Evidence Based Physical Therapy, 2nd Edition

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Teaching and learning are a constant dynamic. My dedication is to the world’s
most dynamic teacher both in the classroom and in life, my husband Mike Fetters;
to all the students and colleagues who continue to give me feedback about best
teaching, including my co-author Julie Tilson, and to my sons Seth and Zachary,
who taught me how to learn.
LF

Life is neither in the wick nor in the wax, but in the burning. My dedication is
to those who light may way in life: to my husband, Donovan Steutel, without
who’s unwavering support and guidance I’d lose my way; my daughter, Skye,
who reminds me every day that life is amazing and precious; my students who
never fail to inspire me as they kindle their own professional paths; my colleagues
who provide endless support and friendship; my co-author, Linda Fetters, who’s
guidance throughout my career has been immeasurable; and to my parents and
siblings who remind me to trust my own light and believe in myself.
JT
 Foreword

I rarely read forewords, so I will keep this one short and cut EBP are seen as essential skills in the lifelong learning now
to the chase. The last few decades have seen a revolution needed in the fast-moving world of clinical care.
in medical care, particularly in physiotherapy. Research is Physiotherapy has undergone its own revolution in the
shedding light on many old and new practices. Harnessing past few decades, emerging from its apprenticeship craft to
this research for the benefit of patients means that modern become a more scientifically focused discipline. The growth
practitioners will need new skills—evidence based practice in research has been astonishing. The Physiotherapy Evi-
(EBP)—that are complementary to the clinical skills and dence Database (PEDro) (www.pedro.org.au) now contains
patient-centeredness needed for good care. Good clinical over 37,000 randomized trials, systematic reviews, and clin-
practice now requires the three pillars shown in Chapter 1, ical practice guidelines in physiotherapy, and it continues to
Figure 1.1, of this book: (1) clinical expertise (gained by grow rapidly. Currently, the number of randomized trials in
good training plus years of experience with feedback), (2) physiotherapy doubles about every 7 years (see Chapter 7,
understanding of patient values (requiring good history- Fig. 7.1). This implies that the last 7 years have seen as many
taking skills and shared decision-making skills), and (3) trials as in all the previous history of physiotherapy. Whereas
skills in locating and appraising research literature. All three some trials merely confirm current practice as correct, some
are the subjects of this book. will overturn ideas, and others will introduce new methods
The ideas behind EBP—the empirical testing of theories and practices. This growth, challenge, and change is poten-
about treatment and diagnosis by careful study in groups tially a great blessing for patients. However, for that bless-
of patients—date back many centuries to at least the 10th ing to reach the bedside, clinicians must be highly skilled in
century and Al Razi in Persia (for those interested in learn- accessing, interpreting, and applying this wealth of research
ing more about Al Razi, Lind, Bradford-Hill, and the whole evidence.
history of clinical trials, an excellent resource is www.james- The goal of this book is to support the learning of those
lindlibrary.org). The 20th century saw a rapid development skills. This new edition has a modified and extended range
in the methods for both clinical research and connecting this of content based on observed learners’ use of the text. It now
research directly to clinical practice. A pivotal moment in includes more on clinically relevant statistics, knowledge
this long development was Gordon Guyatt’s coining of the translation, and technology to support evidence based prac-
term “evidence based medicine” for a series of articles—the tice. Additionally, the case studies are better integrated and
“user guides”—published in the Journal of the American run through several chapters.
Medical Association (JAMA) in the 1990s. The new term However, EBP must be adapted to be adopted. Although
and the JAMA series helped spark the interest of clinicians the fundamental principles are the same, the needs and con-
across countries and disciplines. Professional curricula have tents of each health-care discipline require the principles of
been slowly catching up with this revolution. Whereas some EBP to be framed and applied in ways that suit its special
educational programs still debate the need to include EBP, issues and research base. EBP looks somewhat different in
for many others, it has become the norm. The three pillars of medicine, psychiatry, nursing, and physiotherapy. This book,
 Foreword v

then, is an essential bridge to assist the application of EBP to book will help. But the most difficult part is integrating these
physiotherapy. Dr. Fetters and Dr. Tilson have done an excel- skills into your professional life and clinical care for the
lent job in describing the fundamentals of EBP and expertly real benefits to patients to be seen. I wish you well with that
adapting them to the needs of physiotherapists, using every- vital task.
day clinical examples to illustrate the processes. Using this
book will help in learning these vital skills for 21st-century Paul Glasziou
practice. But that is not enough. The methods of EBP must Professor, Centre for Research in Evidence-Based Practice
also be practiced as any skill would; the exercises in this Bond University
 Preface

