled
trials (MeSH), random allocation (MeSH) searched from 1988-1998
The Study
107 patients with acute knee injury examined by arthroscopy under anaesthesia. There were four groups:
Group A included 24 patients with an isolated ACL tear that was repaired and augmented surgically. Group
B included 31 patients with an isolated ACL tear that was not repaired. Group C included 24 patients who
had an ACL tear combined with an MCL tear and both were repaired. Group D consisted of 28 patients with
both ACL and MCL tears where only the MCL was repaired.
The Evidence
The Outcome: return to sport
Well-defined sample at uniform (early) stage of illness..?, yes; Follow-up long enough..?, yes; Follow-up
complete..?, yes; Blind and objective outcome criteria..?, no; Adjustment for other prognostic factors..?, no;
Validation in an independent "test-set" of patients..?, no
THE EVIDENCE: (FOR GROUP A)
Prognostic Factor Outcome Time Measure Confidence
Interval
Isolated injury Return
to sport
52
months
57% 37% to 77%
Combined injury Return
to sport
52
months
50% 29% to 71%
Comments:
1. Potentially important prognostic factors were not adjusted for.
2. Outcome assessment was not blind.
3. Allocation to groups was by alternation.
4. The patients had surgery between 1980-1985 in Sweden. Given the dates of surgery and surgical
technique, it is unclear if the results would be applicable to current standards of practice.
Appraised by Chesworth and OBrien 1999; Expiry date: 2001
C. Therapy
Section Author: Jean Crowe, Mary Ann O'Brien
Email: crowej@fhs.mcmaster.ca
Clinical Scenario
You have recently started working as a physiotherapist on a post-surgical unit. The unit is very busy and
you are the only physiotherapist. You are wondering whether you should provide prophylactic physiotherapy
for all patients undergoing upper abdominal surgical procedures. You decide to visit the hospital librarian to
plan a search for up to date information. Your questions is: Is prophylactic physiotherapy for patients
undergoing upper abdominal surgery effective in preventing post-operative pulmonary complications?
Search Terms: physical therapy (MeSH), postoperative pulmonary complications (textword) were used to
search the current MEDLINE file. You located the following article:
Citation:
Fagevik Olsen M, Hahn I, Nordgren S, Lonroth H, Lundholm K. Randomized controlled trial of prophylactic
chest physiotherapy in major abdominal surgery. British Journal of Surgery 1997;84:1535-1538.
1. Is the evidence from this randomised trial valid?
2. If valid, is this evidence important?
3. If valid and important, can you apply this evidence in caring for your patient?
SAMPLE COMPLETED THERAPY WORKSHEET: page 1 of 2
Citation: Fagevik Olsen M, Hahn I, Nordgren S, Lonroth H, Lundholm K. Randomized controlled trial of
prophylactic chest physiotherapy in major abdominal surgery. British Journal of Surgery 1997;84:1535-
1538.
Are the results of this single preventive or therapeutic trial valid?
Was the assignment of patients to
treatments randomised?
-and was the randomisation list
concealed?
Yes
No
Were all patients who entered the trial
accounted for at its conclusion? -and
were they analysed in the groups to
which they were randomised?
Yes (control 192/194; experimental
172/174)
No
Were patients and clinicians kept blind
to which treatment was being received?
Not possible to blind patients.
Outcome assessors were not blind.
Aside from the experimental treatment,
Were the groups treated equally?
Yes
Were the groups similar at the start of the
trial?
Yes
Are the valid results of this randomised trial important?
YOUR CALCULATIONS:
Post-operative Pulmonary
Complications (all
patients)
Relative Risk
Reduction
RRR
Absolute Risk
Reduction
ARR
Number
Needed to
Treat
NNT
CER EER CER - EER
CER
CER - EER 1/ARR
0.27 0.06
79%
52% to 100%
21%
14% to 29%
5
(4-8)
YOUR CALCULATIONS:
Post-operative Pulmonary
Complications (high risk
patients)
Relative Risk
Reduction
RRR
Absolute Risk
Reduction
ARR
Number
Needed to
Treat
NNT
CER EER CER - EER
CER
CER - EER 1/ARR
0.51 0.15
71%
33% to 100%
36%
17% to 56%
3
(2-6)
SAMPLE THERAPY WORKSHEET: page 2 of 2
Can you apply this valid, important evidence about therapy in caring for your patient?
Do these results apply to your
patient?
