Evidence BasedPhysical Therapy

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Evidence Based Physical Therapy

Linda Fetters, PhD, PT, FAPTAProfessorSkyes Family Chair in Pediatric Physical Therapy,Health & DevelopmentDivision of Biokinesiology & Physical TherapyDepartment of Pediatrics, Keck School of MedicineUniversity of Southern CaliforniaLos Angeles, California

Julie Tilson, PT, DPT, MS, NCSAssistant Professor of Clinical Physical TherapyDivision of Biokinesiology and Physical TherapyUniversity of Southern CaliforniaLos Angeles, California

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Library of Congress Cataloging-in-Publication Data

Fetters, Linda, 1948-Evidence-based physical therapy / Linda Fetters, Julie Tilson.

p. ; cm.Includes bibliographical references and index.ISBN 978-0-8036-1716-2 (pbk. : alk. paper)I. Tilson, Julie. II. Title.[DNLM: 1. Physical Therapy Modalities. 2. Evidence-Based Medicine. WB 460]

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Teaching and learning is a constant dynamic. My dedication is to the worlds mostdynamic 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 bestteaching, 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 tothose who light my way in life: my parents, Mike and Jennifer, who taught me tobelieve in myself; the many students and colleagues who inspire me, particularlymy co-author Linda Fetters, who generously invited me on this journey; and mostimportant, my ever supportive and loving husband Donovan Steutel, truly the lightof my life.JT

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Foreword

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As someone interested in action, I rarely read forewords. So I will keep this one short and cut to the chase. The last fewdecades have seen a revolution in medical care, particularly inphysiotherapy. Research is shedding light on many old and newpractices. Harnessing this research for the benefits of patientsmeans that modern practitioners will need new skillsevidencebased practice (EBP)that are complementary to the clinicalskills and patient orientation needed for good care. Good clin-ical practice now requires the three pillars shown in Chapter 1,Figure 1.1, of this book: (1) clinical expertise (gained by goodtraining plus years of experience with feedback), (2) under-standing of patient values (requiring good history-taking skillsand shared decision-making skills), and (3) skills in locatingand appraising research literature: all three the subjects of this book.

The ideas behind EBPthe empirical testing of theoriesabout treatment and diagnosis by careful study in groups of patientsdate back many centuries to at least the 10th centuryand Al Rhazi in Persia (for those interested in learning moreabout Al Rhazi, Lind, Bradford-Hill, and the whole history ofclinical trials, an excellent resource is www.jameslindlibrary.org).The 20th century saw a rapid development in the methods forboth clinical research and connecting this research directly toclinical practice. A pivotal moment in this long developmentwas the coining of the term evidence-based medicine for aseries of articles the user guides published in the Jour-nal of the American Medical Association (JAMA) in the 1990s.The new term and the JAMA series helped spark worldwideinterest of clinicians across countries and disciplines. Profes-sional curricula have been slowly catching up with this

revolution. Whereas some educational programs still debatethe need to include EBP, for many others it has become the norm. The three pillars of EBP are seen as essential skills inthe lifelong learning now needed in the fast-moving world ofclinical care.

Physiotherapy has undergone its own revolution in the pastfew decades, emerging from its apprenticeship craft to becomea more scientifically focused discipline. The growth in researchhas been astonishing. The Physiotherapy Evidence Database(PEDro) (www.pedro.org.au) now contains over 19,000 ran-domized trials, systematic reviews, and clinical practice guide-lines in physiotherapy, and it continues to grow rapidly.Currently, the number of randomized trials in physiotherapydoubles about every 7 years (see Chapter 7, Figure 7.2). Thatimplies that the last 7 years has seen as many trials as in all theprevious history of physiotherapy. Whereas some trials merelyconfirm current practice as correct, some will overturn ideas,and others will introduce new methods and practices. Thisgrowth and change is potentially a great blessing for patients.However, for that blessing to reach the bedside, clinicians mustbe highly skilled in accessing, interpreting, and applying thiswealth of research evidence.

The goal of this book is to support the learning of thoseskills. However, EBP must be adapted to be adopted. Althoughthe fundamental principles are the same, the needs and contentsof each health-care discipline require the principles of EBP tobe framed and applied in ways that suit its special issues andresearch base. EBP looks somewhat different in medicine, psychiatry, nursing, and physiotherapy. This book, then, is an essential bridge to assist the application of EBP to physiotherapy.

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Dr. Fetters and Dr. Tilson have done an excellent job in describing the fundamentals of EBP and expertly adaptingthem to the needs of physiotherapists using everyday clinicalexamples to illustrate the processes. Using this book will helpin learning these vital skills for 21st century practice. But thatis not enough. The methods of EBP must also be practiced andintegrated into your professional life and clinical care for the

real benefits to patients to be seen. I wish you well with thatvital task.

Paul GlasziouProfessor, Centre for Research in Evidence-Based PracticeBond University

viii Foreword

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ix

Preface

We created this book as a learning tool for physical therapystudents and clinicians who want to become evidence basedpractitioners. It can also serve as a tool for more experiencedphysical therapists who want to continue to improve theirknowledge and skills as evidence based therapists. With thisbook you can develop skills to search the literature for the bestand most applicable research for your patients and criticallyappraise this literature for quality and clinical application. Wehave included chapters on the use of current technology andforms of communication in order to support realistic practicein the busy clinical workplace.

This book is the product of our years of teaching evidencebased practice (EBP) to physical therapy students, physicaltherapists, and faculty. Our teaching has taken many forms in-cluding online, classroom, laboratory, and through institutesorganized specifically for faculty who teach EBP to physicaltherapists. Throughout our teaching years, we searched for abook that was targeted to physical therapists and supported thedynamic learner. When our search failed, we decided to writeour own book! During this process, we asked and receivedfeedback from many students and colleagues. This feedback

was critical to our final product; the book has been greatly im-proved as a result. We owe thanks to the anonymous reviewerswho were solicited by F.A. Davis. Their thoughtful and thor-ough reviews were valuable to our process. Finally, a specialthanks to Weslie Holland, whose enthusiastic, prompt, and expert assistance was greatly appreciated.

Writing a book is a lot of work over an extensive period.One sure way to complete a book is to be passionate about thesubject and, more important, to be passionate about not justteaching the subject, but learning the subject. We are both. Inaddition, it helps to have a sense of humor. In fact, a sense ofhumor helps everything in life, particularly those aspects thatare a lot of work over an extensive period. Our passion forteaching and learning has always been complemented by ourhumor, enjoyment of the content and process, and respect andenjoyment of each other. We wish you a successful journey toward becoming an evidence based physical therapist.

Linda FettersJulie Tilson

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Reviewers

Peter Altenburger, MS, PTAssistant ProfessorUniversity of NevadaHenderson, Nevada

Sherrilene Classen, PhD, MPH, OTRUniversity of FloridaGainesville, Florida

Deanna C. Dye, PT, PhDAssistant ProfessorIdaho State UniversityPocatello, Idaho

Marie Earl, PhD, PTAssistant ProfessorDalhousie UniversityHalifax, Nova Scotia, Canada

Steven Z. George, PT, MS, PhDAssistant ProfessorUniversity of FloridaGainesville, Florida

Shelley Goodgold, PT, ScDProfessorSimmons CollegeBoston, Massachusetts

Brenda L. Greene, PT, PhDAssistant ProfessorEmory UniversityAtlanta, Georgia

Penelope J. Klein, PT, EdDProfessorDYouville CollegeBuffalo, New York

Barbara J. Norton, PT, PhDAssociate Professor and Associate DirectorWashington UniversitySt. Louis, Missouri

Jena B. Ogston, PhD, PTAssociate ProfessorCollege of St. ScholasticaDuluth, Minnesota

Christopher Powers, PhD, PTAssociate ProfessorUniversity of Southern CaliforniaLos Angeles, California

Kelly Sass, PT, MPTAssistant Academic Coordinator and Associate FacultyUniversity of Iowa Iowa City, Iowa

Joseph Schreiber, PT, MS, PCSAssistant ProfessorChatham CollegePittsburgh, Pennsylvania

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Contents

nSection I: Finding and Appraising Evidence to Improve Patient Care, 1

Chapter 1: The Evidence Based Practice Model, 1Introduction, 2

What Is EBP and Why is it Important? 2Understanding the EBP Model, 3

What are the Sources of Evidence? 3The EBP Process: What Does the Evidence Based Therapist Actually Do? 7

Five Steps in the EBP Process, 7EBP in the Context of Real-Time Clinical Practice: Can EBP Work in theReal World? 9

Chapter 2: Asking a Clinical Question and Searching for ResearchEvidence, 13

Introduction, 14How Do I Know if I Need Information? 14What is a Searchable Clinical Question? 15Which Types of Studies are You Looking for? 18Using Search Engines to Find Research Evidence, 18Searching in PubMed, 20Choosing and Retrieving Evidence, 27

