Evidence-Based Physiotherapy Practice Contact Author: Mary Ann O’Brien MSc, BHSc(PT) School of Rehabilitation Science McMaster University HSC 3H7 1200 Main Street West Hamilton Ont L8N 3Z5 Phone (905) 525-9140 ext 22344 Email [email protected]

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Evidence-Based Physiotherapy Practice Table of Contents Ø Introduction to Evidence-Based Physiotherapy Practice Ø Other resources for Evidence-Based Physiotherapy Ø Sample clinical scenarios, searches, critical appraisal worksheets and CATs for Physiotherapy

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Evidence-Based Physiotherapy Practice

Introduction to Evidence-Based Physiotherapy Practice

Thomson-O’Brien MA, Moreland J. Evidence-based Information Circle. Physiotherapy Canada 1998;50:171:205.

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Evidence-Based Physiotherapy Practice

Evidence-Based Practice Information Circle

Mary Ann Thomson-O’Brien1,2 Julie Moreland1,3

McMaster University1, Hamilton Health Sciences Corporation2 , St. Joseph’s Hospital3 Hamilton ON L8N 3Z5 Key Words: decision-making; information processing; critical appraisal Adapted from a presentation at the Canadian Physiotherapy Association Congress, June 1996, Victoria, British Columbia.

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Evidence-Based Physiotherapy Practice Abstract Physiotherapists make decisions at many points in the care of patients or clients, yet the information upon which we base these decisions may be of variable quality. The purpose of this paper is to present a model to integrate the activities of information processing, critical appraisal, evidence-based practice and continuing education into clinical decision-making. The Evidence-based Practice Information Circle model (EPIC) is constructed of concepts with a supporting framework, assumptions and theories. At the centre of the model are the fundamental clinical actions which occur between the client and the therapist. These clinical actions generate information needs, which elicit a circle of events leading back to clinical action. Several clinical problems relevant to physiotherapy are given as examples to illustrate the model. EPIC provides a framework for continuing clinical excellence in this era of health care reform. There are implications for undergraduate training as well as continuing education endeavours. The primary goal of physiotherapy is to provide the highest quality of care to achieve the best outcomes for clients in a cost-effective manner. The care process involves assessment, physical diagnosis or problem summary, identification of client-centred goals (outcomes), selection of effective therapeutic interventions and evaluation of progress. In order to make sound decisions throughout this process, physiotherapists require valid information.

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Evidence-Based Physiotherapy Practice Some information sources may be dependable such as published reports of rigorous clinical studies and validated theoretical models. Other conventional sources of information such as personal experience, peers, ‘experts’ and even medical textbooks may be subject to bias. For example, Antman et al1 found that standard medical textbooks contained some information which was out of date or even incorrect. A paradigm shift for the processing of information for medical practice has been suggested by the Evidence-based Working Group.2 Evidence-based medicine is founded on the examination of findings from sound clinical research. They propose that intuition, unsystematic clinical experience, and pathophysiological explanations be de-emphasized for the process of clinical decision-making. In a recent publication of the Canadian Physiotherapy Association, evidence-based practice (EBP) has been identified as a priority.3 The implementation of evidence-based practice may require upgrading of skills or even the acquisition of new skills. This has implications for the design of both undergraduate and continuing education. One preliminary skill is the ability to examine one's practice in order to identify opportunities for improvement. These opportunities may include utilizing the best diagnostic and assessment tools, carrying out the most effective treatment, accurately predicting the outcome of treatment, and being knowledgeable about etiological factors for health promotion and secondary prevention.

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Evidence-Based Physiotherapy Practice Given that we acknowledge that valid information is required, the busy clinician is faced with a formidable task. To obtain the required information, therapists need skills to utilize informatic tools such as computerized data bases for searching the literature and systems for storing relevant material. The availability of high quality information may be hampered by physical and financial access to computerized data bases, the large volume of available literature, the lack of user friendliness of research reports and the inconvenience of obtaining information.4 Once studies are located, critical appraisal skills are needed to evaluate whether the conclusions are valid and applicable to the treatment setting. The purpose of this paper is to provide a framework and model to help clinicians integrate EBP, critical appraisal, informatics and continuing education. Framework The framework for the model builds upon the following values and assumptions. 1. Using evidence derived from sound research will result in improved quality of care. 2. Evidence should be used to assist in decision-making. Other factors which contribute to decision-making include the client's individual problem, preferences and environment.

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Evidence-Based Physiotherapy Practice 3. Clinical experience is valuable in the many situations where there is no evidence. However, decisionmaking based solely on clinical experience may be biased. Experience is also valuable for generating research questions. 4. Professional values include the maintenance of a knowledge base which is current and based on research. This research should use valid methods (qualitative and quantitative) for designing and performing studies. Model The model5 (see Figure 1) of interaction between EBP, critical appraisal, informatics, and continuing education uses the following concepts and theories. Concepts The following definitions are used within this model. Informatics: The science concerned with systems and tools to gather, organize, process, store, transmit, and present information.6 Effective information management has become important due to the information

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Evidence-Based Physiotherapy Practice explosion and time constraints of busy clinicians. It is ideal to have access to relevant evidence in proximity to the patient care setting. Evidence: Anything that establishes a fact or gives reason for believing something.7 The strength of the evidence is related to the methods of obtaining it. Some methods are more subject to bias than others. For example, the evidence derived from a case series study is weaker than that derived from a randomized controlled trial.8 The potential for or the presence of bias in a research project calls into question the validity of the conclusions. Critical Appraisal: The evaluation of research papers to determine the validity and applicability of the conclusions. Guidelines have been published to assist readers. Separate guidelines are available for critically appraising papers on causation, diagnosis, natural history, prognosis, and treatment.9 Guidelines also exist for appraising literature reviews,10 practice guidelines,11 clinical decision analyses,12 and qualitative research.13 As a result of the critical appraisal process, a reader is able to judge how much confidence to place in the conclusions of the study and whether the results apply to their patients/clients. Evidence-based Practice: The process of using the results of sound research (as determined by critical appraisal) to guide clinical care within the context of the individual client and local environment. Continuing Education: Activities to directly or indirectly improve clinical competence so that clients may benefit from the best quality of care. The continuing education process may be traditional or informal and

