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Objective The aim of this systematic review was to determine what percentages of physical therapists provide interventions that are of high value, low value, or unknown value for cardiorespiratory conditions, neurological conditions, or conditions requiring acute hospital care. Whether an intervention was considered high or low value was determined by reference to guidelines or systematic reviews. Methods Searches of numerous databases were performed by combining terms synonymous with “practice patterns” and “physical therapy” until April 2018. Studies that investigated what interventions physical therapists provide for any cardiorespiratory condition, neurological condition, or condition requiring acute hospital care through surveys and audits of clinical notes were included. Through the use of medians and interquartile ranges, the percentages of physical therapists who provided interventions that were of high value, low value, or unknown value were summarized. Results Twenty-six studies were included. The median percentages of physical therapists who provided interventions of high, low, and unknown value for chronic obstructive pulmonary disease ranged from 78% to 96%, 67% to 100%, and 56% to 91%, respectively. These percentages ranged from 61% to 97%, 87% to 98%, and 83% to 98% for adults who were critically ill in intensive care units; 70% to 93%, 38% to 50%, and 8% to 95% before or after cardiac/thoracic surgery; 25% to 96%, 23% to 84%, and 96% for acute stroke; and 11% (high value) and 13% (unknown value) for Parkinson disease, respectively. Conclusions This review found patterns of physical therapist practice for cardiorespiratory conditions, neurological conditions, and conditions requiring acute hospital care that were both evidence based and not evidence based. A concern is that a substantial percentage of physical therapists provided interventions that were of low or unknown value despite the availability of high-value interventions. Impact This systematic review is the first, to our knowledge, to summarize the percentage of physical therapist treatment choices that were high versus low value for cardiorespiratory conditions, neurological conditions, and conditions requiring acute hospital care. The findings highlight areas of practice where low-value care could be replaced with high-value care—such as in the management of patients who have chronic obstructive pulmonary disease or who are in intensive care—and identify an urgent need to develop and test strategies to ensure that patients with these conditions receive the interventions most likely to improve their outcomes.

Background. Although many people recover quickly from an episode of low back pain (LBP), recurrence is very common. There is limited evidence on effective prevention strategies for recurrences of LBP. Objective. The purpose of this study was to determine the effectiveness of a McKenzie method–based self–management approach in the secondary prevention of LBP. Design. This will be a pragmatic randomized controlled trial. Setting. Participants will be recruited from the community and primary care, with the intervention delivered in a number of physical therapist practices in Sydney, Australia. Participants. The study will have 396 participants, all of whom are at least 18 years old. Intervention. Participants will be randomly assigned to either the McKenzie method–based self-management approach group or a minimal intervention control group. Measurements. The primary outcome will be days to first self-reported recurrence of an episode of activity-limiting LBP. The secondary outcomes will include: days to first self–reported recurrence of an episode of LBP, days to first self-reported recurrence of an episode of LBP leading to care seeking, and the impact of LBP over a 12-month period. All participants will be followed up monthly for a minimum of 12 months or until they have a recurrence of activity-limiting LBP. All participants will also be followed-up at 3, 6, 9, and 12 months to assess the impact of back pain, physical activity levels, study program adherence, credibility, and adverse events. Limitations. Participants and therapists will not be masked to the interventions. Conclusions. To our knowledge, this will be the first large, high-quality randomized controlled trial investigating the effectiveness of a McKenzie method–based self–management approach for preventing recurrences of LBP. If this approach is found to be effective, it will offer a low-cost, simple method for reducing the personal and societal burdens of LBP.

