2. INTRODUCTION
At the conclusion of the examination and evaluation process,
physical therapists consider the interventions that are
available to address identified patient/ client needs.
Factors influencing decision making process for a treatment
Determine whether the signs and symptoms fit an established
classification scheme
Consider the complexity of the case
Prioritise problem list
Determine what resources are required, as well as their availability.
Identify the patient/clients educational needs
Make a judgement about enables and barriers to patient/ clients
adherence to treatment plan
3. Benefits and risk of interventions
If the intervention ( versus another ) is applied, will the
condition improve, regress, remain unchanged, are will
a new problem develop
If the intervention ( versus another ) not applied, will the
condition improve, regress, remain unchanged, are will
a new problem develop
Ideally, the answer to these questions will include details
about the different responses. Physical therapist may
use previous experiences with similar patient / client as
well as theoretical premises based on biologic
plausibility to answer these question.
4. STUDY CREDIBILITY
Evidence pertaining to interventions physical
therapists use first should be evaluated with an
assessment of its research validity.
Higher research validity provides greater
confidence that a study’s findings are reasonably
free from bias. In other words the results are
believable
5. QUESTIONS TO DETERMINE THE VALIDITY OF
EVIDENCE ABOUT INTERVENTIONS
1. DID THE INVESTIGATOR RANDOMLYASSIGN ( OR ALLOCATE)
SUBJECTS TO GROUPS?
2. WAS EACH SUBJECTS GROUP ASSIGNMENT CONCEALED FROM THE
PEOPLE ENROLLING INDIVIDUALS IN THE STUDY?
3. DID THE GROUPS HAVE SIMILAR SOCIO DEMOGRAPHIC, CLINICAL,
AND PROGNOSTIC CHARACTERISTICS AT THE START OF THE STUDY?
4. WERE SUBJECTS MASKED (OR BLINDED ) TO THEIR GROUP
ASSIGNMENT ?
5. WERE CLINICIANS AND L OR OUTCOMES ASSESSORS MASKED (OR
BLINDED) TO THE SUBJECTS GROUPASSIGNMENT ?
6. DID THE INVESTIGATORS MANAGE ALL OF THE GROUP IN THE SAME
WAY EXCEPT FOR THE EXPERIMENTAL INTERVENTIONS?
6. CONT……
7. DID THE INVESTIGATORS APPLY THE STUDY PROTOCOLAND
COLLECT FOLLOW-UP DATA ON ALL SUBJECTS OVER A TIME FRAME
LONG ENOUGH FOR THE OUTCOMES OF INTEREST TO OCCUR?
8. DID SUBJECTS ATTRITION (Eg, WITHDRAWAL, LOSS TO FOLLOW-
UP) OCCUR OVER THE COURSE OF THE STUDY?
9. IF ATTRITION OCCURRED, DID THE INVESTIGATORS PERFORM AN
INTENTION- TO- TREAT ANALYSIS?
10. DID THE INVESTIGATORS CONFIRM THEIR FINDINGS WITH A
NEW SET OF SUBJECTS?
7. 1. DID THE INVESTIGATOR RANDOMLYASSIGN ( OR
ALLOCATE) SUBJECTS TO GROUPS?
This question represents the minimum threshold in the evidence
selection process. Randomization of subjects to groups in the
assignment method most likely to reduce bias by creating groups
with equally distributed characteristics
2. WAS EACH SUBJECTS GROUPASSIGNMENT
CONCEALED FROM THE PEOPLE ENROLLING
INDIVIDUALS IN THE STUDY
the issue of concealment alludes to the possibility that study
personnel may interfere with randomisation process such that bias
is introduced in to the study. This interference may be well
intended.
8. 3. DID THE GROUPS HAVE SIMILAR SOCIO
DEMOGRAPHIC, CLINICAL, AND PROGNOSTIC
CHARACTERISTICS AT THE START OF THE STUDY?