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Evidence-Based Physiotherapy Practice done as an individual, small or large group. Traditional activities usually include attending inservices, conferences, courses and discussions with peers. Contemporary methods include identifying and critically appraising relevant literature, journal clubs, and small group discussions with peers targeted at specific patient problems.14 Practitioners may use informatics to help educate themselves about a specific patient problem. Regardless of the method, critical appraisal of information is important to ensure that it is founded on valid evidence or tested theories. Theories Underlying the Model 1. The client and physiotherapist form a fiduciary relationship within several internal and external contexts. The major external context is the health care setting. Internal contexts for the client include: economic, cultural, and educational background, their roles in their family and society and their vocational and avocational interests. For the physiotherapist, these contexts also include economic, cultural and educational background, personal beliefs, and community and administrative environments. 2. The major interactions between the client and physiotherapist involve: assessment, physical diagnosis or problem formulation, planning (including identification of important client-centred goals and outcomes, therapy and evaluation). These interactions define the nature of the information which physiotherapists will require. Other factors which will shape the search for information include the experience and

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Evidence-Based Physiotherapy Practice expertise (novice vs expert) of the physiotherapist and the degree of uncertainty about the client's problem. 3. Identifying information needs, locating, obtaining, critically appraising, and storing relevant information are the informatic processes which lead to evidence-based practice. 4. There are many factors which influence the adoption of relevant information into clinical practice. Information alone may not be adequate to change practice, however, it may serve to provide an impetus to change. Contemporary continuing education activities need to support evidence-based practice. These theories combine to form the Evidence-based Practice Information Circle (EPIC).

The model consists of three circles. The inner circle represents the interaction between the client and the therapist. At any point during the assessment and treatment process, the therapist may identify the need for further information in order to provide the best possible care. A number of questions may arise about the management of this client or a group of clients. For example, the effectiveness of different treatments may not be known by the therapist.

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Evidence-Based Physiotherapy Practice Once the information needs are specified, the middle circle represents the method which is used to obtain and process information. Traditionally, information has been located in textbooks or journals in libraries. The science of informatics has generated other options such as online and CD-ROM searching. MEDLINE and CINAHL databases are commonly used to obtain relevant citations. Sometimes computer searching may lead directly to the information which has been critically appraised as in the case of computerized journal clubs. Another example of computer accessible material is the Cochrane Library.15 This electronic journal is updated regularly and contains 65 systematic reviews on topics such as pregnancy and childbirth, schizophrenia, and stroke. Once the relevant articles have been critically appraised, the clinician must decide whether this information is applicable to their practice. This step provides a link back to the inner circle, the client-therapist interaction. Continuing education is a key component in the entire process since therapists may require new knowledge and skills at any point e.g. basic computer skills, searching, and critical appraisal skills. Traditional inservices or conferences may not be adequate to meet these needs. The outer circle represents the contexts which may have an impact on decision-making. Economic factors include the ability of society to fund treatment. Personal beliefs, the community and cultural environments may influence the type of treatment that the client may find acceptable. For the clinician, the influence of peers may be an important factor in deciding to use newly acquired information. The educational background (both undergraduate and continuing education) of the therapist may or may not have provided

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Evidence-Based Physiotherapy Practice the necessary skills to implement an evidence-based approach. The administrative environment such as workload expectations for the number of patients seen may make access to valid information sources difficult during the work day. Conversely, administrators and colleagues may expect therapists to provide care based on evidence. Case Scenarios In order to illustrate the model, two examples are provided. These are based upon actual situations encountered in two physiotherapy departments located in teaching hospitals. A physiotherapist received a referral for an older adult aged 78 years who was beginning to have problems moving about in her home. The client reported feeling exhausted after climbing and descending the stairs to her basement. Subjective and objective assessment revealed that muscle weakness was the primary problem. Before discussing possible treatments, the physiotherapist wonders how elderly individuals respond to strengthening exercises. The therapist identifies this as a need for information and schedules some time to go to the library. The search for information and the critical appraisal process are represented by the middle circle. The therapist decided to search the CINAHL and MEDLINE databases to determine if any recent clinical trials had been published. Three randomized controlled trials were identified. The librarian assisted the therapist

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Evidence-Based Physiotherapy Practice in obtaining the papers. In 1989, Hagberg et al16 conducted a trial of lower and upper body strengthening using Nautilus machines in adults aged 70 to 79 years. Subjects were randomized to a control group, an endurance training group and a resisted strengthening exercise group. Training sessions were done for 26 weeks, 3 times a week. The results showed that the experimental groups improved in endurance and strength respectively and this was statistically significant in comparison to the control group. There were no adverse effects reported. Critical appraisal of the study using criteria suggested by Guyatt et al 17,18 identified that there were few methodological flaws in the study with the exception of a potential for bias because of lack of blinding of the therapist performing the treatments and measuring their effectiveness. This may have resulted in a bias in favour of the treatment groups. Despite the potential for bias, this study provides reasonably strong evidence that muscle strength improves with resisted dynamic exercises in older adults. Charette et al19 reported a randomized controlled trial with women aged 64 to 86 years in which weight training was done for the knee and hip muscle groups for 12 weeks, 3 times a week. The control group did not receive an exercise program. The results of the study were statistically significant in that both one repetition maximum and type II fibre area increased. One of the subjects reported experiencing discomfort during the exercise. Critical appraisal of the study identified that the post-treatment assessment was not blinded and the control group did not receive a placebo intervention. These factors may have potentially biased the outcome in favour of the treatment group. Taking this into consideration, this study provides

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Evidence-Based Physiotherapy Practice moderately convincing evidence that resisted dynamic exercises improve strength in older women. One of the limitations of both studies was that none measured functional outcomes. Topp et al20 also performed a randomized controlled trial using a weight lift machine for adults over 65 years. The experimental group received dynamic resistance strength training three times per week for 12 weeks while the control group received a placebo intervention. There were statistically significant differences between the two groups for isokinetic strength but not for balance or gait velocity. It was unclear whether the sample size was large enough to detect a statistically significant difference for the last two variables. There were no adverse effects. Critical appraisal of the study revealed that there was adequate follow-up of participants. However, the outcome assessment was not blinded and there was potential for contamination and co-intervention which may have biased the results. Because of these factors, it is difficult to draw practical conclusions from this study. As a result of this information, the therapist discussed a strengthening program with the client and suggested that it take place three times a week for 12 weeks. The therapist also informed the client that there was a risk that some discomfort from the exercises may occur. The therapist also decided to include functional exercises for stair climbing, since the client had indicated that this was an important activity. The therapist monitored the response to treatment through periodic measurements of strength and stair climbing

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Evidence-Based Physiotherapy Practice function. Personal, economic, cultural, and educational factors (outer circle) were taken into consideration in implementing the treatment plan. As the second example, a group of physiotherapists who were treating individuals with stroke identified that they needed to measure gross motor outcomes in order to determine if the clients were improving (inner circle). One of the physiotherapists offered to search the literature for gross motor outcome measures. As a group, they decided to search for a measure which was reliable, valid (with longitudinal construct validity to demonstrate change) and responsive to change. From the MEDLINE and CINAHL databases and discussions with colleagues, seven assessments were identified and a table was developed (Table 1). As a result, the physiotherapists selected the instrument 21 which best met their inclusion criteria (middle circle). They incorporated this instrument into their practice as a valid and feasible (outer circle) way of measuring treatment outcomes.