Pulling it All Together: Your First Search, 28Chapter 3: Critically Appraise the Applicability and Quality of an

Intervention Research Study, 32Introduction: The Process of Study Appraisal, 33

Part A: Determining Applicability of an Intervention Study, 33Part B: Determining Quality of an Intervention Study, 36

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Determining Threats and Strengths of a Research Study, 39Testers and Treaters: The Importance of Masking, 40Equivalent Treatment, 40Summary of Research Study Quality, 40

Research Notation, 42Chapter 4: Critically Appraise the Results of an Intervention

Research Study, 45Introduction, 46

Part C: Interpreting Results of an Intervention Study, 46Part D: Summarizing the Clinical Bottom Line of an Intervention Study, 54

nSection II: Appraising Other Types of Studies: Beyond the Randomized Clinical Trial, 59

Chapter 5: Appraising Diagnostic Research Studies, 59Introduction, 60

The Diagnostic Process in Physical Therapy, 60Diagnostic Questions in the Clinic, 61Searching the Literature: Research Designs Specific to Diagnostic Tests, 61

The Process of Study Appraisal, 62Part A: Determining Applicability of a Diagnostic Study, 62Part B: Determining Quality of a Diagnostic Study, 63Part C: Interpreting Results of a Diagnostic Study, 63Part D: Summarizing the Clinical Bottom Line of a Diagnostic Study, 67Clinical Prediction Rules for Diagnosis, 69

Chapter 6: Appraising Prognostic Research Studies, 74Introduction, 75

Prognostic Questions in the Clinic, 75Research Designs That are Specific to Prognostic Studies, 75

The Process of Study Appraisal, 76Part A: Determining Applicability of a Prognostic Study, 76Part B: Determining Quality of a Prognostic Study, 77Part C: Interpreting Results of a Prognostic Study, 79Part D: Summarizing the Clinical Bottom Line of a Prognostic Study, 81

Chapter 7: Appraising Research Studies of Systematic Reviews, 86Introduction, 87

What is a Systematic Review? 87Why Are Systematic Reviews at the Top of the Evidence Pyramid? 89

Appraising Systematic Reviews, 91How do You Determine if a Systematic Review is of Sufficient Quality to Inform Clinical Decisions? 91

Part A: Determining Applicability of a Systematic Review, 91Part B: Determining Quality of a Systematic Review, 92Part C: Interpreting Results of a Systematic Review Study, 95Part D: Summarizing the Clinical Bottom Line of a Systematic Review, 97

Chapter 8: Appraising Clinical Practice Guidelines, 101Introduction, 102

What Are Clinical Practice Guidelines? 102What Search Strategies are Best for CPGs? 103

xiv Contents

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Appraising Clinical Practice Guidelines, 105Part A: Determining Applicability of a CPG, 105Part B: Determining Quality of a CPG, 106Part C: Interpreting the Results of a CPG, 106Part D: Summarizing the Clinical Bottom Line of a CPG, 107

Chapter 9: Appraising Studies With Alternative Designs, 114Introduction, 115Single-Subject Research, 115

Example Designs and Notation, 115Combining Multiple SSR Studies, 115

Appraising SSR Designs, 117Part A: Determining Applicability of SSR, 117Part B: Determining the Quality of SSR, 117Part C: Interpreting Results of SSR, 118Part D: Summarizing the Clinical Bottom Line, 120

Summary of SSR, 120Qualitative Research, 120Appraising Qualitative Research, 121

Qualitative Research Designs, 122Summary of Qualitative Research, 123

Chapter 10: Appraising Research Studies of Outcome Measures, 125Introduction, 126Types and Utility of Outcome Measures, 126

What Is an Outcome Measure? 126What Makes an Outcome Measure Useful in the Clinic? 129

Studies That Assess Outcome Measure Reliability, 129Types of Reliability and Terms Associated With Reliability Studies, 129Appraising the Quality of Studies of an Outcome Measures Reliability, 131

Studies That Assess Outcome Measure Validity, 133Types of Validity, 133Appraising the Applicability of Studies of an Outcome Measures Validity, 135

Studies That Assess an Outcome Measures Clinical Meaningfulness, 138Types of Clinical Meaningfulness, 138Appraising Studies That Assess an Outcome Measures Clinical Meaningfulness, 140

nSection III: Communication and Technology for Evidence Based Practice, 145

Chapter 11: Communicating Evidence for Best Practice, 145Introduction, 146Integration of Research, Clinical Expertise, and the Patients Values and Circumstances, 146

Health Literacy, 146Communication With Decision Makers for Physical Therapy, 146Summarizing and Storing Research Evidence for Communication, 147

The Critically Appraised Topic, 147Other Examples of Summaries of Evidence, 148

Contents xv

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Chapter 12: Technology and Evidence Based Practice in the RealWorld, 153

Introduction, 154The History of Technology and Evidence Based Practice (EBP), 154Evaluating and Improving Your EBP Efforts, 154Developing Your Technology Profile, 154Components of an EBP Technology Profile, 154Selecting Technologies for Your Profile, 155

Appendix: Key Question Tables, 161Glossary 172

xvi Contents

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How to Use This Book

Goals and Audience

This book was created for the physical therapy student and clinician who want to practice evidence based physical therapy.Our goal is to provide sufficient information to guide the development of the necessary skills to become an independentevidence based practitioner. We recognize that, just like anyother skill, practice is essential to effective and efficient learn-ing. We assume the reader is at the beginning of the learningprocess and, therefore, the content of the book includes thenecessary information to become an entry-level evidence basedphysical therapist.

Content

The book is divided into three sections, but chapters can beused independently.

Section I: Finding and Appraising Evidence to Improve Patient Care

Section II: Appraising Other Types of Studies: Beyond theRandomized Clinical Trial

Section III: Communication and Technology for EvidenceBased Practice

Each chapter in our book was designed to stand alone,such that each chapter can be assigned in any order and doesnot necessarily proceed from Chapter 1 through Chapter 12.The organization of the content of this book does, however, re-flect our teaching process. More important, it reflects the learn-ing process that our students have taught us. Over our years of

teaching both separately and together, we have organized ourevidence based practice (EBP) course using various sequencesof the topics included in this book. Our students have com-mented on each sequence, and we have reflected on the studentsknowledge and skills achieved through the use of each sequence.Although there is no one sequence that is best to teach EBP,we suggest that the novice to EBP benefits from reading SectionI: Finding and Appraising Evidence to Improve Patient Care,Chapters 14, first and in this order. These chapters provide thebasics of identifying clinical questions that can be searched effectively in the literature and the necessary search skills to findthe best available research evidence (Chapters 1 and 2). Basicappraisal skills for intervention research that can be combinedeffectively with clinical expertise and patient goals and valuesare the topics of Chapters 3 and 4. Many of the basic skills thatare developed in Chapters 14 can then be applied to specifictopic areas found in Section II: Appraising Other Types of Studies: Beyond the Randomized Clinical Trial (Chapters 58). Section II includes, for example, appraisal skills for the diagnosticliterature (Chapter 5) and the prognostic literature (Chapter 6).But teachers and learners combine in unique ways, and this bookis designed to be used effectively for a variety of teaching andlearning styles.

Most chapters include Digging Deeper sections. Thesesections include material that offers depth in a topic and may be considered either optional or required learning mate-rial. We designed these for the learner who wants more in-formation on a topic, but with the view that the materialpresented in these sections may be beyond entry level. Wealso include Self-Tests in most chapters. These should be

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used as opportunities for learners to reflect on their knowl-edge and skills in EBP and determine if additional study of atopic is warranted.

The text is abundantly supported with visual informationto support EBP concepts. Teachers and learners may find it

helpful to concentrate first on the illustrations of a concept andlater on the text supporting the concept.

We believe that this book can be used to support the learn-ing of effective and efficient skills to become evidence basedphysical therapists.

xviii How to Use This Book

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S E C T I O N IFinding and Appraising Evidence to Improve Patient Care

The Evidence BasedPractice Model

1

C H A P T E R - A T - A - G L A N C E

This chapter will help you understand the following:

n Definition and purpose of EBP

n Three principal sources of evidence for EBP: research,patient perspective, clinical expertise

n The five steps of EBP: identify a question, search, appraise, integrate, evaluate

n The challenges of and solutions for EBP in the realworld

P R E - T E S T

1. Can you explain to someone elsewhat evidence based practice (EBP)is and why it is important?

2. Can you describe the three primary sources of evidence for EBP?

3. What are the five steps of EBP?

4. What is known about EBP in thereal world?

1

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n Introduction

What is EBP and Why is it Important?