Background Although recurrence is common after an acute episode of low back pain, estimates of recurrence rates vary widely and predictors of recurrence remain largely unknown. Objective The purposes of the study were to determine the 1-year incidence of recurrence in participants who recovered from an acute episode of low back pain and to identify predictors of recurrence. Design The design was an inception cohort study nested in a case-crossover study. Methods For 12 months, 832 of the 999 participants who initially presented to primary care within the first 7 days of an episode of low back pain were followed. Of these participants, 469 recovered (1 month pain free) from the index episode within 6 weeks and were included in this study. Recurrence was defined as a new episode lasting more than 1 day, or as an episode of care seeking. Putative predictors were assessed at baseline and chosen a priori. Multivariable regression analysis was used to calculate odds ratios (OR) and 95% confidence intervals (CI). Results The 1-year incidence of recurrence of low back pain was 33%, and the 1-year incidence of recurrence of low back pain with care seeking was 18%. Participants reporting more than 2 previous episodes of low back pain had increased odds of future recurrences (OR = 3.18, CI = 2.11–4.78). This factor was also associated with recurrent episodes that led to care seeking (OR = 2.87, CI = 1.73–4.78). No other factors were associated with recurrences. Limitations There are limitations inherent in reliance on recall. Conclusions After an acute episode of low back pain, one-third of patients will experience a recurrent episode, and approximately half of those will seek care. Experiencing more than 2 previous episodes of low back pain triples the odds of a recurrence within 1 year.

Objective The objective of this study was to evaluate the effectiveness of implementation strategies aimed at improving the adherence of physical therapists’ treatment choices to clinical practice guidelines for a range of musculoskeletal conditions. Methods For this review, searches were performed in several databases combining terms synonymous with “practice patterns” and “physical therapy” until August 2019. The review included randomized controlled trials that investigated any intervention to improve the adherence of physical therapists’ treatment choices to clinical practice guidelines or research evidence. Treatment choices assessed by surveys, audits of clinical notes, and treatment recording forms were the primary measures of adherence. Self-reported guideline adherence was the secondary measure. Three reviewers independently assessed risk of bias. Because of heterogeneity across studies, only a narrative synthesis of the results was performed. Results Nine studies were included. Four demonstrated a positive effect on at least 1 measure of treatment choices for low back pain and acute whiplash. One involved a comparison with no intervention, and 3 involved a comparison with another active intervention. The interventions that demonstrated a positive effect included dissemination of clinical practice guidelines, with additional elements including interactive educational meetings (3 studies), tailored interventions and monitoring of the performance of health care delivery (1 study), peer assessment (1 study), and local opinion leaders plus educational outreach visits (1 study). Conclusions Although this review revealed limited trials evaluating interventions to increase physical therapists’ use of evidence-based treatments for musculoskeletal conditions compared with no intervention, it highlighted some interventions that may be effective. Impact Dissemination of clinical practice guidelines, interactive educational meetings, tailored interventions and monitoring the performance of health care delivery, peer assessment, and use of local opinion leaders plus educational outreach visits should be implemented to improve physical therapists’ adherence to clinical practice guidelines for a range of musculoskeletal conditions.

Background Current treatments for low back pain have small effects. A research priority is to identify patient characteristics associated with larger effects for specific interventions. Objective The aim of this study was to identify simple clinical characteristics of patients with chronic low back pain who would benefit more from either motor control exercises or graded activity. Design This study was a secondary analysis of the results of a randomized controlled trial. Methods One hundred seventy-two patients with chronic low back pain were enrolled in the trial, which was conducted in Australian physical therapy clinics. The treatment consisted of 12 initial exercise sessions over an 8-week period and booster sessions at 4 and 10 months following randomization. The putative effect modifiers (psychosocial features, physical activity level, walking tolerance, and self-reported signs of clinical instability) were measured at baseline. Measures of pain and function (both measured on a 0–10 scale) were taken at baseline and at 2, 6, and 12 months by a blinded assessor. Results Self-reported clinical instability was a statistically significant and clinically important modifier of treatment response for 12-month function (interaction: 2.72; 95% confidence interval=1.39 to 4.06). Participants with high scores on the clinical instability questionnaire (≥9) did 0.76 points better with motor control exercises, whereas those who had low scores ( Limitations The psychometric properties of the instability questionnaire have not been fully tested. Conclusions A simple 15-item questionnaire of features considered indicative of clinical instability can identify patients who respond best to either motor control exercises or graded activity.