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Evidence-Based Physiotherapy Practice Table 1 Summary of Gross Motor Assessments Test-retest Reliability (ICC or Kappa > .80)

Construct/Criterion Longitudinal Validity

Responsiveness

Chedoke-McMaster Yes Gross Motor Function and Walking (GMF) Inventory 21

Yes, rehab unit stroke patients

Yes, rehab unit stroke patients

Yes, rehab unit stroke patients

Motor Assessment Scale (MAS) 22

Not reported

Yes, patients who had reached a plateau, patients were > 5 months post-stroke

Yes, rehab unit stroke patients

Not reported

Clinical Outcome Variables Scale 23

Not reported

Yes, rehab unit patients, 5 patient programs

Not reported

Not reported

Modified Chart for Motor Capacity Assessment 24

Not reported

Not reported

Not reported

Not reported

Functional Mobility Yes, Not reported 25 Assessment Tool professional consensus

Not reported

Not reported

Rivermead Stroke Assessment 26

Not reported

Not reported, Pearson cor. of .66 for gross motor function

Not reported

Not reported

Ashburn Physical Assessment for Stroke Patients 27

Not reported

Not reported

Not reported

Not reported

Measure

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Evidence-Based Physiotherapy Practice Discussion Two of the major assumptions of the framework is that high quality evidence exists and that evidence-based practice improves quality of care. In many areas of physiotherapy, evidence does not exist. Many of the orthopaedic joint mobilization techniques have not been evaluated. Since mobilizations are dependent upon individual patient findings, they are difficult to study using traditional group designs. N of 1 studies may be helpful in this area. Some authors suggest that grey areas of practice where evidence is incomplete or conflicting will always exist.28,29 Other barriers to incorporating evidence into practice may include problems with the research methods and applicability of the studies. Examples of problems with the study methods include failure of the randomization process and loss of patients to follow-up. For example, Inaba et al 30 studied progressive resisted exercises in patients undergoing rehabilitation following a stroke. The results were positive at one month; however, at two months, the results were not significant. Since 56% of the patients were not available for testing, this loss to follow-up may have resulted in a systematic bias which may have strengthened or weakened the conclusion. The reader cannot tell if patients were not available because they were worse off or because they improved. This presents the clinician with a dilemma. In light of insufficient evidence, the clinician may need to rely on the following sources of information in decreasing order of rigour: substantiated theory, unsubstantiated theory, expert opinion, and clinical experience. In

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Evidence-Based Physiotherapy Practice these cases, it is paramount for clinicians to objectively document their treatments and outcomes. This type of documentation provides a clear indication of the client's response to treatment and these data may suggest research questions. Another problem may be the limited applicability of the findings. For example, the sample may be very narrowly defined. Przybylski et al 31 found that decreasing the ratios of nursing home residents to physiotherapists from 200:1 to 50:1 resulted in improved function. Generalization of this finding to patients on maintenance programs in acute hospitals would be questionable if the patients in nursing homes are substantially different from those in acute hospitals. The implementation of evidenced-based practice has not been evaluated in physiotherapy. It is not clear that using evidence to make decisions will result in improved quality of care for patients although this is a logical assumption. Practice guidelines which are systematically developed approaches to guide clinicians’ and clients’ health care choices for specific problems have been studied in physicians. Grimshaw and Russell 32 conducted a systematic review of the effect of clinical guidelines on medical practice. They reported that 55 of 59 studies detected significant improvements in the process of care while nine of 11 studies demonstrated significant improvement in patient outcomes. Browman et al 199533 have provided a framework to assist clinicians to develop guidelines based on evidence from clinical studies.

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Evidence-Based Physiotherapy Practice It may not be reasonable to expect the busy clinician to have the skills or time necessary to search, obtain, and critically appraise relevant articles. What processes would assist us to use evidence as a basis for our practice? The availability of systematic research reviews and meta-analyses, evidence-based practice guidelines, journal clubs in which members critically appraise papers or topics may facilitate this process. There may be a place for consensus conferences in the development of practice guidelines but unless they are based on evidence, they may be biased. Further, consensus conferences have been ineffective in changing the practice of physicians.34 Newer technologies such as electronic textbooks, reference management software and clinical informatics networks may prove useful. Perhaps the most promising method of implementing evidence-based practice is to assist undergraduate students to acquire skills as information consumers. Obviously, there would be a lengthy lead-in time before a sufficient number of physiotherapists graduate and percolate into the health care system. Other promising methods include better linkage between academic programs in physiotherapy and the clinical communities. Conclusion Physiotherapists face a great challenge in trying to integrate sound research findings into their clinical practice. Barriers include the amount of new information, as well as a lack of skills in accessing and appraising relevant studies. The EPIC Model provides a framework for continuing clinical excellence by

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Evidence-Based Physiotherapy Practice linking clinical decision-making and relevant research. Future directions include exploring the relationship between implementation of evidence-based practice and quality of care. In addition, we need to develop strategies to cope with situations where evidence does not exist or is conflicting. Those responsible for undergraduate curriculum development and continuing education endeavours have a key role in facilitating the process of implementing valid research findings in clinical practice. References 1 2

Antman EM, Lao J, Kupelnick B, Mosteller F, Chalmers TC. A comparison of results of meta-analyses of randomized control trials and recommendations of clinical experts: treatments for myocardial infarction. JAMA 1992:268:240-248. Evidence Based Medicine Working Group. Evidence Based Medicine: a new approach to teaching the practice of medicine. JAMA. 1992:268:2420-2425.

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Contact, Official Newsletter of the Canadian Physiotherapy Association. 1995:December 1994/January:2. Bohannon RW, LeVeau BF. Clinicians' use of research findings: a review of literature with implications for physical therapists. Phys Ther 1986:66:45-50.