We created this book as a learning tool for physical therapy evidence based practice (EBP) to physical therapy students,
students and clinicians who want to become evidence based physical therapists, and faculty. Our teaching has taken many
practitioners. It can also serve as a tool for more experienced forms, including online, classroom, and laboratory settings
physical therapists who want to continue to improve their and through institutes organized specifically for faculty who
knowledge and skills as evidence based therapists. Evidence teach EBP to physical therapists. During this process, we
Based Physical Therapy, second edition, features improved asked for and received feedback from many students and
clarity and depth of the important topics that support stu- colleagues. This feedback was critical to our new edition; the
dents and clinicians to become evidence based practitioners. book has been greatly improved as a result. We owe thanks
The textbook continues to provide a succinct, straightfor- to the anonymous reviewers who were solicited by F. A.
ward presentation of the important concepts, with updated Davis. Their thoughtful and thorough reviews were valuable
resources for further study. Assignments for students are to our process.
now included in each chapter, with separate links to online Writing a book is a lot of work over an extensive period.
resources. With this book, you can develop skills to search One sure way to complete a book is to be passionate about
the literature for the best and most applicable research for the subject and, more important, to be passionate about not
your patients and critically appraise this literature for quality just teaching the subject but also learning the subject. We are
and clinical application. We have updated chapters on the use both. In addition, it helps to have a sense of humor. In fact,
of current technology and forms of communication in order a sense of humor helps everything in life, particularly those
to support realistic practice in the busy clinical workplace. aspects that are a lot of work over an extensive period. Our
The five steps of evidence-based practice are illustrated passion for teaching and learning has always been comple-
in the chevron figure used throughout this book. These five mented by our humor, enjoyment of the content and process,
steps are: identify a question, search, appraise, integrate and and respect for and enjoyment of each other. We wish you a
evaluate. Sections of the chevron figure are used within chap- successful journey toward becoming an evidence based phys-
ters to orient the reader to the topics covered in that section ical therapist.
while reminding the reader of the place of the content in the
five steps that are used by an evidence-based practitioner. Linda Fetters
This book is the product of reflection on the first edition Julie Tilson
and comments from users and of our years of teaching
 Reviewers

Debra A. Bierwas, PT, DPT, DHSc Greg A. Koberstein, PT, DPT

Director of Clinical Education & Assistant Professor Faculty
Physical Therapy Physical Therapy Assistant Program
Midwestern University Provo College
Glendale, AZ Provo, UT
Christopher G. Bise, PT, MS, DPT, OCS Toran D. MacLeod, PT, PhD
Assistant Professor Assistant Professor
Physical Therapy Physical Therapy
University of Pittsburgh California State University
Pittsburgh, PA Sacramento, CA
Daniel Cipriani, PT, PhD Alan R. Needle, PhD, ATC, CSCS
Professor Assistant Professor
Physical Therapy Health & Exercise Science
Chapman University Appalachian State University
Irvine, CA Boone, NC
Ashraf Elazzazi, PT, PhD Evan Voy Papa, DPT, PhD
Associate Professor & Department Chair Assistant Professor
School of Health Professions and Education Physical Therapy
Physical Therapy University of North Texas Health Science Center
Utica College Fort Worth, TX
Utica, NY David A. Scalzitti, PT, PhD
Courtney D. Hall, PT, PhD Assistant Professor
Research Health Scientist/ Associate Professor Physical Therapy
Auditory Vestibular Research Enhancement Award George Washington University
Program/ Department of Physical Therapy Washington, DC
James H. Quillen VAMC/ East Tennessee State University Catherine A. Stevermer, PT, PhD, GCS
Johnson City, TN Associate Professor
Han-Hung Huang, PT, Ph.D Department of Physical Therapy
Assistant Professor Des Moines University
Physical Therapy Des Moines, IA
Angelo State University, Member, Texas Tech University Elise Townsend, PT, DPT, PhD, PCS
System Associate Professor
San Angelo, TX Department of Physical Therapy
MGH Institute of Health Professions, School of
Rehabilitation and Health Sciences
Charlestown, MA
Contents

Section I: Finding and Appraising Evidence to

Improve Patient Care, 1
Chapter 1: The Evidence Based Practice Model, 1
Introduction, 2
What Is EBP, and Why Is It Important? 2
Understanding the EBP Model, 3
Scientific Research, 3
Clinical Expertise, 5
Patient Values and Circumstances, 5
The EBP Process, 8
Step 1: Identify the Need for Information, and Develop a Focused and
Searchable Clinical Question, 8
Step 2: Conduct a Search to Find the Best Possible Research Evidence
to Answer Your Question, 8
Step 3: Critically Appraise the Research Evidence for Applicability and
Quality, 9
Step 4: Integrate the Critically Appraised Research Evidence
With Clinical Expertise and the Patient’s Values and
Circumstances, 9
Step 5: Evaluate the Effectiveness and Efficacy of Your Efforts in Steps
1–4, and Identify Ways to Improve Them in the Future, 9
Can EBP Work in the Real World? 10
Summary, 11
Chapter 2: Asking a Clinical Question and Searching for Research
Evidence, 14
Introduction, 15
How Do I Know If I Need Information? 15
Searchable Clinical Questions, 17
Research Your Clinical Question, 18
Summarized Evidence, 20
Searching for Individual Studies, 21
Using Search Engines to Find Research Evidence, 22
x Contents