Low back pain (LBP) is highly prevalent2 and a common reason for presentation to primary care. 3 The direct and indirect costs associated with this condition are enormous and represent a significant economic burden to health care systems. The prognosis of those with acute LBP is generally positive, with approximately 72% recovering by 1 year. 4 For those who recover, recurrences within the next 12 months following recovery are common. 5,6 It has been well-established that nonspecific LBP is often recurrent and that 24% to 87% of those who recover from an episode of LBP will have a recurrence within 1 year. 5‐8 A theme that is current among clinicians and researchers is the difficulty in defining a recurrence of LBP. Various clinicians and researchers

Background The impact of the relationship (therapeutic alliance) between patients and physical therapists on treatment outcome in the rehabilitation of patients with chronic low back pain (LBP) has not been previously investigated. Objective The purpose of this study was to investigate whether the therapeutic alliance between physical therapists and patients with chronic LBP predicts clinical outcomes. Design This was a retrospective observational study nested within a randomized controlled trial. Methods One hundred eighty-two patients with chronic LBP who volunteered for a randomized controlled trial that compared the efficacy of exercises and spinal manipulative therapy rated their alliance with physical therapists by completing the Working Alliance Inventory at the second treatment session. The primary outcomes of function, global perceived effect of treatment, pain, and disability were assessed before and after 8 weeks of treatment. Linear regression models were used to investigate whether the alliance was a predictor of outcome or moderated the effect of treatment. Results The therapeutic alliance was consistently a predictor of outcome for all the measures of treatment outcome. The therapeutic alliance moderated the effect of treatment on global perceived effect for 2 of 3 treatment contrasts (general exercise versus motor control exercise, spinal manipulative therapy versus motor control exercise). There was no treatment effect modification when outcome was measured with function, pain, and disability measures. Limitations Therapeutic alliance was measured at the second treatment session, which might have biased the interaction during initial stages of treatment. Data analysis was restricted to primary outcomes at 8 weeks. Conclusions Positive therapeutic alliance ratings between physical therapists and patients are associated with improvements of outcomes in LBP. Future research should investigate the factors explaining this relationship and the impact of training interventions aimed at optimizing the alliance.

Objective The objective of this study was to identify core journals in physical therapy by identifying those that publish the most randomized controlled trials of physical therapy interventions, provide the highest-quality reports of randomized controlled trials, and have the highest journal impact factors. Design This study was an audit of a bibliographic database. Methods All trials indexed in the Physiotherapy Evidence Database (PEDro) were analyzed. Journals that had published at least 80 trials were selected. The journals were ranked in 4 ways: number of trials published; mean total PEDro score of the trials published in the journal, regardless of publication year; mean total PEDro score of the trials published in the journal from 2000 to 2009; and 2008 journal impact factor. Results The top 5 core journals in physical therapy, ranked by the total number of trials published, were Archives of Physical Medicine and Rehabilitation, Clinical Rehabilitation, Spine, British Medical Journal (BMJ), and Chest. When the mean total PEDro score was used as the ranking criterion, the top 5 journals were Journal of Physiotherapy, Journal of the American Medical Association (JAMA), Stroke, Spine, and Clinical Rehabilitation. When the mean total PEDro score of the trials published from 2000 to 2009 was used as the ranking criterion, the top 5 journals were Journal of Physiotherapy, JAMA, Lancet, BMJ, and Pain. The most highly ranked physical therapy–specific journals were Physical Therapy (ranked eighth on the basis of the number of trials published) and Journal of Physiotherapy (ranked first on the basis of the quality of trials). Finally, when the 2008 impact factor was used for ranking, the top 5 journals were JAMA, Lancet, BMJ, American Journal of Respiratory and Critical Care Medicine, and Thorax. There were no significant relationships among the rankings on the basis of trial quality, number of trials, or journal impact factor. Conclusions Physical therapists who are trying to keep up-to-date by reading the best available evidence on the effects of physical therapy interventions have to read more broadly than just physical therapy–specific journals. Readers of articles on physical therapy trials should be aware that high-quality trials are not necessarily published in journals with high impact factors.