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Moreland J, Thomson MA. The relationship of evidence-based practice, critical appraisal of the literature, and CLINT. unpublished. School of Occupational Therapy and Physiotherapy, McMaster University, December 1994. Van Nostrant/Reinholt Dictionary of Information Technology, Third Edition 1989.

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The Oxford Paperback Dictionary, Oxford University Press, Oxford 1979.

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Evidence-Based Physiotherapy Practice 8 9 10 11 12

Sackett DL. Rules of evidence and clinical recommendations on the use of antithrombotic agents. Chest 1992:102:305S311S Oxman AD, Sackett DL, Guyatt GH, et al. Users' guides to the medical literature. How to get started. JAMA 1993:270:2093-2095. Oxman AD, Cook DJ, Guyatt GH. Users' guides to the medical literature. VI. How to use an overview. JAMA 1994:272:1367-71. Hayward RS, Wilson MC, Tunis SR, Bass EB, Guyatt G. Users' guides to the medical literature. VIII. How to use clinical practice guidelines. A Are the recommendations valid? JAMA 1995:274:570-4. Richardson WS, Detsky AS. Users' guides to the medical literature. VII How to use a clinical decision analysis. A Are the results of the study valid? JAMA 1995:273:1292-5.

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Morse JM. Evaluating qualitative research. Qualitative Health Research. 1991:1:283-286. Evidence-Based Care Resource Group. Evidence-based care: improving performance: how can we improve the way we manage this problem. Can Med Assoc J 1994:150:1793-1796.

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Cochrane Library, BMJ Publishing Group and Update Software, London, England, 1995. Hagberg JM, Graves JE, Limacher M, et al. Cardiovascular responses of 70-to 79-yr-old men and women to exercise training. J Appl Physiol 1989:66:2589-2594.

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Guyatt GH, Sackett DL, Cook DJ, et al. Users' guides to the medical literature. II. how to use an article about therapy or prevention. A. Are the results of the study valid? JAMA 1993:270:2598-2601. Guyatt GH, Sackett DL, Cook DJ, et al. Users' guides to the medical literature. II. how to use an article about therapy or prevention. B. What were the results and will they help me in caring for my patients? JAMA 1994:271:59-63.

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Evidence-Based Physiotherapy Practice 19 20 21 22 23 24 25 26 27 28 29 30

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Charette SL, McEvoy L, Pyka G, et al. Muscle hypertrophy response to resistance training in older women. J Appl Physiol. 1991:70:1912-1916. Topp R, Michesky A, Wigglesworth J, et al. The effect of a 12-week dynamic resistance strength training program on gait velocity and balance of older adults. The Gerontologist 1993:33:501-506. Gowland C, Stratford P, Ward M, et al. Measuring physical impairment and disability with the Chedoke-McMaster Stroke Assessment. Stroke 1993:24:58-63. Carr JH, Shepherd RB, Nordholm L, Lynne D. Investigation of a new motor assessment scale for stroke patients. Physical Therapy 1985:65:175-180. Poole JL, Whitney SL. Motor assessment scale for stroke patients: concurrent validity and interrater reliability. Arch Phys Med Rehabil 1988:69:195-197. Seaby L, Torrance G. Reliability of a physiotherapy functional assessment used in a rehabilitation setting. Physiotherapy Canada 1989:41:264-271. Badke MB, DiFabio RP, Leonard E et al. Reliability of a functional mobility assessment tool with application to neurologically impaired patients: a preliminary report. Physiother Can 1993:45:15-20. Lincoln N, Leadbitter D. Assessment of motor function in stroke patients. Physiotherapy 1979:65:48-51. Ashburn A. A physical assessment for stroke patients. Physiotherapy 1982:68:109-113. Naylor CD. Grey zones of clinical practice: some limits to evidence-based medicine. The Lancet 1995:345:840-842. Rees J. Where medical science and human behaviour meet. BMJ 1995:310:850-853. Inaba M, Edberg E, Montgomery J, et al. Effectiveness of functional training, active exercise and resistive exercise for patients with hemiplegia. Phys Ther 1973:53:28-30. CD Contents ã

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Evidence-Based Physiotherapy Practice 31

32. 33.

34.

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Przybylski B, See D, Watkins M. A study of the outcomes of enhanced physical therapy and occupational therapy hours of service to long term care residents in a nursing home setting. A project submitted to the Long Term Care Branch, Alberta Health, Sept. 1993, Alberta, Canada. Grimshaw J, Russell I. The effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet.1993:342:1317-22. Browman GP, Levine MN, Mohide EA, Hayward RSA, Pritchard KI, Gafni A, Laupacis A. The practice guidelines development cycle: a conceptual tool for practice guidelines development and implementation. J Clin Oncol 1995:13:502512. Lomas J, Anderson GM, Domnick-Pierre K, Vayda E, Enkin MW, Hannah WJ. Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians. N Engl J Med 1989:321:1306-11.

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Evidence-Based Physiotherapy Practice Other sources of Evidence-Based Physiotherapy

Cochrane Rehabilitation and Related Therapies Field Contact Dr. Henrica (Riekie) de Vet Department of Epidemiology University of Limburg Email: [email protected] Orthopaedic Division Review Orthopaedic Division of the Canadian Physiotherapy Association September/October 1998 Issue Evidence-Based Practice Email: [email protected] Note: The entire issue was devoted to different aspects of evidence-based physiotherapy practice in orthopaedics including selecting the best clinical diagnostic tests and measurement of functional status, progress, and outcome.

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Evidence-Based Physiotherapy Practice

Sample scenarios, searches, completed worksheets and CATs for Physiotherapy A. Diagnosis Section Authors: Anita Gross, Ted Haines, Diane Hartley. Contact Details: Anita Gross fax (905) 521-5090 Clinical Scenario A 24 year old woman with a gradual onset of left temporomandibular joint (TMJ) pain after yawning 10 days ago, reports severe worsening over the past 5 days resulting in a change to a soft diet. Her past history reveals recurrent episodes of jaw joint locking. Clinical findings are reduced mouth opening (maximum active opening 35mm, passive opening 36 mm), right laterotrusion (5mm) and a reproducible reciprocal click (early on opening and late on closing). There is no crepitus. Some local muscle tenderness exists (masseter, medial pterygoid). There is reduced joint play. Tomography results in the medical record