Although randomised assignment methods are likely to result in
equivalent groups at the start of the study, this result is not
guaranteed. This question acknowledges this fact by asking whether
the investigators confirmed group equally through statistical analysis
of the relevant socio demographic , clinical, and prognostic
characteristics.
4. WERE SUBJECTS MASKED (OR BLINDED ) TO THEIR
GROUPASSIGNMENT ?
This question explores the possibility that subjects behaviour
may have changed during the study as a result of knowledge
about the group to which they were assigned.
9. 5. WERE CLINICIANS AND / OR OUTCOMES ASSESSORS
MASKED (OR BLINDED) TO THE SUBJECTS GROUP
ASSIGNMENT ?
This question explores the possibility that clinician or study
personnel behaviour may have changed during the study as a result
of knowledge about the group to which subjects were assigned
6. DID THE INVESTIGATORS MANAGE ALL OF THE GROUP
IN THE SAME WAY EXCEPT FOR THE EXPERIMENTAL
INTERVENTIONS?
This question clarifies the degree to which group equality was
maintained when study personnel and/or clinicians interacted with
subjects over the course of the project. the only difference between
or among the study groups will be the application of the
experimental interventions.
The timing of the treatment application and outcomes measurement
The environmental conditions in these activities are performed
The methods for provision of instructions and application of the treatment.
10. 7. DID THE INVESTIGATORS APPLY THE STUDY
PROTOCOLAND COLLECT FOLLOW-UP DATA ON ALL
SUBJECTS OVER A TIME FRAME LONG ENOUGH FOR
THE OUTCOMES OF INTEREST TO OCCUR?
The issue regarding subjects follow- up involves the time frame over
which the study was conducted. Specifically readers must determine
whether the time allotted for application of the outcomes of the
study protocol and the measurement of its effect was long enough
for the outcomes of the interest to occur.
8. DID SUBJECTS ATTRITION (Eg, WITHDRAWAL, LOSS TO
FOLLOW-UP) OCCUR OVER THE COURSE OF THE
STUDY?
Readers must determine whether all of the subjects who were
enrolled at the start of the study remained at the end of the study.
The loss of the subjects, or attrition, may unbalanced the groups
such that inequalities in group characteristics influence the study’s
result.
11. 9. IF ATTRITION OCCURRED, DID THE INVESTIGATORS
PERFORM AN INTENTION- TO- TREAT ANALYSIS?
This question pertains to situation in which some of the subjects are
not compliant with the protocol for their, assigned group.
Noncompliance may occur because of factors the outside of the
subjects control, such as illness, or because of the purposeful
decision by the subjects not to participate according to plan.
10. DID THE INVESTIGATORS CONFIRM THEIR FINDINGS
WITH A NEW SET OF SUBJECTS?
This question alludes to the possibility that the research findings
regarding an intervention of interest occurred due to unique
attributes of the sample. Repeating the study on a second group of
subjects who match the inclusion and exclusion criteria outlined for
the first group provides am opportunity to evaluate the consistency
of an intervention’s effect
12. THE STATISTICAL IMPORTANCE OF STUDY
RESULTS
As in the case for evidence about diagnostics tests,
clinical measures and prognostic( risk) factors, p
values, and confidence intervals may be employed
in evidence about interventions to help determine
the statistical importance of the study’s result.
Recall that a p value indicates the probability that
the result obtained occurred due to chance.
The smaller the p value(eg., <0.005), the more
convincing the result become because the role of
chance is so diminished, although not eliminited.
13. CONT……
The p value usually are reported in conjunction with
statistical tests of differences to determines whether
an experimental intervention was more effective
than a control or comparison intervention.
14. SUMMARY
Physical therapist and patients/ clients select
interventions in consideration of variety of objective
and subjective factors.
Evidence about interventions may inform the
selection process if its design ,minimizes bias.
Evidence based physical therapists must evaluate
the evidence on its merits and use their clinical
judgment to determine the strength of the
researcher design.