Evidence based practice (EBP) is a method of clinical deci-sion making and practice that integrates the best availablescientific research evidence with clinical expertise and a pa-tients unique values and circumstances.1,2 For the evidencebased therapist, these three sources of evidence (scientificresearch, clinical expertise, and patient values and circum-stances) form a foundation on which you and your patientswill work together to determine the best course of physicaltherapy care in any given circumstance (Fig. 1.1). The goalof evidence based therapists is to ensure that the best avail-able evidence informs patient care to optimize the benefitthat patients gain from therapy.

As an evidence based therapist, you will provide care thatis grounded in scientific research, guided by clinical exper -tise, and ultimately directed by your patients individual values and circumstances. Third-party payers, patients, andthe general health-care community have a steadily increasingexpectation that physical therapists will be evidence based.The effort that you put into EBP will not only fulfill the expectations of others, it will also enhance the quality andcredibility of your services. This will lead to enhanced con-fidence and ability to assist patients in choosing their bestoptions for physical therapy care. EBP moves the physicaltherapy profession away from practice based on habit andtoward a careful, systematic assessment of the best availableevidence to inform patient care. By carefully appraising whatis known from multiple reference points, you will be betterprepared to provide your patients with the best care thatphysical therapy has to offer.

2 SECTION I Finding and Appraising Evidence to Improve Patient Care

Think back to the last time that you or a close friend or familymember saw a health-care provider for a medical problem. Didyou expect that the diagnosis, treatment plan, and prognosis tobe based on current research, the medical professionals expe-rience, and consideration for you or your loved one? Wouldyou have been satisfied if those decisions had been based onknowledge that was out of date, the most recent market fad, orinformation that the physician learned in school 20 years ago?

Picture yourself sitting in an orthopedic surgeons office receiving a diagnosis of rotator cuff tear. The surgeon wouldneed to decide whether to recommend that you have surgery.

n List three things the surgeon would need to know about you toguide the decision making.

n Name the key decision makers who would help you decidewhether to have surgery.

n What questions would you need to ask the surgeon to ensurethat the right decision was made about your care?

n What sources of information would you expect the surgeon touse to answer your questions?

Patients expect, even demand, that medical care be based on thebest available evidence. Patients and the public expect this of youas a physical therapist.

D I G G I N G D E E P E R 1 . 1

CASE STUDY 1.1 June Wilson

Consider June Wilson, a 17-year-old swimmer referred to your outpatient clinic for neck pain 3 days before the state high schoolswimming championships in which she is scheduled to compete.June and her parents will expect you, the movement expert, to beable to answer their questions. June might ask you:

Why does my neck hurt? What are the chances that I will be able to swim without pain

in 3 days?What will you be able to do to help me get better?

As an evidence based therapist, you will be able to give June andher family answers based on the best available evidence from scien-tific research, clinical expertise, and Junes personal values and cir-cumstances. This is likely to enhance the quality of your care andincrease your credibility with June and her parents. In addition,your EBP skills can make you more effective when working withmedical care providers, third-party payers, and legislators.

June and her family maintain ultimate control over all of hermedical decisions. As a therapist, you make recommendations abouthow June should proceed in physical therapy. As an evidence basedtherapist you will be able to provide patients with the informationand education they need to work with you to make a shared-in-formed decision. A shared-informed decision is defined as a choicethat is generated through a partnership between the therapist and patient and that is informed by the best evidence.3This case is followed from Chapters 1 through 4.

EBP provides a structured method for thinking about andcollecting the different types of evidence used to make clin-ical decisions. As described above and in Figure 1.1, evidencecan be thought of as coming from three different sources:

1. Scientific research 2. Clinical expertise 3. Patient values and circumstances

What do you expect when you are the patient?

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Figure 1.2 illustrates how the patient and therapist use thethree sources of evidence to identify a shared-informed deci-sion that is likely to lead to the best possible outcomes.

nUnderstanding the EBP Model

What are the Sources of Evidence?

Continuing with the case, June Wilson and her parents will ex-pect your answers to their questions and recommendations forJunes care to be based on high-quality evidence. As an evi-dence based therapist it is important to consider all threesources of evidencetogether the three sources are strongerthan any one source on its own. In this section the three sourcesof evidence are presented in detail.

Scientific Research

Scientific research evidence is empirical evidence acquiredthrough systematic testing of a hypothesis. Therapists accesstwo general types of scientific research, clinical research and basic science research. Clinical research involveshuman subjects and answers questions about diagnosis, intervention, prevention, and prognosis in relation to diseaseor injury.

For example:

A diagnostic study by Wainner et al3 showed that several testsconducted together (Upper Limb Tension Test A, cervical rotation

n SELF-TEST 1.1

expectations of treatment success, and severity of neck pain atthe beginning of therapy.

Hill JC, Lewis M, Sim J, et al. Predictors of poor outcome in patients withneck pain treated by physical therapy. Clin J Pain. 2007;23:683-690.

Familiarity with each of these studies could influence and im-prove your ability to treat June and other patients with neck pain.

Research EvidenceSample Abstract Results of clinical research studies are published as articles inpeer-reviewed scientific journals. The abstract is a summaryof a study. With practice, therapists learn to quickly review anabstract to understand the overall purpose, design, results, andconclusions of a study. Figure 1.3 illustrates the abstract andauthor information from an article published in Physical Ther-apy (www.ptjournal.org), the official journal of the AmericanPhysical Therapy Association, that compared the efficacy of thrust with non-thrust manipulation/mobilization to the thoracic spine in persons with neck pain.4

reported on the attachment sites, serrations, length, and girthof the muscles.

Smith R, Nyquist-Battie C, Clark M, et al. Anatomical characteristics ofthe upper serratus anterior: Cadaver dissection. J Ortho Sports PhysTher. 2003;33:449-454.

If you decided to use a manual therapy technique to reducepain and increase flexibility of Junes serratus anterior muscle,this article could inform your understanding of the anatomy ofthis muscle and how you should apply the technique.

Clinical research should be founded on principles learnedfrom basic science research with the goal of understandingthose principles when they are applied in the patient care en-vironment (Fig. 1.4). However, clinical research is time- andresource-intensive. Therefore, it is common to find intriguingbasic science that has not been investigated in a patient popu-lation. For example, the Kluemper et al7 study reported an ex-ercise program that improved posture for swimmers withoutneck pain. You might hypothesize that swimmers with neckpain associated with poor posture might benefit from the sameprogram. A clinical research study involving patients with neckpain would help you to know if your hypothesis is correct.Until the program is tested on swimmers with shoulder and/orneck injury, your knowledge about how the program will affectpatients is limited. In this case, however, if the Kluemper et al7study is judged to be of sufficient quality, you might tell swim-mers such as June that this particular stretching and strength-ening program might improve forward shoulder posture.Naturally, when you educate a patient about research evidence,it is important to use layperson terms and to confirm that thepatient understands by asking follow-up questions.

Therapists have the primary responsibility to identify, evaluate, and summarize research evidence concerning a patients care. Sometimes, however, a patient will acquire research evidence relevant to his or her condition. In this case,the clinician can assist the patient to ensure accurate evaluationand interpretation of the evidence. Methods for effectively and efficiently appraising research evidence are presented inChapters 3 through 10.

Clinical Expertise

Clinical expertise refers to implicit and explicit knowledgeabout physical therapy diagnosis, treatment, prevention, andprognosis gained from cumulative years of caring for patientswith disease and injury and working to improve and refine thatcare. Therapists share a collective professional wisdom ac-quired through decades of providing patient care. Much of thatwisdom has yet to be tested, and some cannot be tested, by sci-entific inquiry. Professional clinical expertise is passed fromclinician to clinician in the formal academic setting, post-professional education (e.g., continuing education courses, residencies), formal mentorship, and informally between colleagues. As a new therapist you will discover that identify-ing an expert mentor who readily shares his or her clinical

4 SECTION I Finding and Appraising Evidence to Improve Patient Care

Read the abstract in Figure 1.3, then close the book and writedown as many facts about the study as you can remember. Asyou gain skills as an evidence based therapist you will find thatkey facts from the abstract help you to quickly understand thefundamental aspects of a research study.

When there is insufficient clinical research on a particulartopic, therapists can look to research in similar fields (e.g., stud-ies on healthy participants) and basic science research. Fromthese studies you can extrapolate, with caution, how patientswill respond in a clinical situation. Studies of healthy individu-als help therapists understand what is normal and can lead tohypotheses about how best to care for persons with an injury ordisease condition.

For example:

A study by Kluemper et al7 involving swimmers without pain or injury found that a shoulder stretching and strengthening program reduced forward shoulder posture after 6 weeks.

Kluemper M, Uhl T, Hazelrigg H. Effect of stretching and strengtheningshoulder muscles on forward shoulder posture in competitive swimmers.J Sport Rehab. 2006;15:58-70.