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Evidence-Based Physiotherapy Practice demonstrated diminished anterior translation of both condyles. No osseous changes were noted. The clinical impression is internal derangement. You wonder if your diagnosis is correct, so you develop the following question and make plans to search MEDLINE: “Is your clinical impression of temporomandibular joint disorder (internal derangement) correct for your patient with the following clinical [history of locking, preauricular pain, reproducible and reciprocal click, local muscle tenderness, reduced joint play, reduced mouth opening (35 mm)] plus tomography findings (diminished anterior translation of both condyles, no osseous changes)? Is this diagnostic impression important for clinical management? You do a MEDLINE search (1988 - 1998) using the MESH heading ‘temporomandibular joint disorders’ and find one article assessing a cluster of clinical tests and tomography: Citation Schiffman EL, Anderson GC, Fricton JR, Burton K, Schellhas KP. Diagnostic criteria for intrarticular temporomandibular disorders. Community Dent Oral Epidemiol 1989;17:252-257. Read this article and decide:

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Evidence-Based Physiotherapy Practice 1. Is the evidence from this study valid for the clinical diagnosis? 2. If valid, is this evidence important? 3. If valid and important, and if your patient was shown to have internal derangement can you apply this evidence in caring for your patient?

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Evidence-Based Physiotherapy Practice DIAGNOSTIC WORKSHEET Citation: Schiffman EL, Anderson GC, Fricton JR, Burton K, Schellhas KP. Diagnostic criteria for intrarticular temporomandibular disorders. Community Dent Oral Epidemiol 1989; 17:252-257. Are the results of this diagnostic study valid? Schiffman et al 1989

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1. Was there an independent, blind comparison with a reference (‘gold’) standard of diagnosis?

A blind comparison was made. However, it is not clear if the reference test (arthrotomography) was performed independent of the clinical tests. The validity of the reference standard is not specified. No convincing evidence was provided in the article to support that this test is the best reference or gold standard. There is some evidence that MRI is the best reference standard.

2. Was the diagnostic test evaluated in an appropriate spectrum of patients (like those in whom it would be used in practice)?

A representative mix of cases appears to be present.

3. Was the reference standard applied regardless of the diagnostic test result?

Yes

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Evidence-Based Physiotherapy Practice Are the valid results of this diagnostic study important? YOUR CALCULATIONS: Study Setting: tertiary care Target disorder: internal derangement Reference standard: arthrotomography Diagnostic test: diagnostic criteria for intraarticular TM disorder (Table 3 of the paper) included positive history of mandibular limitation, no reciprocal click, no coarse crepitus, maximum opening less than or equal to 35 mm, passive opening stretch less than 40 mm, contralateral movement less than 7 mm, no S-curve deviation and tomography findings of decreased translation of the ipsilateral condyle. Internal Derangement of TMJ Present Diagnostic Criteria (Sample A)

Positive Negative Totals

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Absent

43

a

b

2

a+b

7

c

d

8

c+d

50

a+c

b+d

10

a+b+c+d

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Schiffman et al 1989 (Sample A)

*

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Sensitivity* = a/(a+c)

0.86

Specificity* = d/(b+d)

0.80

Likelihood ratio for a positive test = LR+ = sens/(1spec)

4.30

Likelihood Ratio for a negative test = LR- = (1sens)/spec

0.18

Positive Predictive Value = a/(a+b)

0.96

Pre-test Probability (prevalence) = (a+c)/(a+b+c+d)

0.83

0.50

0.20

Pre-test odds = prevalence/(1-prevalence)

4.88

1.00

0.25

Post-test odds (+ test) = Pre-test odds x LR+

20.99

4.3

1.08

Post-test odds (- test) = Pre-test odds x LR-

0.86

0.18

0.05

Post-test Probability (+ test) = Post-test odds/(post-test odds +1)

0.95

0.81

0.52

Post-test Probability (- test) = Post-test odds/(post-test odds +1)

0.46

0.15

0.05

Sensitivity and specificity are reported in the text and the marginal total for a+c and b+d were reported in table 2. No further data were available to allow for extraction of the 2x2 table (cells a, b, c, d). The highlighted segments of the above table reflect the Schiffman et al 1989 sample A results. To assist the reader in applying these clinical findings, the additional calculations present calculations for a low (e.g. 0.20) and intermediate (e.g. 0.50) pre-test probability / prevalence. CD Contents ã

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Evidence-Based Physiotherapy Practice Can you apply this valid, important evidence about a diagnostic test in caring for your patient?

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Is the diagnostic test available, affordable, accurate, and precise in your setting?

Yes. History, clinical evaluation and tomography are commonly available, affordable, done accurately (the imaging protocol would need to be determined per site) and precisely in our community.

Can you generate a clinically sensible estimate of your patient’s pre-test probability (from practice data, from personal experience, from the report itself, or from clinical speculation)?

This is dependent on the reader’s data management system available in the practice setting. The prevalence in the study sample was 0.83.

Will the resulting post-test probabilities affect your management and help your patient? (Could it move you across a test-treatment threshold? Would your patient be a willing partner in carrying it out?)

Yes. If the pretest probability is a toss-up (e.g. 0.50) the post-test probability for positive test results firms up to 81%. However, if the pretest probability is low (e.g. 0.20), neither a positive nor a negative test result brings the post-test probability into a range where intervention would likely change (0.05, 0.52 respectively). Similarly, for the high pretest probability (e.g. 0.83, as in Schiffman et al 1989) a negative test result does not exclude internal derangement (post-test probability = 0.46) and a positive result further confirms your previous strong clinical impression. The tests are of minimal risk to the patient and therefore one should be willing to carry them out.

Would the consequences of the test help your patient?

Marginally to definitely Yes depending on the prevalence of ID in your practice setting. The treatment for internal derangement differs to some extent in physiotherapy management from other TMD. It would be more informative if the LR+ for each subgroup (for example: internal derangement with reduction and without reduction) were reported.

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Evidence-Based Physiotherapy Practice Comments and Additional Notes: 1. In Schiffman et al 1989, the assumption is made that there were no missing data. Table 4 notes that 10% of the normals of sample A and 27% with the disorder were not classifiable. This is contrary to table 2 where the sample number are noted to be as follows: target disorder present n = 50, target disorder absent n =10. 2. see also Schiffman E, Haley D. Sensitivity and specificity of diagnostic criteria for temporomandibular internal derangements. J Dent Res 1994;73(1 NSI):440.

TEMPOROMANDIBULAR JOINT DISORDERS: CLINICAL EXAM MAY BE HELPFUL IN THE DIAGNOSIS Clinical Bottom Line: If the pre-test probability is intermediate (e.g. 50%), the post-test probability for positive test results increases to 81%. The validity of the reference standard was not specified in the article; there is evidence that MRI may be the best reference standard.