Searching in PubMed, 23
Choosing and Retrieving Evidence, 26
Summary, 31
Chapter 3: Critically Appraise the Applicability and Quality of an
Intervention Research Study, 37
Introduction, 38
The Process of Study Appraisal, 38
Determining the Applicability of an Intervention Study, 38
Determining the Quality of an Intervention Study, 41
Research Notation, 47
Using Research Notation for Example Study Designs, 47
Summary, 48
Chapter 4: Critically Appraise the Results of an Intervention
Research Study, 57
Introduction, 58
Appraising Results, 58
Interpreting the Results of an Intervention Study, 58
Summarizing the Clinical Bottom Line, 68
Summary, 70

Section II: Appraising Other Types of Studies:

Beyond the Randomized Clinical Trial, 77
Chapter 5: Appraising Diagnostic Research Studies, 77
Introduction, 78
The Diagnostic Process in Physical Therapy, 78
Diagnostic Questions in the Clinic, 79
Searching the Literature: Research Designs Specific to Diagnostic
Tests, 79
The Process of Study Appraisal, 80
Determining the Applicability of a Diagnostic Study, 81
Determining the Quality of a Diagnostic Study, 81
Interpreting the Results of a Diagnostic Study, 82
Sensitivity, 83
Summarizing the Clinical Bottom Line of a Diagnostic Study, 86
Clinical Prediction Rules for Diagnosis, 88
CPR for Diagnosis and Prognosis, 89
Development of the CPR, 89
Summary, 90
Chapter 6: Appraising Prognostic Research Studies, 96
Introduction, 97
Research Designs Specific to Prognostic Studies, 97
Cohort Studies, 97
Case Control Studies, 97
Cross-Sectional Studies, 98
Determining the Applicability of a Prognostic Study, 98
Determining the Quality of a Prognostic Study, 99
Study Sample, 99
Outcome Measures and Factors Associated With These Measures, 99
Study Process, 101
Interpreting the Results of a Prognostic Study, 101
Correlation, 101
 Contents xi

Regression, 102
Simple Linear Regression, 102
Multiple Regression, 103
Logistic Regression, 103
Application of Regression Analysis, 103
Summarizing the Clinical Bottom Line of a Prognostic
Study, 103
Risk Ratio, 104
Odds Ratio, 104
Summary, 106
Chapter 7: Appraising Research Studies of Systematic
Reviews, 112
Introduction, 113
What Is a Systematic Review? 113
Systematic Reviews at the Top of the Evidence Pyramid, 113
Determining the Applicability of a Systematic Review, 117
Determining the Quality of a Systematic Review, 117
Study Sample, 118
Data Reduction and Analysis, 120
Interpreting the Results of a Systematic Review Study, 121
Interpretation of Qualitative Results, 121
Interpretation of Quantitative Results, 122
Summarizing the Clinical Bottom Line of a Systematic Review, 124
Summary, 125
Chapter 8: Appraising Clinical Practice Guidelines, 132
Introduction, 133
What Are Clinical Practice Guidelines? 133
What Search Strategies Are Best for CPGs? 133
Determining the Applicability of a CPG, 136
Determining the Quality of a CPG, 136
Stakeholder Involvement, 136
Rigor of Development, 136
Interpreting the Results of a CPG, 137
Editorial Independence, 137
Summarizing the Clinical Bottom Line of a CPG, 137
Clarity of Presentation, 138
Attention to Implementation, 138
Using Clinical Practice Guidelines in Practice, 138
Summary, 141
Chapter 9: Appraising Studies With Alternative Designs, 147
Introduction, 148
Single-Subject Research, 148
RCTs, 150
RCT With Crossover, 150
Determining the Applicability of SSR, 150
Determining the Quality of SSR, 151
Interpreting the Results of SSR, 152
Summarizing the Clinical Bottom Line of SSR, 153
Summary of SSR, 153
Qualitative Research, 153
Appraising Qualitative Research, 154
Summary, 156
xii Contents