If, based on your knowledge of anatomy and biomechanics, youbelieve that Junes pain is associated with forward shoulder pos-ture, this study could affect your prescription of shoulderstretching and strengthening exercises.

Basic science research often involves non-human researchand is fundamental to evidence based physical therapy.

For example:

A study by Smith et al8 involved a series of 13 dissections of serratus anterior muscles in human cadavers. The study

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CHAPTER I The Evidence Based Practice Model 5

Short-Term Effects of Thrust VersusNonthrust Mobilization/ManipulationDirected at the Thoracic Spine inPatients With Neck Pain:A Randomized Clinical TrialJoshua A Cleland, Paul Glynn, Julie M Whitman, Sarah L Eberhart,Cameron MacDonald, John D Childs

Background and PurposeEvidence supports the use of manual physical therapy interventions directed at the thoracic spine in patients with neck pain. The purpose of this study was to compare the effectiveness of thoracic spine thrust mobilization/manipulation with that of nonthrust mobilization/manipulation in patients with a primary complaint of mechanical neck pain. The authors also sought to compare the frequencies, durations, and types of side effects between the groups.

SubjectsThe subjects in this study were 60 patients who were 18 to 60 years of age and had a primary complaint of neck pain.

MethodsFor all subjects, a standardized history and a physical examination were obtained. Self-report outcome measures included the Neck Disability Index (NDI), a pain diagram, the Numeric Pain Rating Scale (NPRS), and the Fear-Avoidance Beliefs Questionnaire. After the baseline evaluation, the subjects were randomly assigned to receive either thoracic spine thrust or nonthrust mobilization/manipulation. The subjects were reexamined 2 to 4 days after the initial examination, and they again completed the NDI and the NPRS, as well as the Global Rating of Change (GROC) Scale. The primary aim was examined with a 2-way repeated-measures analysis of variance (ANOVA), with intervention group (thrust versus nonthrust mobilization/manipulation) as the between-subjects variable and time (baseline and 48 hours) as the within-subject variable. Separate ANOVAs were performed for each dependent variable: disability (NDI) and pain (NPRS). For each ANOVA, the hypothesis of interest was the 2-way group X time interaction.

ResultsSixty patients with a mean age of 43.3 years (SD12.7) (55% female) satisfied the eligibility criteria and agreed to participate in the study. Subjects who received thrust mobilization/ manipulation experienced greater reductions in disability, with a between-group difference of 10% (95% confidence interval [CI]5.314.7), and in pain, with a between-group difference of 2.0 (95% CI1.4 2.7). Subjects in the thrust mobilization/manipulation group exhibited significantly higher scores on the GROC Scale at the time of follow-up. No differences in the frequencies, durations, and types of side effects existed between the groups.

Discussion and ConclusionThe results suggest that thoracic spine thrust mobilization/manipulation results in significantly greater short-term reductions in pain and disability than does thoracic nonthrust mobilization/manipulation in people with neck pain.

JA Cleland, PT, DPT, PhD, OCS, FAAOMPT, is Assistant Professor, Department of Physical Therapy, Franklin Pierce College, 5 Chenell Dr, Concord, NH 03301 (USA); Research Coordinator, Rehabilita-tion Services, Concord Hospital, Concord, NH; and Faculty, Manual Physical Therapy Fellowship Program, Regis University, Denver, Colo. Address all correspondence to Dr Cleland at: joshcleland@ comcast.net.

P Glynn, PT, DPT, OCS, FAAOMPT, is Physical Therapy Clinical Special-ist, Newton-Wellesley Hospital, Newton, Mass, and Fellow, Manual Physical Therapy Fellowship Program, Regis University.JM Whitman, PT, DSc, OCS, FAAOMPT, is Assistant Faculty, Department of Physical Therapy, and Faculty, Manual Physical Therapy Fellowship Program, Regis University.

SL Eberhart, PT, MPT, is PhysicalTherapist and Clinical II, Rehabilita-tion Services, Concord Hospital. C MacDonald, PT, DPT, GCS, OCS, FAAOMPT, is Physical Therapist, Centennial Physical Therapy, Colorado Sport and Spine Centers, Colorado Springs, Colo.JD Childs, PT, PhD, MBA, OCS, FAAOMPT, is Assistant Professor and Director of Research, Doctoral Program in Physical Therapy, US ArmyBaylor University, San Antonio, Tex.

[Cleland JA, Glynn P, Whitman JM, et al. Short-term effects of thrust versus nonthrust mobilization/ manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial. Phys Ther. 2007;87:431440.] 2007 American Physical Therapy Association. Research Report

For The Bottom Line: www.ptjournal.org

Volume 87 Number 4 Physical Therapy 431April 2007

Research Report

F I GURE 1 . 3 Abstract from Cleland JA, Glynn P,Whitman JM, Eberhart SL, MacDonald C, Childs JD. Short-term effects of thrust versus nonthrust mobilization/manipulation directed at the thoracic spine in patientswith neck pain: A randomized clinical trial. Phys Ther. 2007;87:431-440.

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expertise with you is a critical component to becoming an evidence based therapist. As does research evidence, clinicalexpertise needs to be appraised for quality.

In addition to gaining evidence from experts in the profes-sion, each individual therapist develops his or her own clinicalexpertise (Fig. 1.5). Reflective therapists develop clinicalknowledge by explicitly thinking about their clinical encoun-ters with patients.9 As a reflective therapist, you will use experience from previous patients to generate expectations forfuture patients. Those expectations play an important role inthe shared decision-making process with patients. Finally, asan individual, each therapist uses his or her own values andpreferences as evidence. Our values and preferences are important, but they naturally lead to biases in decision making.It is important to evaluate and recognize your biases so thatthey do not overpower other sources of evidence.

Lets explore clinical expertise as a source of evidence withrespect to caring for June Wilson (Case Study 1.1). Althoughthere are numerous studies that have examined what tests andmeasures should be used to diagnose Junes condition andwhich interventions are most likely to reduce her pain and im-prove her function, there will never be research evidence thatdescribes the effectiveness of every element of your interactionwith June. For example, suppose June has a significant forwardhead-and-shoulders posture. Studies that report the value ofeducating a 17-year-old swimmer with neck pain about the

impact of body mechanics during swimming may not exist.However, based on anatomical evidence, physical therapistshave hypothesized that forward head-and-shoulders posturecan put increased strain on the soft-tissue structures of theneck, causing pain. As Junes therapist, you would need to useclinical expertise and your observations of her movement toinform the degree to which postural education should consti-tute Junes physical therapy treatment.

Patient Values and Circumstances

The patient and his or her caregivers create the most importantpillar of evidence to the decision-making process. Figure 1.6illustrates that evidence from the patient can be divided intotwo categories: values and circumstances. Patient values in-clude the beliefs, preferences, expectations, and cultural iden-tification that the patient brings to the therapy environment.1Fundamentally, values are the core principles that guide a per-sons life and life choices. Therapists will encounter patientswith diverse values that affect their physical therapy care. Forexample, patients may weigh the value of family involvementand independence differently. Consider June; she may feelstrongly that her parents should be directly involved in all ther-apy decisions. Conversely, she may have a strong desire forpersonal independence, wishing to have autonomous control

6 SECTION I Finding and Appraising Evidence to Improve Patient Care

Basic Science

Research Evide

nce

Clinica

l Research EvidenceDiagnosis

OutcomeMeasurement

Examination Intervention

Screening Prognosis

F I GURE 1 . 4 How different types of research contribute to evidencebased patient care. Basic science research evidence informs clinical researchevidence, which informs how we provide care in all aspects of patient man-agement (screening, examination, diagnosis, intervention, prognosis, and out-come measurement). The dashed line arrows indicate that basic scienceresearch evidence informs patient management when clinical research evidence is not sufficient. F I GURE 1 . 5 The interplay between components of collective and individ-

ual clinical expertise.

Collective Clinical Expertise

IndividualClinicalExpertise

PreferencesProfessionalExperiences

PersonalExperiences

Values

Expectations

ProfessionalWisdom

Experience

Expectations

Expertise

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over as many decisions as possible. Either scenario, if recog-nized by the therapist, can be leveraged to help June benefitoptimally from therapy. Values are generated from personaland spiritual beliefs and must be respected and accommodatedeven when they do not match yours.

Patient preferences serve as important evidence for guidingtreatment decisions. For example, some patients excel at com-pleting a therapy exercise program consistently on a dailybasis. They can readily incorporate a prescribed home exerciseprogram into their lifestyle and monitor their progress inde-pendently. Other patients prefer to avoid therapeutic exerciseto the fullest extent possible. If the latter represents Junes pref-erence, she may need to see a direct benefit before she will en-gage in any exercise program to address her neck pain. Whenpatients are resistant to sharing preferences, consider whetherthey lack sufficient understanding of the situation to develop apreference, lack confidence to make or share a preference, orfeel uncomfortable or embarrassed about their preference.Considering the situation from the patients perspective cansignificantly enhance communication.