Background The working alliance, or collaborative bond, between client and psychotherapist has been found to be related to outcome in psychotherapy. Purpose The purpose of this study was to investigate whether the working alliance is related to outcome in physical rehabilitation settings. Data Sources A sensitive search of 6 databases identified a total of 1,600 titles. Study Selection Prospective studies of patients undergoing physical rehabilitation were selected for this systematic review. Data Extraction For each included study, descriptive data regarding participants, interventions, and measures of alliance and outcome—as well as correlation data for alliance and outcomes—were extracted. Data Synthesis Thirteen studies including patients with brain injury, musculoskeletal conditions, cardiac conditions, or multiple pathologies were retrieved. Various outcomes were measured, including pain, disability, quality of life, depression, adherence, and satisfaction with treatment. The alliance was most commonly measured with the Working Alliance Inventory, which was rated by both patient and therapist during the third or fourth treatment session. The results indicate that the alliance is positively associated with: (1) treatment adherence in patients with brain injury and patients with multiple pathologies seeking physical therapy, (2) depressive symptoms in patients with cardiac conditions and those with brain injury, (3) treatment satisfaction in patients with musculoskeletal conditions, and (4) physical function in geriatric patients and those with chronic low back pain. Limitations Among homogenous studies, there were insufficient reported data to allow pooling of results. Conclusions From this review, the alliance between therapist and patient appears to have a positive effect on treatment outcome in physical rehabilitation settings; however, more research is needed to determine the strength of this association.

Background Graded activity and graded exposure are increasingly being used in the management of persistent low back pain; however, their effectiveness remains poorly understood. Purpose The aim of this study was to systematically review randomized controlled trials that evaluated the effectiveness of graded activity or graded exposure for persistent (>6 weeks in duration or recurrent) low back pain. Data Sources Trials were electronically searched and rated for quality by use of the PEDro scale (values of 0–10). Study Selection Randomized controlled trials of graded activity or graded exposure that included pain, disability, global perceived effect, or work status outcomes were included in the study. Data Extraction Outcomes were converted to a scale from 0 to 100. Trials were pooled with software used for preparing and maintaining Cochrane reviews. Results are presented as weighted mean differences with 95% confidence intervals. Data Synthesis Fifteen trials with 1,654 patients were included. The trials had a median quality score of 6 (range=3–9). Pooled effects from 6 trials comparing graded activity with a minimal intervention or no treatment favored graded activity, with 4 contrasts being statistically significant: mean values (95% confidence intervals) for pain in the short term, pain in the intermediate term, disability in the short term, and disability in the intermediate term were −6.2 (−9.4 to −3.0), −5.5 (−9.9 to −1.0), −6.5 (−10.1 to −3.0), and −3.9 (−7.4 to −0.4), respectively. None of the pooled effects from 6 trials comparing graded activity with another form of exercise, from 4 trials comparing graded activity with graded exposure, and from 2 trials comparing graded exposure with a waiting list were statistically significant. Limitations Limitations of this review include the low quality of the studies, primarily those that evaluated graded exposure; the use of various types of outome measures; and differences in the implementation of the interventions, adding to the heterogeneity of the studies. Conclusions The available evidence suggests that graded activity in the short term and intermediate term is slightly more effective than a minimal intervention but not more effective than other forms of exercise for persistent low back pain. The limited evidence suggests that graded exposure is as effective as minimal treatment or graded activity for persistent low back pain.