Is your patient so different from
those in the trial that its results
cant help you?
Similar
How great would the potential
benefit of therapy actually be
for your individual patient?
Similar
Method I: f Risk of the outcome in your patient, relative to
patients in the trial. Expressed as a decimal: 1
NNT/F = _5__/__1__ = ____5__
(NNT for patients like yours)
Method II: 1 / (PEER x RRR) Your patients expected event rate if they
received the control treatment: PEER:______
1 / (PEER x RRR) = 1/________ = _______
(NNT for patients like yours)
Are your patients values and preferences satisfied by the regimen and its
consequences?
Do your patient and you have
a clear assessment of their
values and preferences?
Needs to be addressed in each patient
Are they met by this regimen
and its consequences? Needs to be addressed in each patient
Additional Notes:
1. Need to know the post-operative pulmonary complication rate for my unit.
UPPER ABDOMINAL SURGERY - PERIOP PHYSIO DECREASES POSTOP PULMONARY
COMPLICATIONS
Clinical Bottom Line:
Perioperative physio decreases post-op pulmonary complications in patients undergoing upper abdominal
surgery (NNT=5).
Citation:
Fagevik Olsen M, Hahn I, Nordgren S, Lonroth H, Lundholm K. Randomized controlled trial of prophylactic
chest physiotherapy in major abdominal surgery. British Journal of Surgery 1997;84:1535-1538.
Clinical Question
Is prophylactic physiotherapy for patients undergoing upper abdominal surgery effective in preventing post-
operative pulmonary complications?
Search Terms: physical therapy (MeSH), postoperative pulmonary complications (textword) were used to
search the current MEDLINE file. You located the following article:
The Study:
Non-blinded non-randomised trial without intention-to-treat.
The Study Patients: Series of 368 consecutive patients aged 19-92 (mean 53.4 years) undergoing elective
open abdominal surgery in Goteborg, Sweden. The baseline characteristics (sex, age, height, weight,
smoking status, existing lung disease, high risk status, and American Society of Anesthesiologists score)
were similar in both groups. The study design was described as randomized but used alternation by month.
Control group (N = 194; 192 analysed): Patients did not receive any information or training
Experimental group (N = 174; 172 analysed): Patients were seen the day before surgery and post
operatively and given information and training. The training consisted of pursed lip breathing exercises,
huffing, and coughing to be done hourly as well as information about positioning changes while in bed and
early mobilization. High risk patients received positive respiratory pressure (PEP) masks. Patients were told
to take 30 deep breaths with huffing and coughing after every 10th breath every hour during the daytime
after the surgery. The duration of physiotherapy was 10-15 minutes prior to surgery and 15-20 minutes after
the operation.
The Evidence:
Outcome Time to
Outcome
CER EER RRR ARR NNT
Post-operative
pulmonary
complication
PPC(all
patients)
1-6 days 27% 6% 79% 21% 5
95% Confidence
Intervals:
52% to
100%
14% to
29%
4 to 8
PPC (high risk
patients)
1-6 days 51% 15% 71% 36% 3
95% Confidence
Intervals:
33% to
100%
17% to
56%
2 to 6
Pneumonia (all
patients)
1-6 days 6.8% 6% 91% 6% 17
95% Confidence
Intervals:
36% to
100%
3% to
10%
11 to 41
Comments:
1. The limitations of the study were lack of true randomisation (alternation by month was used) and lack of
blind outcome assessment.
2. A post-operative pulmonary complication was defined as oxygen saturation less than 92% OR two of the
following three criteria: temperature greater than 38.2 degrees C, auscultation findings and x-ray
changes.
Appraised by: Jean Crowe, Mary Ann O'Brien; January 1999, Update By: January 2001.
D. Systematic Reviews
Section Author: Mary Ann O'Brien
Email: maobrien@fhs.mcmaster.ca
Clinical scenario
You receive a referral for a 65-year-old woman with a diagnosis of chronic obstructive pulmonary disease
(COPD). She tells you that her main problems are breathlessness, fatigue, and general weakness. She
feels her quality of life has been getting worse because she is too tired to leave the house and visit friends
and family. A friend has been to an in-patient exercise program in the hospital and she wonders if this type
of program would help her. Together you formulate a question: In a patient with chronic obstructive
pulmonary disease, does an in-patient pulmonary rehabilitation program improve strength, endurance, and
quality of life?