Patient expectations may also affect their responses to physicaltherapy. If Junes father had previous physical therapy for an an-terior cruciate ligament (ACL) repair, the family might concludethat physical therapy for Junes neck injury will be painful (oftenthe case for ACL repair rehabilitation programs but rarely forneck pain). In addition, because June is slated to swim in herstate championships in 3 days, she is likely to have high expec-tations for a rapid solution to her pain. Conversely, she and/orher parents might have unusually high or low expectations forJunes recovery depending on previous life experiences.

Patient circumstances encompasses information about the pa-tients medical history (e.g., co-morbidities), access to medicalservices (e.g., rural versus urban or insured versus uninsured),and family environment (e.g., lives with parents versus lives infoster home). For example, if June has a history of juvenilerheumatoid arthritis, the use of thrust and non-thrust manipu-lation of the thoracic spine for reduction of neck pain may notbe appropriate.

All patient values and circumstances can be influenced bythe culture(s) with which a patient identifies. Some culturalidentifications are easy to recognize, whereas others are moresubtle. The therapist who learns about the cultural norms ofunique patient populations and remembers that individuals mayor may not follow those norms will be well served. For example,if June and her family are recent immigrants from Iraq, the ther-apist might expect that the family will have significant concernsabout June exposing her torso to a male therapist.10 That said,if the male therapist did not discuss this with the family butrather referred June to a female therapist without explanation,June might interpret this action as unwarranted rejection.

The ability to integrate what you, as an evidence basedtherapist, learn from scientific research, from clinical expertise,and from patient values and circumstances is essential to pro-viding the best possible physical therapy care. Integration ofthe three evidence pillars into daily patient interactions takespractice. Patients benefit when you judiciously share the clin-ical bottom-line message from quality research articles. Youcan share clinical experience and expectations with your pa-tients, using phrases such as, I have found that or You mayrespond best to. By conducting a skilled interview, you learnabout patient values and circumstances. Figure 1.7 illustratesan example of the contributions that different components ofevidence can make for both you and the patient.

nThe EBP Process: What Doesthe Evidence Based TherapistActually Do?

EBP can be thought of as having five fundamental steps (Fig. 1.8) that facilitate successful evidence collection, appraisal, and integration.11 This section summarizes each ofthe steps and indicates where they are addressed in this book.

Five Steps in the EBP Process

STEP 1: Identify the need for information and develop afocused and searchable clinical questionThe first step of EBP involves collecting information from thepatient and identifying a need for additional information for

CHAPTER I The Evidence Based Practice Model 7

F I GURE 1 . 6 Components of patient values and circumstances that contribute to patient perspective as evidence.

Values

Beliefs

Preferences

Expectations

Cultural Identities

Circumstances

Co-morbidities

Access to Care

Support Network

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clinical decision making. Once you identify that you need in-formation, you will develop a specific question called a search-able clinical question. In Chapter 2 we will explore thedifferent types of searchable clinical questions, and you willhave a chance to practice writing your own. A well-developedsearchable clinical question has a specific structure that makesit easier to search databases for the best available research evidence. A question that is too narrow may not lead to any applicable articles. A question that is too broad could result inan overwhelming set of possible articles.

STEP 2: Conduct a search to find the best possible research evidence to answer your question

The second step of the EBP process involves using electronicdatabases to search for specific research evidence to answeryour clinical question. Chapter 2 describes how to search forand retrieve the best available research to inform your questionfrom step 1. First, you need to know what type of research evidence will assist you in making clinical decisions. The Evidence Pyramid (Fig. 1.9) illustrates a hierarchy that can beused as an initial filter for identifying high-quality research evidence. Systematic Reviews (SRs), studies that combineother studies, are at the top of the pyramid and represent thehighest level of research evidence. Below SRs are individualstudies including randomized clinical trials (RCTs) and cohortstudies. Evidence based clinical practice guidelines (CPGs) are illustrated separately from the pyramid but slightly aboveSRs. CPGs are not research studies but rather a comprehensivesummary of research studies developed by experts in the field.CPGs include direct recommendations for practice that com-bine best clinical research and clinical expertise.

The most efficient way to search for the best research evi-dence is to start by searching for CPGs and then, if necessary

8 SECTION I Finding and Appraising Evidence to Improve Patient Care

Example of a possible distribution ofsources of evidence for a therapist

Example of a possible distribution ofsources of evidence for a patient

ScientificResearch

Patient Values

PatientCircumstances

Collectiveprofessional

expertise

Past patientexperiences

Skills, preferences,and expectations

Care ProviderRecommendations

ScientificResearch

Preferences

CulturalBeliefs

Expectations

F I GURE 1 . 7 An example of the diverse sources of information that con-tribute to patient and therapist evidence when making a decision about besthealth care.

F I GURE 1 . 8 The five-step EBP process. This figure is used throughoutthis book to orient you to the step being addressed.

F I GURE 1 . 9 The Evidence Pyramid illustrates a hierarchy of best sourcesof evidence for searchable clinical questions. Categories of research evi-dence are ordered from top to bottom; higher levels on the pyramid repre-sent the most likely sources of high-quality research evidence. This pyramidis specific to studies about treatment intervention.

Identify the need for information and develop a focused andsearchable clinical question.

Conduct a search to find the best possible research evidence to answer your question.

Critically appraise the research evidence for applicabilityand quality.

Integrate the critically appraised research evidence withclinical expertise and the patients values and circumstances.

Evaluate the effectiveness and efficacy of your efforts inSteps 14 and identify ways to improve them in the future.

1Step

2Step

3Step

4Step

5Step

Research Evidence PyramidIntervention Studies

Evidence-BasedClinical Practice

GuidelinesSystematicReviews

RandomizedClinical Trials

Cohort Studies

Case-Control Studies

Case Series

Case Studies

Narrative Reviews, Expert Opinion, Textbooks

1716_Ch01_001-012 30/04/12 4:41 PM Page 8

(as is frequently the case), proceed down the levels of the pyra-mid. Learning to search in research databases, such as PubMed,to find the best research evidence takes practice and persistence.

STEP 3: Critically appraise the research evidence forapplicability and quality

After identifying potentially useful research evidence, you willbegin the appraisal process. Study appraisal is the process of de-termining whether an article is applicable to your question and ifit is of sufficient quality to help you make a decision. Chapters 3through 10 are dedicated to helping you learn to appraise differenttypes of studies on the Evidence Pyramid. Figure 1.10 illustratesthe rating of research evidence on two scalesapplicability andquality. It is unusual for an article to have perfect applicabilityand perfect quality. Rather, articles fall along a continuum on eachscale, and it is up to you to determine if an article is or is not valu-able for answering your clinical question. When you are apprais-ing an article, it is important to balance skepticism withopen-mindedness. Every study has some deficitsyou will learnto read studies critically while avoiding the temptation to dismissimperfect studies that have value to clinical practice.

STEP 4: Integrate the critically appraised researchevidence with clinical expertise and the patients values and circumstances

Having identified and appraised relevant and quality researchto inform your searchable clinical question, the fourth step isto integrate the three pillars of EBP. Chapter 11 addresses theart of integrating and communicating the best available evi-dence to colleagues and patients. As discussed above, researchevidence does not provide answers about how to rehabilitatepatients. Rather, it informs and provides a framework for prac-tice. Integration of research evidence, clinical expertise, and

patient values and circumstances is completed in partnershipwith the patient and/or his or her family and caregivers. Eachcase example throughout the book will explore the process ofintegrating clinical expertise and patient values and circum-stances with appraised research evidence to inform your clin-ical practice.

STEP 5: Evaluate the effectiveness and efficacy of yourefforts in Steps 1 Through 4 and identify ways to improvethem in the futureIn step 5 the evidence based therapist reflects on the EBP processand looks for ways to improve. You can do this at the level ofthe individual patient and at the level of overall practice habitsand skills. Chapters 11 and 12 explore methods that you can useto reflect on and continually improve your skills as an evidencebased therapist. For example, by using standardized outcomemeasures consistent with those used in physical therapy re-search, you will be able to compare your patients progress withresults in the literature. In addition, by learning to use technolo-gies developed to support the evidence based therapist, you canimprove your efficiency and effectiveness. By reflecting on youroverall habits and skills as a clinician, you will identify knowl-edge gaps that, when addressed, can lead to a more effective andrewarding quality of life as a practitioner.

To help you picture the five steps in action, Figure 1.11provides an example of how the EBP process might look forthe care of June Wilson.

nEBP in the Context of Real-Time Clinical Practice:Can EBP Work in the RealWorld?