Chapter 10: Appraising Research Studies of Outcome

Measures, 162
Introduction, 163
Types and Utility of Outcome Measures, 163
Two Types of Outcome Measures, 163
What Makes an Outcome Measure Useful in the Clinic? 166
Studies That Assess Outcome-Measure Reliability, 166
Types of Reliability and Terms Associated With Reliability
Studies, 166
Determining the Applicability of a Reliability Study, 168
Determining the Quality of a Reliability Study, 168
Interpreting the Results of a Reliability Study, 169
Summarizing the Clinical Bottom Line, 169
Studies That Assess Outcome-Measure Validity, 169
Types of Validity, 169
Determining the Applicability of a Validity Study, 171
Determining the Quality of a Validity Study, 171
Interpreting the Results of a Validity Study, 171
Summarizing the Clinical Bottom Line, 172
Studies That Assess an Outcome Measure’s Clinical
Meaningfulness, 172
Types of Clinical Meaningfulness, 172
Determining the Applicability of a Clinical Meaningfulness
Study, 176
Determining the Quality of a Clinical Meaningfulness
Study, 176
Interpreting the Results of a Clinical Meaningfulness
Study, 176
Summarizing the Clinical Bottom Line of a Clinical Meaningfulness
Study, 177
Finding Research on Outcome Measures, 177
Summary, 177

Section III: Communication and Technology for

Evidence Based Practice, 185
Chapter 11: Communicating Evidence for Best Practice, 185
Introduction, 186
Integration of Research, Clinical Expertise, and the Patients’ Values
and Circumstances, 186
Health Literacy, 186
Communication With Decision-Makers for Physical Therapy, 186
Summarizing and Storing Research Evidence for
Communication, 187
The Critically Appraised Topic, 188
Other Examples of Summaries of Evidence, 188
Summary, 190
Chapter 12: Technology and Evidence Based Practice in the Real
World, 191
Introduction, 192
A History of Technology and EBP Efforts, 192
Developing Your Technology Profile, 192
 Contents xiii

Components of an EBP Technology Profile, 192

Push and Pull Information Technology, 192
Reference Management Systems, 196
Selecting Technologies for Your Profile, 196
Summary, 198

Appendix: Appraising the Evidence Tables, 199

Glossary, 210

Index, 217
 How to Use This Book

have taught us. Over our years of teaching both separately

GOALS AND AUDIENCE
and together, we have organized our evidence based practice
(EBP) course using various sequences of the topics included
This book was created for physical therapy students and
in this book. Our students have commented on each sequence,
clinicians who want to practice evidence based physical
and we have reflected on the students’ knowledge and skills
therapy. Our goal is to provide sufficient information to
achieved through the use of each sequence. Although there is
guide the development of the necessary skills to become an
no one sequence that is “best” to teach EBP, we suggest that
independent evidence based practitioner. We recognize that,
the novice to EBP benefits from reading Section I: Finding
just like any other skill, practice is essential to effective and
and Appraising Evidence to Improve Patient Care, Chap-
efficient learning. We assume the reader is at the beginning
ters 1–4, first and in this order. These chapters provide the
of the learning process, and therefore the content of the book
basics of identifying clinical questions that can be searched
includes the necessary information to become an entry-level
effectively in the literature and the necessary search skills to
evidence based physical therapist.
find the best available research evidence (Chapters 1 and 2).
Basic appraisal skills for intervention research that can be
CONTENT combined effectively with clinical expertise and patient goals
and values are the topics of Chapters 3 and 4. Many of the
The book is divided into three sections, but chapters can be basic skills that are developed in Chapters 1–4 can then be
used independently: applied to specific topic areas found in Section II: Apprais-
ing Other Types of Studies: Beyond the Randomized Clini-
Section I: Finding and Appraising Evidence to Improve
cal Trial (Chapters 5–8). Section II includes, for example,
Patient Care
appraisal skills for the diagnostic literature (Chapter 5) and
Section II: Appraising Other Types of Studies: Beyond the
the prognostic literature (Chapter 6). But teachers and learn-
Randomized Clinical Trial
ers combine in unique ways, and this book is designed to be
Section III: Communication and Technology for Evidence
used effectively for a variety of teaching and learning styles.
Based Practice
Most chapters include “Digging Deeper” sections. These
Each chapter in our book was designed to “stand alone,” sections include material that offers depth for a topic and
such that each chapter can be assigned in any order and the may be considered either optional or required learning mate-
use of the book does not necessarily need to proceed from rial. We designed these for the learner who wants more
Chapter 1 through Chapter 12. The organization of the content information on a topic but with the view that the material
of this book does, however, reflect our teaching process. More presented in these sections may be beyond entry level. We
important, it reflects the learning process that our students also include “Self-Tests” in most chapters. These should be