You search MEDLINE using the terms pulmonary rehabilitation and chronic obstructive airways disease
and find a promising systematic review.
LacasseY, Wong E, Guyatt GH, King D, Cook DJ, Goldstein RS. Meta-analysis of respiratory rehabilitation
in chronic obstructive pulmonary disease. Lancet 1996;348:1115-9.
Read the systematic review and decide,
1. Is the evidence from this systematic review valid?
2. Is this valid evidence from this systematic review important?
3. Can you apply this valid and important evidence from this systematic review in caring for your patient?
SYSTEMATIC REVIEW (of Therapy) WORKSHEET: page 1 of 2
Citation:
Are the results of this systematic review (systematic review) of therapy
valid?
Is it a systematic review of
randomised trials of the treatment
youre interested in?
YES
Does it include a methods section
that describes:
YES
Finding and including all the
relevant trials?
Assessing their individual
validity?
YES
Were the results consistent from
study to study?
Consistent results for health
related quality of life (dyspnoea,
and control over CAL). Functional
exercise capacity results showed
heterogeneity that could not be
explained by sensitivity analysis.
SYSTEMATIC REVIEW (of Therapy) WORKSHEET: page 2 of 2
Are the valid results of this systematic review important?
Can you apply this valid, important evidence from a systematic review in caring
for your patient?
Do these results apply to your patient?
Is your patient so different from those in
the systematic review that its results cant
help you?
No
How great would the potential benefit of
therapy actually be for your individual
patient?
Method I: In the table on page 1, find the
intersection of the closest odds ratio from
the overview and the CER that is closest
to your patients expected event rate if
they received the control treatment
(PEER):
In the systematic review, the
authors report the minimum
clinically important difference
(MCID). This was defined, as the
smallest difference perceived by
the average patient.
Method II: To calculate the NNT for any
OR and PEER:
___1 - {PEER x (1 - OR)}____
NNT = (1 - PEER) x PEER x (1 - OR)
Are your patients values and preferences satisfied by the regimen and its
consequences?
Do your patient and you have a clear
assessment of their values and
preferences?
YES
Are they met by this regimen and its
consequences?
YES
Should you believe apparent qualitative differences in the efficacy of
therapy in some subgroups of patients? Only if you can say yes to all
of the following:
1. Do they really make biologic and clinical sense?
2. Is the qualitative difference both clinically (beneficial for some but useless
or harmful for others) and statistically significant?
3. Was this difference hypothesised before the study began (rather than the
product of dredging the data), and has it been confirmed in other, independent
studies?
4. Was this one of just a few subgroup analyses carried out in this study?
Additional Notes:
COPD - RESPIRATORY REHABILITATION RELIEVES DYSPNEA
Clinical bottom line
Respiratory rehabilitation that includes at least 4 weeks of exercise training relieves dyspnoea and improves
control over COPD
Citation
Clinical Question
In a patient with COPD, does an in-patient pulmonary rehabilitation program improve strength, endurance,
and quality of life?
Search terms
You search MEDLINE using the terms pulmonary rehabilitation and chronic obstructive lung disease and
find a promising systematic review.
The study
Systematic review of 14 RCTs of respiratory rehabilitation programs. The respiratory program for patients
with a diagnosis of COPD, had to have been compared with conventional community care or other
interventions that were unlikely to affect exercise capacity or quality of life.
The evidence
Significant improvements were found for maximum exercise capacity, functional exercise capacity, and
health related quality of life (HRQL). The pooled effect size for maximum exercise capacity was 0.3 SD
units (0.1 to 0.6) and corresponded to 8.3 watts (2.8 to 16.5) on a cycle ergometer test. For functional
exercise capacity, the pooled effect size was 0.6 SD units (0.3 to 1.0) corresponding to 55.7 meters (27.8 to
92.8) on a six minute walk test. For two aspects of HRQL (dyspnoea and mastery), the overall treatment
effect was larger than the minimal important clinical difference, 1.0 (0.6 to 1.5) and 0.8 (0.5 to 1.2)
respectively. The results for functional exercise capacity showed heterogeneity unexplained by sensitivity
analysis.
Comments
1. Patients with multiple health problems were excluded from the trials. The most common exclusion
criteria were ischaemic heart disease, heart failure, intermittent claudication, disabling musculoskeletal
problems, and at home oxygen use.
Appraiser
Mary Ann O'Brien
Expiry date January 2001

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Evidence-Based Physiotherapy Practice

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