You may be wondering if EBP is a realistic expectation forphysical therapists working under the pressure of the modernhealth-care system. In fact, although physical therapists as agroup report high value for the importance of EBP they alsoidentify barriers that must be addressed.12,13 In this book weaddress these barriers directly to provide you with the toolsyou need to overcome them. Table 1.1 summarizes these bar-riers and describes suggestions for how to overcome them.

In 2000, the American Physical Therapy Association established Vision 2020. The vision states that physical ther-apists and physical therapist assistants will render evidencebased services throughout the continuum of care.14 With acommitment to lifelong learning, all physical therapists cancontribute to the achievement of this goal. Chapters 11 and 12 address mechanisms that you can use to develop lifelongEBP habits and ultimately become a leader in the effort forphysical therapy to be an evidence based profession.

CHAPTER I The Evidence Based Practice Model 9

F I GURE 1 . 1 0 Research studies are ranked on two distinct scales: appli-cability and quality. Study 1 has low applicability to the therapists case andhigh quality. Study 2 has moderate applicability and quality. Study 3 has highapplicability and low quality. Weighing strengths and weaknesses of each ofthese studies, the clinician may glean value from all three for guiding prac-tice. The appraisal process allows clinicians to determine the extent towhich individual studies should influence their practice.

Low High

1) Applicability to your question:

Low High

2) Quality of the study:

One study can have very different rankings on the two scales.

Two Independent Scales for Research Evidence Appraisal:

Study 1

Study 2

Study 3

1716_Ch01_001-012 30/04/12 4:41 PM Page 9

10 SECTION I Finding and Appraising Evidence to Improve Patient Care

Step 4: Integrate

Step 1: Clinical Question

Step 2: Search

Step 3: Appraise

Step 5: Evaluate

The EBP process starts with a patient interaction, in this case, your

initial evaluation of June Wilson.

After Junes first treatment she is feeling 50% better. You are pleased with this progress. You wonder if you had looked for a Systematic Review or Clinical Practice Guideline you would have found evidence from more than one study to inform Junes care. Next time you might try that first and see how it goes.

You find a randomized controlled trial by Walker et al published in the journal Spine in 2008. You determine that the study is of high quality and has acceptable applicability to your question. You learn that a program of manual therapy and exercise was more effective than a minimal exercise and education program for adults with a primary complaint of neck pain.

You talk again with June and her parents and learn that Junes mother has high anxiety about the use of cracking treatments of the spine. You know from your knowledge of skeletal development that Junes age is not a contraindication for mobilization. You also feel strongly that movement patterns could be contributing to Junes pain based on anatomical principles. With June and her parents, you develop a program that includes non-thrust mobilization, daily home exercise, and postural reeducation. You will monitor Junes progress with standardized outcome measures to assess her progress.

You search in PubMed for Randomized Controlled Trials or Systematic Reviews that investigate the merits of manual therapy and therapeutic exercise compared with therapeutic exercise alone.

In Junes case you ask: For a 17 year old female swimmer, is manual therapy combined with therapeutic exercise more effective than therapeutic exercise alone for rapid reduction of pain and return to swimming?

F I GURE 1 . 1 1 The EBP model contains five steps that start with the patient. Each step is described in thecontext of Case Study 1.1 concerning June Wilson.

TABLE 1.1 Breaking Down Barriers to EBP

BARRIER BARRIER BUSTER

Time Time is the most common barrier to using EBP. Faster searches and study appraisalare keys to success and we will teach you how to optimize speed while maintainingquality in these processes.

Lack of generalizability of research Therapists treat individual patients but research evidence generally addresses groupsof patients. In the chapters on appraisal you will learn how to determine if a study canbe applied to a particular patient even if the study sample is not a perfect fit with yourpatient. You will see that critical thinking skills are an important component to inform-ing care for individual patients with research evidence.

Lack of research skills Chances are that you did not decide to become a physical therapist so that you coulddo research. This is the beauty of EBP. As an evidence based therapist you only needto learn to be a consumer of research, not a doer of research. This book focuses onthe skills you need to be a consumer of research.

Lack of understanding of statistics Statistics are an integral part of most research studies and they can be intimidating.This book will help you to understand and interpret the most common statistical con-cepts encountered in clinical physical therapy literature.

Lack of search and appraisal skills Searching for research evidence and appraising it for quality and applicability takepractice. Just like completing a subjective historyyou wont be very good at it atfirst. But with practice, you can learn to become very skilled. The examples and exer-cises in this book will guide your skill development in these key areas.

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CHAPTER I The Evidence Based Practice Model 11

TABLE 1.1 Breaking Down Barriers to EBPcontd

BARRIER BARRIER BUSTER

Lack of Information Resources Dissemination of information is a business. Many therapists encounter barriers whentrying to search for and retrieve research evidence. In this book we focus on freeresources to ensure that any therapist with an Internet connection can find the bestavailable evidence without breaking the bank.

Inconsistent Culture of EBP in Physical therapists have vastly different EBP skills and knowledge. In addition, Physical Therapy although most studies show that the majority of therapists value EBP, there are

certainly therapists who do not. As a new learner of EBP you may be challenged to justify your efforts to integrate all three sources of evidence into patient care. In this book we illustrate this type of conflict through patient cases and study questions to help you develop your leadership skills as an evidence based therapist.

S U M M A R YStep 3: Critically appraise the research evidence for validity

and applicability.Step 4: Integrate the critically appraised research evidence

with clinical expertise and patient values and circumstances.

Step 5: Evaluate the effectiveness and efficacy of your effortsin Steps 1 through 4 and identify ways to improve them inthe future.

Your efforts to become an evidence based therapist will beheavily influenced by the clinical environment in which youpractice. Key challenges to EBP reported by therapists are in-sufficient time, inability to generalize research, lack of knowl-edge about statistics and research, lack of search and appraisalskills, and the presence of a culture that does not consistentlysupport EBP. This book is designed to help you overcome eachof these barriers and become an agent of change as the physicaltherapy profession earns the reputation of being an evidencebased profession.

Evidence based practice (EBP) is defined as the integration ofthe best available research evidence with clinical expertise andpatients unique values and circumstances. The purpose of EBPis to use the best available evidence from all sources to opti-mize our patients benefit from physical therapy. There arethree principal sources of evidence for EBP:

1. Research evidence2. Clinical expertise 3. Patient values and circumstances

The five steps of EBP are designed to facilitate a structured ap-proach to EBP. By making a habit of following the five steps,you will find it easier to succeed as an evidence based therapist.They are:

Step 1: Identify a need for information and construct a fo-cused and searchable clinical question.

Step 2: Conduct a search to find the best possible researchevidence to answer your question.

1. Define and describe the purpose of EBP. What health-careprofessions are or are not evidence based? How doesbeing evidence based (or not) influence a professions rep-utation? Do you think outsiders would consider physicaltherapy to be evidence based? How could EBP strengthenthe quality of care that you and other therapists provide?

2. Think back to a person whom you know (yourself, a family member, a patient) with a medical condition whoreceived medical or therapy care.

n Describe what you know about the patients perspectivein this situation (consider the persons values, preferences,

expectations, and circumstances). Did the patients per-spective influence the care that he or she received?

n Describe any clinical expertise (your own or others) thatinfluenced the care that the person received.

n What do you know about the research evidence that in-fluenced the persons care?

n What questions do you have about the diagnosticprocess, intervention plan, or prognosis associated withthis persons health condition?

n Can you describe how the five steps of EBP would guideyou to answer one of those questions?

R E V I E W Q U E S T I O N S

Continued

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12 SECTION I Finding and Appraising Evidence to Improve Patient Care

3. Can you think of an instance when you have observedEBP in action? Describe the situation. Can you identifyevidence that came from each of the three sources of evi-dence in EBP?

4. You might want to know if ultrasound therapy would beeffective for reducing the neck pain experienced by patientJune Wilson in Case Study 1-1. Complete the followingsteps to focus your learning efforts in future chapters:

Step 1. Identify a gap in your knowledge about ultrasoundtherapy for neck pain and try writing a searchable clini-cal question.

Step 2. List sources you might use to find research evi-dence to answer this question. Can you name some ofthe benefits and drawbacks of those sources? Do youknow what type of research evidence you might look forto answer your question?

Step 3. When you find research evidence, how will youdecide if the research is applicable to your question?How will you decide if the research has sufficient qual-ity to influence your practice? How will you decide ifthe results of the research are of sufficient magnitude tochange your practice?

Step 4. What questions would you ask June and her par-ents to ensure that you understood the patient and fam-ilys values and circumstances? How would you balancethat information with your own and others clinical expertise and the patient perspective that you have gathered?

Step 5. What questions will you ask yourself to ensure thatyou reflect on this process to facilitate your growth in the future?