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Evidence-Based Physiotherapy Practice Citation: Schiffman EL, Anderson GC, Fricton JR, Burton K, Schellhas KP. Diagnostic criteria for intrarticular temporomandibular disorders. Community Dent Oral Epidemiol 1989; 17:252-257

Clinical question: Is your clinical diagnosis of: internal derangement correct when presented with a patient with the following clinical [history of locking, preauricular pain, reproducible and reciprocal click, reduced mouth opening (35 mm), local muscle tenderness, reduced joint play] and tomography findings (diminished anterior translation of both condyles, no osseous changes)? Search terms: You do a MEDLINE search (1988 - 1998) using the MESH heading ‘temporomandibular joint disorders’ you find one article assessing a cluster of clinical tests and tomography.

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Evidence-Based Physiotherapy Practice The Study: 1. Gold Standard A reference test (arthrotomography) was used. A blind comparison was made. However, it was not clear if the reference test was performed independently of the clinical tests. The validity of the reference standard was not specified. 2. Study Setting - tertiary care 3. The Evidence

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Diagnostic Criteria

Internal Derangement

No Internal Derangement

Likelihood Ratio

Present

43/50

2/10

4.30

Absent

7/50

8/10

0.18

50

10

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Evidence-Based Physiotherapy Practice If the pre-test probability is intermediate (e.g. 50%) then a positive clinical test would be helpful, yielding a post-test probability of 81%. If the pre-test probability is low (e.g. 20 %) then the clinical test is not useful (post-test probability = 52%). Comments 1. Diagnostic test: diagnostic criteria for intraarticular TM disorder (Table 3 of the paper) included positive history of mandibular limitation, no reciprocal click, no coarse crepitus, maximum opening less than or equal to 35 mm, passive opening stretch less than 40 mm, contralateral movement less than 7 mm, no S-curve deviation and tomography findings of decreased translation of the ipsilateral condyle. 2. Uncertain if the reference standard that was used was the best available 3. Unclear if the reference standard performed independently of the clinical tests Appraised by: Anita Gross; February 16, 1999. Expiry date: 2001

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Evidence-Based Physiotherapy Practice B. Prognosis Section Authors: Bert Chesworth, Mary Ann O'Brien Clinical Scenario You are a newly graduated physiotherapist working in an out-patient clinic. Your client, a 22 year old male university student, had an open surgical repair of his torn left anterior cruciate ligament 8 weeks ago. In your discussion of treatment goals, he tells you he hopes to be able to return to intramural basketball. You decide that you need more information so you plan to search MEDLINE on-line at the end of the day. Prior to searching, you form the following question: “In people who have had an open surgical repair to the anterior cruciate ligament, what are the chances of returning to strenuous sport?” Search Terms Knee injuries (MeSH), anterior cruciate ligament repair (text word) combined with randomized controlled trials (MeSH), random allocation (MeSH) searched from 1988-1998

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Evidence-Based Physiotherapy Practice Citation Andersson C, Gillquist J. Treatment of acute isolated and combined ruptures of the anterior cruciate ligament. Am J Sport Med 1992;20:7-12. Read this article and decide: 1. Is the evidence about prognosis valid? 2. Is this valid evidence about prognosis important? 3. Can you apply this valid and important evidence about prognosis in caring for your client?

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Evidence-Based Physiotherapy Practice PROGNOSIS WORKSHEET: page 1 of 2 Andersson C, Gillquist J. Treatment of acute isolated and combined ruptures of the anterior cruciate ligament. Am J Sport Med 1992;20:7-12. Are the results of this prognosis study valid? Yes 1. Was a defined, representative sample of patients assembled at a common (usually early) point in the course of their disease?

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2. Was patient follow-up sufficiently long and complete?

Yes up to 52 months

3. Were objective outcome criteria applied in a blind fashion?

No

4. If subgroups with different prognoses are identified, was there adjustment for important prognostic factors?

Looked at patients with isolated anterior cruciate injuries as well as those with combined injuries e.g. meniscal tears

5. Was there validation in an independent group (test-set) of patients?

No

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Evidence-Based Physiotherapy Practice PROGNOSIS WORKSHEET: page 2 of 2 Are the valid results of this prognosis study important?

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1. How likely are the outcomes over time?

13/23 (57%) at a mean follow-up time of 52 months

2. How precise are the prognostic estimates?

95% confidence interval: 37% to 77%

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Evidence-Based Physiotherapy Practice If you want to calculate a Confidence Interval around the measure of Prognosis: Clinical Measure Proportion (as in the rate of some prognostic event, etc) where:

Standard Error (SE) Ö {p x (1-p) / n} where p is proportion and n is number of patients

the number of patients = n the proportion of these patients who experience the event = p

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Typical calculation of CI If p = 13/23 = 0.57 (or 57%) & n=23 SE= Ö {0.57 x (1-0.57) / 23} = 0.103 (or 10.3%) 95% CI is 57% +/- 1.96 x 10.3% or 36.8% to 77%

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Can you apply this valid, important evidence about prognosis in caring for your patient? Not Clear 1. Were the study patients similar to your own?

2. Will this evidence make a clinically important impact on your conclusions about what to offer or tell your patient?

This evidence will provide long term guidance but isn’t helpful in the short term.

Additional Notes:

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Evidence-Based Physiotherapy Practice OPEN ACL REPAIR: CHANCE OF RETURNING TO SPORT AFTER SURGERY Clinical Bottom Line 57% (95% CI 37 to 77%) chance of returning to sport 4 years after surgical repair of an isolated tear of the anterior cruciate Citation: Andersson C, Gillquist J. Treatment of acute isolated and combined ruptures of the anterior cruciate ligament. Am J Sport Med 1992;20:7-12. Clinical question: In people who have had an open surgical repair to the anterior cruciate ligament, what are the chances of returning to strenuous sport?”

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Evidence-Based Physiotherapy Practice Search Terms Knee injuries (MeSH), anterior cruciate ligament repair (text word) combined with randomised controlled trials (MeSH), random allocation (MeSH) searched from 1988-1998 The Study 107 patients with acute knee injury examined by arthroscopy under anaesthesia. There were four groups: Group A included 24 patients with an isolated ACL tear that was repaired and augmented surgically. Group B included 31 patients with an isolated ACL tear that was not repaired. Group C included 24 patients who had an ACL tear combined with an MCL tear and both were repaired. Group D consisted of 28 patients with both ACL and MCL tears where only the MCL was repaired. The Evidence The Outcome: return to sport Well-defined sample at uniform (early) stage of illness..?, yes; Follow-up long enough..?, yes; Follow-up complete..?, yes; Blind and objective outcome criteria..?, no; Adjustment for other prognostic factors..?, no; Validation in an independent "test-set" of patients..?, no

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Evidence-Based Physiotherapy Practice THE EVIDENCE: (FOR GROUP A) Prognostic Factor

Outcome Time

Measure Confidence Interval 57% 37% to 77%

Isolated injury

Return to sport

52 months

Combined injury

Return to sport

52 50% months

29% to 71%

Comments: 1. 2. 3. 4.

Potentially important prognostic factors were not adjusted for. Outcome assessment was not blind. Allocation to groups was by alternation. The patients had surgery between 1980-1985 in Sweden. Given the dates of surgery and surgical technique, it is unclear if the results would be applicable to current standards of practice.

Appraised by Chesworth and OBrien 1999; Expiry date: 2001

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Evidence-Based Physiotherapy Practice C. Therapy Section Author: Jean Crowe, Mary Ann O'Brien Email: [email protected] Clinical Scenario You have recently started working as a physiotherapist on a post-surgical unit. The unit is very busy and you are the only physiotherapist. You are wondering whether you should provide prophylactic physiotherapy for all patients undergoing upper abdominal surgical procedures. You decide to visit the hospital librarian to plan a search for up to date information. Your questions is: ‘Is prophylactic physiotherapy for patients undergoing upper abdominal surgery effective in preventing post-operative pulmonary complications?’ Search Terms: physical therapy (MeSH), postoperative pulmonary complications (textword) were used to search the current MEDLINE file. You located the following article:

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Evidence-Based Physiotherapy Practice Citation: Fagevik Olsen M, Hahn I, Nordgren S, Lonroth H, Lundholm K. Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery. British Journal of Surgery 1997;84:1535-1538. Read this article and decide: 1. Is the evidence from this randomised trial valid? 2. If valid, is this evidence important? 3. If valid and important, can you apply this evidence in caring for your patient?

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Evidence-Based Physiotherapy Practice SAMPLE COMPLETED THERAPY WORKSHEET: page 1 of 2 Citation: Fagevik Olsen M, Hahn I, Nordgren S, Lonroth H, Lundholm K. Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery. British Journal of Surgery 1997;84:15351538. Are the results of this single preventive or therapeutic trial valid? Was the assignment of patients to treatments randomised? Yes -and was the randomisation list No concealed?

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Were all patients who entered the trial accounted for at its conclusion? -and were they analysed in the groups to which they were randomised?

Yes (control 192/194; experimental 172/174) No

Were patients and clinicians kept “blind” to which treatment was being received?

Not possible to blind patients. Outcome assessors were not blind.

Aside from the experimental treatment, Were the groups treated equally?

Yes

Were the groups similar at the start of the trial?

Yes

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Evidence-Based Physiotherapy Practice Are the valid results of this randomised trial important? YOUR CALCULATIONS:

Post-operative Pulmonary Complications (all patients) CER EER

0.27

0.06

Relative Risk Reduction RRR

Absolute Risk Reduction ARR

CER - EER CER 79% 52% to 100%

CER - EER

Number Needed to Treat NNT 1/ARR

21% 14% to 29%

5 (4-8)

Relative Risk Reduction RRR

Absolute Risk Reduction ARR

CER - EER CER 71% 33% to 100%

CER - EER

Number Needed to Treat NNT 1/ARR

36% 17% to 56%

3 (2-6)

YOUR CALCULATIONS:

Post-operative Pulmonary Complications (high risk patients) CER EER

0.51

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Evidence-Based Physiotherapy Practice SAMPLE THERAPY WORKSHEET: page 2 of 2 Can you apply this valid, important evidence about therapy in caring for your patient? Do these results apply to your patient? Is your patient so different from those in the trial that its results Similar can’t help you?

How great would the potential benefit of therapy actually be for your individual patient?

Similar

Method I: f

Risk of the outcome in your patient, relative to patients in the trial. Expressed as a decimal: 1

Method II: 1 / (PEER x RRR)

NNT/F = _5__/__1__ = ____5__ (NNT for patients like yours) Your patient’s expected event rate if they received the control treatment: PEER:______

1 / (PEER x RRR) = 1/________ = _______ (NNT for patients like yours) Are your patient’s values and preferences satisfied by the regimen and its consequences? Do your patient and you have a clear assessment of their values and preferences?

Are they met by this regimen and its consequences?

Needs to be addressed in each patient

Needs to be addressed in each patient

Additional Notes: 1. Need to know the post-operative pulmonary complication rate for my unit.

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Evidence-Based Physiotherapy Practice UPPER ABDOMINAL SURGERY - PERIOP PHYSIO DECREASES POSTOP PULMONARY COMPLICATIONS Clinical Bottom Line: Perioperative physio decreases post-op pulmonary complications in patients undergoing upper abdominal surgery (NNT=5).

Citation: Fagevik Olsen M, Hahn I, Nordgren S, Lonroth H, Lundholm K. Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery. British Journal of Surgery 1997;84:1535-1538. Clinical Question Is prophylactic physiotherapy for patients undergoing upper abdominal surgery effective in preventing postoperative pulmonary complications?

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Evidence-Based Physiotherapy Practice Search Terms: physical therapy (MeSH), postoperative pulmonary complications (textword) were used to search the current MEDLINE file. You located the following article: The Study: Non-blinded non-randomised trial without intention-to-treat. The Study Patients: Series of 368 consecutive patients aged 19-92 (mean 53.4 years) undergoing elective open abdominal surgery in Goteborg, Sweden. The baseline characteristics (sex, age, height, weight, smoking status, existing lung disease, high risk status, and American Society of Anesthesiologists score) were similar in both groups. The study design was described as randomized but used alternation by month. Control group (N = 194; 192 analysed): Patients did not receive any information or training Experimental group (N = 174; 172 analysed): Patients were seen the day before surgery and post operatively and given information and training. The training consisted of pursed lip breathing exercises, huffing, and coughing to be done hourly as well as information about positioning changes while in bed and early mobilization. High risk patients received positive respiratory pressure (PEP) masks. Patients were told to take 30 deep breaths with huffing and coughing after every 10th breath every hour during the daytime after the surgery. The duration of physiotherapy was 10-15 minutes prior to surgery and 15-20 minutes after the operation.