R E V I E W Q U E S T I O N S contd

R E F E R E N C E S

8. Smith R, Nyquist-Battie C, Clark M, et al. Anatomical characteristics ofthe upper serratus anterior: cadaver dissection. J Orthop Sports PhysTher. 2003;33:449-454.

9. Jensen GM, Gwyer J, Shepard KF, et al. Expert practice in physical therapy. Phys Ther. 2000;80:28-43.

10. Milne D. Culture, religion frame care for Muslim patients. PsychiatrNews. 2005;40:13-58.

11. Dawes M, Summerskill W, Glasziou P, et al. Sicily statement on evidence based practice. BMC Med Educ. 2005;5:1.

12. Salbach NM, Jaglal SB, Korner-Bitensky N, et al. Practitioner and orga-nizational barriers to evidence-based practice of physical therapists forpeople with stroke. Phys Ther. 2007;87:1284-1303.

13. Jette DU, Bacon K, Batty C, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther.2003;83:786-805.

14. American Physical Therapy Association. www.apta.org Accessed April 1, 2008.

1. Straus S, Richardson S, Glasziou P, et al, eds. Evidence-Based Medicine:How to Practice and Teach EBM. 3rd ed. Endinburgh, UK, ElsevierChurchill Livingstone; 2005.

2. Towle A, Godolphin W. Framework for teaching and learning informedshared decision making. BMJ. 1999;319:766-771.

3. Wainner RS, Fritz JM, Irrgang JJ, et al. Reliability and diagnostic accu-racy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003;28:52-62.

4. Cleland JA, Glynn P, Whitman JM, et al. Short-term effects of thrust ver-sus nonthrust mobilization/manipulation directed at the thoracic spine inpatients with neck pain: a randomized clinical trial. Phys Ther.2007;87(4):431-440.

5. Linton SJ, Andersson T. Can chronic disability be prevented? A random-ized trial of a cognitive-behavior intervention and two forms of informa-tion for patients with spinal pain. Spine. 2000;25:2825-2831.

6. Hill JC, Lewis M, Sim J, et al. Predictors of poor outcome in patientswith neck pain treated by physical therapy. Clin J Pain. 2007;23:683-690.

7. Kluemper M, Uhl T, Hazelrigg H. Effect of stretching and strengtheningshoulder muscles on forward shoulder posture in competitive swimmers.J Sport Rehab. 2006;15:58-70.

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13

Asking a ClinicalQuestion and Searchingfor Research Evidence

2

C H A P T E R - A T - A - G L A N C E

This chapter will help you understand the following:

n Searchable clinical questions

n Searching for research evidence

n Accessing full text of research articles

P R E - T E S T

1. Why is it important to construct asearchable clinical question?

2. Can you give an example of a back-ground question and a foregroundquestion?

3. What is the difference between adatabase and a search engine?

4. Name a search engine that anyonecan access for free on the Internet.What are this tools strengths andweaknesses for helping therapistsfind research evidence?

5. Name three important techniquesfor narrowing a search in thePubMed search engine. Do thesame for expanding a search.

6. Where could you locate a reposi-tory of full-text articles mandatedby the U.S. Congress?

1716_Ch02_013-031 30/04/12 2:16 PM Page 13

n Introduction

This chapter develops your knowledge and skills in the first twosteps of evidence based practice (EBP) (Fig. 2.1): n Step 1: Identify a need for information, and develop a

focused and searchable clinical question.n Step 2: Conduct a search to find the best possible research

evidence to answer your question.

These steps take you through the process of obtaining researchevidence. Most therapists find that research evidence is the mostdifficult type of evidence to obtain. This chapter will help youlearn to obtain research evidence quickly and efficiently.

STEP 1: Identify the Need forInformation and Develop aFocused and SearchableClinical QuestionHow Do I Know if INeed Information?

Step 1 can be divided into two partsidentifying a need forinformation and then constructing a focused, searchable clini-cal question. How do you identify a need for information? Dur-ing your physical therapy education, you are flooded withinformation about how to care for patients. As an evidencebased therapist and lifelong learner, you will be constantlyadding to your knowledge. Every patient is different, and manywill present in ways that push you to find new information tooptimize their care. Also, scientific evidence rapidly changes.There are now over 2000 new clinical trials published everyyear related to physical therapy (Fig. 2.2). You cannot knowthe answer to every clinical question that will arise. The key isto identify important knowledge gaps and know how to fillthem with the best available evidence.

Identification of your needs for information may occurbefore you see a patient and throughout a patients course of care. The American Physical Therapy Association defines patient management as having six components: examination, evaluation, diagnosis, prognosis, intervention,and outcomes measurement (Fig. 2.3).1

We describe the use of EBP for each of these componentsthroughout this book. This chapter addresses clinical ques-tions related to diagnosis, prognosis, and intervention. Theinformation that the evidence based therapist needs duringday-to-day patient care usually falls into these three categories.

Lets revisit our patient from Chapter 1, June Wilson(Case Study 1.1). Figure 2.4 illustrates some basic informa-tion about June.

From this information, you might have questions aboutseveral areas of patient care:

n What special tests should be done to determine the cause ofher pain? (Diagnosis)

n What treatments will be most effective for reducing herpain quickly? (Intervention)

n How likely is neck pain to recur? (Prognosis)These are examples of background questions. Background

questions ask about general information and are not specificto an individual patient. When you are less familiar with a par-ticular condition, you ask more background questions. As yourknowledge about a condition increases, the frequency of yourbackground questions diminishes, and your need increases forforeground clinical questions.

Answers to background questions are usually best foundin a general resource (e.g., textbook, reliable Web page) ratherthan in a specific research study. In contrast, foregroundquestions are specific to a particular patient, condition, and

14 SECTION I Finding and Appraising Evidence to Improve Patient Care

1 IdentifyClinicalQuestions

Search

Appraise

Integrate

Evaluate

Step

2Step1

3Step

4Step

5Step

Construct2

Identify the need for information and develop a focusedand searchable clinical question.

Conduct a search to find the best possible research evidence to answer your question.

Critically appraise the research evidence for applicabilityand quality.

Integrate the critically appraised research evidence withclinical expertise and the patients values and circumstances.

Evaluate the effectiveness and efficacy of your efforts inSteps 14 and identify ways to improve them in the future.

1Step

2Step

3Step

4Step

5StepF I GURE 2 . 1 EBP steps 1 and 2 discussed in this chapter.

1999

Number of Physical Therapy Clinical TrialsPublished Each Year from 1999 to 2009*

Year

20002001

20022003

20042005

20062007

20082009

2500

2000

1500

1000

500

0

*Search conducted in PubMed, limited to clinical trials and using the terms: physical rehabilitation or physical therapy treatment or physiotherapy.

F I GURE 2 . 2 The growing number of physical therapyrelated clinical trials published each year.

1716_Ch02_013-031 30/04/12 2:16 PM Page 14

clinical outcome of interest. Foreground questions are typically answered using a research study or evidence based clinicalpractice guideline. Electronic databases house thousands tomillions of articles and guidelines. To conduct an efficient andeffective search, you must first develop a focused, searchableclinical question.

What Is a Searchable Clinical Question?

Searchable clinical questions are foreground questions abouta patient that are structured to help you find the necessary research evidence as efficiently as possible. Many hours offrustration can be avoided by following a formula to focus your

search. Focused, searchable, clinical questions contain threeelements:

1. Patient characteristics: Include the most important patient characteristics that relate to a patients health condition.

2. Patient management (e.g., intervention, diagnosis, prognosis):Define the component of interest for patient management.Study designs differ for questions about interventions, diagnostic tests, and prognosis. By specifying the componentof patient management, you focus your question on a partic-ular type of research.

3. Outcome of interest: Determine your patients goals, andidentify an appropriate outcome. This is often difficult for

CHAPTER 2 Asking a Clinical Question and Searching for Research Evidence 15

F I GURE 2 . 3 Elements of patient/client management. From: American Physical Therapy Association: Guide to Physical Therapist Practice, ed 2. Author, Alexandria, VA, 2001; with permission.

Both the process and the end result ofevaluating examination data, which thephysical therapist organizes into definedclusters, syndromes, or categories tohelp determine the prognosis (includingthe plan of care) and the most appropriate intervention strategies.

Results of patient/client management,which include the impact of physical therapy interventions in the followingdomains: pathology/pathophysiology(disease, disorder, or condition);impairments, functional limitations, and disabilities; risk reduction/prevention;health, wellness, and fitness; societalresources; and patient/client satisfaction.

Determination of the level of optimalimprovement that may be attainedthrough intervention and the amount oftime required to reach that level. The plan of care specifies the interventions tobe used and their timing and frequency.

Purposeful and skilled interaction of the physical therapist with the patient/clientand, if appropriate, with other individualsinvolved in care of the patient/client,using various physical therapy methodsand techniques to produce changes in the condition that are consistent with thediagnosis and prognosis. The physicaltherapist conducts a reexamination to determine changes in patient/clientstatus and to modify or redirectintervention. The decision to reexaminemay be based on new clinical findings or on lack of patient/client progress. The process of reexamination also mayidentify the need for consultation with or referral to another provider.

The process of obtaining a history,performing a systems review, andselecting and administering tests andmeasures to gather data about thepatient/client. The initial examination is acomprehensive screening and specifictesting process that leads to a diagnosticclassification. The examination processalso may identify possible problems that require consultation with or referral toanother provider.

A dynamic process in which thephysical therapist makes clinicaljudgments based on data gatheredduring the examination. This process also may identify possibleproblems that require consultation with or referral to another provider.

Prognosis(Including Plan of Care)

Intervention

Outcomes

Evaluation

Examination

The Elements of Patient/Client Management Leading to Optimal Outcomes

Diagnosis

1716_Ch02_013-031 30/04/12 2:16 PM Page 15

new learners. Digging Deeper 2.1 will help you developthis skill more thoroughly.

PICO (Patient, Intervention, Comparison, Outcome)

PICO is an acronym that comprises the key components of asearchable clinical question about interventions. The lettersstand for the following:

n Patient (or Population) and clinical characteristicsn Intervention

n Comparison (referring to an alternative intervention)n Outcome

It is common to have PICO questions without a C (compar-ison). Table 2.1 illustrates two intervention PICO questions aboutJune Wilson.

Questions about diagnosis and prognosis do not conformas easily to the PICO framework but can be formulated intothree general parts. Diagnostic questions can include the diag-nostic test characteristcs (Question A) or the possible resultsfor a particular patient (Question B) (Table 2.2).

Questions may address a patient population rather than aspecific patient. Table 2.3 illustrates searchable clinical ques-tions about prognosis for a patient population (Question A) andfor an individual patient (Question B).

16 SECTION I Finding and Appraising Evidence to Improve Patient Care

Current Condition: Ms. Wilson is a 17-year-old female who presents to physical therapy with worsening neck pain over the past 2 weeks. Past Medical History: Previous episodes of similar neck pain with high intensity swim training. Medications: Ibuprofen 400 mg 3x/day for 1 week Disability/Social History: Ms. Wilson is a high school student and member of her schools swim team. She swims 10,000 yards 5 days per week. She has excelled in the current competition season and is scheduled to compete in the state high school championships (100 yard free-style, 100 yard individual medley) in three days. She has had progressively worsening neck pain that is exacerbated by swimming and prolonged sitting. Her sleep is slightly disturbed. Ms. Wilson lives with her parents who are present at the examination and supportive of her swimming activities.

Functional Status Sitting Tolerance: 30 minutes before onset of painaffects comfort in classroom and doing homework. Sleep: Difficulty falling asleep due to pain, difficult to find a comfortable position. Self-care: Slow in the AM due to morning stiffness but otherwise unlimited. Swimming: Able to complete full 10,000 yard workouts but with pain. Pain is worst with free-style and butterfly strokes. Swim speed has been only mildly affected by the injury ( 5%).

Impairments ROM: Limited cervical ROM for right rotation (45), side bend right (15), and extension (30)all with pain. Shouldersfull, pain-free range bilaterally. Strength: Bilateral shoulders 5/5 strength for all major muscle groups. Isometric testing of neck musculature reproduces pain for extension and right sidebend. No overt cervical muscle weakness. Pain: Neck pain average 4/10; radiates into her right arm to the elbow, interrupts her sleep (1 hour/night) and during swim practice it increases to 7/10. Better with ice, ibuprofen.

Patient Information Summary

Name: Wilson, JuneAge: 17

F I GURE 2 . 4 Information regarding patient June Wilson. Format from:Quinn & Gordon, Functional Outcomes Documentation for Rehabilitation, 2003.

TABLE 2.1 Example Searchable ClinicalQuestions About Interventions

QUESTION ELEMENT PICO QUESTION

1 Patient characteristics P For a 17-year-old female swimmer with neck pain . . .

2 Patient management: I is manual therapy or . . .Intervention C therapeutic exercise

more effective . . .

3 Outcome of interest O for improving functionand sport performance?

S e a r c h ab l e C l i n i c a l Qu e s t i o n :

For a 17-year-old female swimmer with neck pain, ismanual therapy or therapeutic exercise more effectivefor improving function and sport performance?

1 Patient characteristics P For a 17-year-old femaleswimmer with neck pain . . .

2 Patient management: I are manual therapy Intervention techniques effective . . .

3 Outcome of Interest O for short-term pain reduction?

S e a r c h ab l e C l i n i c a l Qu e s t i o n :

For a 17-year-old female swimmer with neck pain, aremanual therapy techniques effective for short-term painreduction?

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CHAPTER 2 Asking a Clinical Question and Searching for Research Evidence 17

CASE STUDY 2.1 Mr. Jose Lopez

Lets consider another patient, Jose Lopez. Figure 2.5 illustratessome basic information about him. Mr. Lopez is a 52-year-oldgrandfather. He works on a peach farm and has had increasingknee pain for the past 4 months. He is not aware of a specificmechanism of injury. His pain has become so severe that he isunable to pick peaches or carry his 5-year-old grandson.

Reflect on the information provided about Mr. Lopez.

1. Write your questions about his care.

2. Determine if each question is a background or a foregroundquestion.

3. Determine the component of patient management for eachquestion (diagnosis, intervention, or prognosis).

4. For the questions that you believe are foreground questions, underline the three key components: patient characteristics, patient management (diagnosis, intervention, or prognosis), andoutcome. If the question does not have all of those parts, tryrewriting.

n SELF-TEST 2.1 Writing Clinical Questions

The outcome(s) component of clinical questions refers to theparticular outcome of interest to the patient and/or clinician.When considering the outcome, the International Classificationof Function, Disability and Health (ICF) model (Fig. 2.6) mayhelp you to frame and focus your question.2

The World Health Organization is encouraging health profes-sionals to use a common language to communicate issues ofhealth and wellness. ICF terms include body functions and struc-tures, activity, and participation. Impairments describe problems

at the level of body functions and structures. Activity describes actions such as walking, climbing stairs, or getting out of bed. Problems with activity are referred to as activity limitations. Participation includes work, school, and community involvement;participation restrictions describes problems at this level.

An outcome is defined at the level of body structures and func-tion (e.g., pain, strength), at the activity level (e.g., prolonged sitting, swimming), or at the participation level (e.g., attend highschool, participate on a sports team).

D I G G I N G D E E P E R 2 . 1

CASE STUDY 2.2 Mr. Ed Dean

You are working with a 55-year-old truck driver, Ed Dean, whohas developed low back pain associated with prolonged periodsof sitting. When not working, Mr. Dean enjoys working on antique tractors and doing odd jobs around the house. He is married and has eight grandchildren.

List five outcome measures at the body structure and function,activity, and participation levels that pertain to Mr. Dean.

Use the outcome measures you have listed above under thethree ICF categories to complete the following foreground questions:

n For a 55-year-old truck driver with low back pain, is physicaltherapy care or chiropractic care more effective for________________________________________________?

n For a 55-year-old male with low back pain, are stabilization exercises or strength-training exercises more effective for ________________________________________________?

n For a 55-year-old male with low back pain, is bedrest or a walking program more likely to improve ________________________________________________?

n SELF-TEST 2.2 Practice Using the ICF Model

Body Structure and Function Activity Participation

Example: Lumbar Example: Example: spine range of Prolonged Occupationmotion sitting truck driver

1. 1. 1. 2. 2. 2.3. 3. 3.4. 4. 4.5. 5. 5.

International Classification of Functioning, Disability and Health

1716_Ch02_013-031 30/04/12 2:16 PM Page 17

STEP 2: Conduct a searchto find the best possibleresearch evidence toanswer your question

The second step in EBP involves searching for the bestavailable research evidence to answer your clinical question.Most often, you will accomplish this by searching a database. In the context of EBP, a database is a compilation of researchevidence resources, primarily lists of peer-reviewed journal arti-cles, designed to organize the large amount of research publishedevery year. Before choosing the best database to search, you willneed to decide which type of research evidence you want to find.

Which Types of Studies are You Looking for?

The Evidence Pyramid (Fig. 2.7) illustrates a hierarchy thatcan serve as an initial filter for identifying high-quality

evidence. Study designs at the top of the pyramid are leastlikely to produce biased results. Bias occurs when a studysresults are affected by unknown or unacknowledged errors re-sulting from the studys design or protocols. Your ability to rec-ognize different study types will improve as you proceedthrough the chapters of this book.

When searching for research evidence about interventions,first search for evidence based clinical practice guidelines, followed by systematic reviews, randomized controlled trials,and so on down the pyramid. Randomized controlled trials areoften not an