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Evidence-Based Physiotherapy Practice The Evidence: Outcome Post-operative pulmonary complication PPC(all patients) 95% Confidence Intervals: PPC (high risk patients) 95% Confidence Intervals: Pneumonia (all patients) 95% Confidence Intervals:

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Time to Outcome 1-6 days

1-6 days

1-6 days

CER

EER

RRR

ARR

NNT

27%

6%

79%

21%

5

14% to 29% 36%

4 to 8

15%

52% to 100% 71%

17% to 56% 6%

2 to 6

6%

33% to 100% 91% 36% to 100%

3% to 10%

11 to 41

51%

6.8%

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Evidence-Based Physiotherapy Practice Comments: 1. The limitations of the study were lack of true randomisation (alternation by month was used) and lack of blind outcome assessment. 2. A post-operative pulmonary complication was defined as oxygen saturation less than 92% OR two of the following three criteria: temperature greater than 38.2 degrees C, auscultation findings and x-ray changes.

Appraised by: Jean Crowe, Mary Ann O'Brien; January 1999, Update By: January 2001.

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Evidence-Based Physiotherapy Practice D. Systematic Reviews Section Author: Mary Ann O'Brien Email: [email protected] Clinical scenario You receive a referral for a 65-year-old woman with a diagnosis of chronic obstructive pulmonary disease (COPD). She tells you that her main problems are breathlessness, fatigue, and general weakness. She feels her quality of life has been getting worse because she is too tired to leave the house and visit friends and family. A friend has been to an in-patient exercise program in the hospital and she wonders if this type of program would help her. Together you formulate a question: “In a patient with chronic obstructive pulmonary disease, does an in-patient pulmonary rehabilitation program improve strength, endurance, and quality of life?” You search MEDLINE using the terms ‘pulmonary rehabilitation’ and ‘chronic obstructive airways disease’ and find a promising systematic review.

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Evidence-Based Physiotherapy Practice LacasseY, Wong E, Guyatt GH, King D, Cook DJ, Goldstein RS. Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease. Lancet 1996;348:1115-9. Read the systematic review and decide, 1. Is the evidence from this systematic review valid? 2. Is this valid evidence from this systematic review important? 3. Can you apply this valid and important evidence from this systematic review in caring for your patient?

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Evidence-Based Physiotherapy Practice SYSTEMATIC REVIEW (of Therapy) WORKSHEET: page 1 of 2 Citation: LacasseY, Wong E, Guyatt GH, King D, Cook DJ, Goldstein RS. Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease. Lancet 1996;348:1115-9. Are the results of this systematic review (systematic review) of therapy valid? YES Is it a systematic review of randomised trials of the treatment you’re interested in?

Does it include a methods section that describes: Finding and including all the relevant trials? Assessing their individual validity?

Were the results consistent from study to study?

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YES

YES

Consistent results for health related quality of life (dyspnoea, and control over CAL). Functional exercise capacity results showed heterogeneity that could not be explained by sensitivity analysis.

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Evidence-Based Physiotherapy Practice SYSTEMATIC REVIEW (of Therapy) WORKSHEET: page 2 of 2 Are the valid results of this systematic review important? Can you apply this valid, important evidence from a systematic review in caring for your patient? Do these results apply to your patient? No Is your patient so different from those in the systematic review that its results can’t help you? How great would the potential benefit of therapy actually be for your individual patient? Method I: In the table on page 1, find the In the systematic review, the intersection of the closest odds ratio from authors report the minimum the overview and the CER that is closest clinically important difference (MCID). This was defined, as the to your patient’s expected event rate if smallest difference perceived by they received the control treatment the average patient. (PEER): Method II: To calculate the NNT for any OR and PEER:

NNT

=

___1 - {PEER x (1 - OR)}____ (1 - PEER) x PEER x (1 - OR)

Are your patient’s values and preferences satisfied by the regimen and its consequences? YES Do your patient and you have a clear assessment of their values and preferences?

Are they met by this regimen and its consequences?

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Should you believe apparent qualitative differences in the efficacy of therapy in some subgroups of patients? Only if you can say “yes” to all of the following: 1. Do they really make biologic and clinical sense? 2. Is the qualitative difference both clinically (beneficial for some but useless or harmful for others) and statistically significant? 3. Was this difference hypothesised before the study began (rather than the product of dredging the data), and has it been confirmed in other, independent studies? 4. Was this one of just a few subgroup analyses carried out in this study?

Additional Notes:

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Evidence-Based Physiotherapy Practice COPD - RESPIRATORY REHABILITATION RELIEVES DYSPNEA Clinical bottom line Respiratory rehabilitation that includes at least 4 weeks of exercise training relieves dyspnoea and improves control over COPD Citation LacasseY, Wong E, Guyatt GH, King D, Cook DJ, Goldstein RS. Meta-analysis of respiratory rehabilitation in chronic obstructive pulmonary disease. Lancet 1996;348:1115-9. Clinical Question In a patient with COPD, does an in-patient pulmonary rehabilitation program improve strength, endurance, and quality of life?

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Evidence-Based Physiotherapy Practice Search terms You search MEDLINE using the terms ‘pulmonary rehabilitation’ and ‘chronic obstructive lung disease’ and find a promising systematic review. The study Systematic review of 14 RCTs of respiratory rehabilitation programs. The respiratory program for patients with a diagnosis of COPD, had to have been compared with conventional community care or other interventions that were unlikely to affect exercise capacity or quality of life. The evidence Significant improvements were found for maximum exercise capacity, functional exercise capacity, and health related quality of life (HRQL). The pooled effect size for maximum exercise capacity was 0.3 SD units (0.1 to 0.6) and corresponded to 8.3 watts (2.8 to 16.5) on a cycle ergometer test. For functional exercise capacity, the pooled effect size was 0.6 SD units (0.3 to 1.0) corresponding to 55.7 meters (27.8 to 92.8) on a six minute walk test. For two aspects of HRQL (dyspnoea and mastery), the overall treatment

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Evidence-Based Physiotherapy Practice effect was larger than the minimal important clinical difference, 1.0 (0.6 to 1.5) and 0.8 (0.5 to 1.2) respectively. The results for functional exercise capacity showed heterogeneity unexplained by sensitivity analysis. Comments 1. Patients with multiple health problems were excluded from the trials. The most common exclusion criteria were ischaemic heart disease, heart failure, intermittent claudication, disabling musculoskeletal problems, and at home oxygen use.

Appraiser Mary Ann O'Brien Expiry date January 2001

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