BackgroundThe evidence that exercise intervention is effective for treatment of chronic low back pain comes from trials that are not placebo-controlled.ObjectiveThe purpose of this study was to investigate the efficacy of motor control exercise for people with chronic low back pain.DesignThis was a randomized, placebo-controlled trial.SettingThe study was conducted in an outpatient physical therapy department in Australia.PatientsThe participants were 154 patients with chronic low back pain of more than 12 weeks’ duration.InterventionTwelve sessions of motor control exercise (ie, exercises designed to improve function of specific muscles of the low back region and the control of posture and movement) or placebo (ie, detuned ultrasound therapy and detuned short-wave therapy) were conducted over 8 weeks.MeasurementsPrimary outcomes were pain intensity, activity (measured by the Patient-Specific Functional Scale), and patient's global impression of recovery measured at 2 months. Secondary outcomes were pain; activity (measured by the Patient-Specific Functional Scale); patient's global impression of recovery measured at 6 and 12 months; activity limitation (measured by the Roland-Morris Disability Questionnaire) at 2, 6, and 12 months; and risk of persistent or recurrent pain at 12 months.ResultsThe exercise intervention improved activity and patient's global impression of recovery but did not clearly reduce pain at 2 months. The mean effect of exercise on activity (measured by the Patient-Specific Functional Scale) was 1.1 points (95% confidence interval [CI]=0.3 to 1.8), the mean effect on global impression of recovery was 1.5 points (95% CI=0.4 to 2.5), and the mean effect on pain was 0.9 points (95% CI=−0.01 to 1.8), all measured on 11-point scales. Secondary outcomes also favored motor control exercise.LimitationClinicians could not be blinded to the intervention they provided.ConclusionsMotor control exercise produced short-term improvements in global impression of recovery and activity, but not pain, for people with chronic low back pain. Most of the effects observed in the short term were maintained at the 6- and 12-month follow-ups.

highlights the findings and application of Cochrane reviews and other evidence pertinent to the practice of physical therapy. The Cochrane Library is a respected source of reliable evidence related to health care. Cochrane systematic reviews explore the evidence for and against the effectiveness and appropriateness of interventions—medications, surgery, education, nutrition, exercises—and the evidence for and against the use of diagnostic tests for specific conditions. Cochrane reviews are designed to facilitate the decisions of clinicians, patients, and others in health care by providing a careful review and interpretation of research studies published in the scientific literature.1Each article in thisPTJseries will summarize a Cochrane review or other scientific evidence resource on a single topic and will present clinical scenarios based on real patients to illustrate how the results of the review can be used to directly inform clinical decisions. This article focuses on the effectiveness of multidisciplinary biopsychosocial rehabilitation for nonspecific chronic low back pain.Can multidisciplinary biopsychosocial rehabilitation help this patient with chronic low back pain?

PTJ strives to improve its processes to enhance readability, simplify manuscript submission for authors, and ensure that only papers with a reasonable likelihood of publication proceed to full review—all with the goal of publishing high-quality, clinically relevant content. In particular, manuscripts reporting clinical trials must be prospectively registered in a publicly accessible trial registry before participant enrollment commences. Although PTJ has required clinical trial registration since 2008, the definition of a clinical trial continues to perplex some authors. Confusion may result in failure to prospectively register a trial, thus preventing PTJ (and many other journals) from publishing the study findings once the study has been completed. So, what is a clinical trial? The National Institutes of Health (NIH) revised its definition of clinical trials in October 2014 in order to more clearly distinguish between clinical trials and clinical research studies.1 The NIH defines a clinical trial as “a research study in which one or more human subjects are prospectively assigned to one or more interventions (which may include placebo or other control) to evaluate the effects of those interventions on health-related biomedical or behavioral outcomes. ” The NIH considers prospective assignment (which may involve randomization but not necessarily) to be a predefined process specified in a protocol that stipulates the assignment of research participants (individually or …

We would like to respond to the statement by Armijo-Olivo and colleagues1 that the Physiotherapy Evidence Database (PEDro) scale has not been adequately developed or adequately tested for reliability and validity. Because no citations …

Background and Purpose. Depression is a condition that worsens the prognosis of low back pain (LBP) and is under-recognized and undertreated in primary care. The purpose of this study was to evaluate the accuracy with which physical therapists screen for depressive symptoms among their patients with LBP. Subjects. Sixty-eight physical therapists and 232 patients with nonspecific LBP from 40 physical therapy clinics participated. Methods. Patients completed the reference standard (Depression Anxiety Stress Scales [DASS]) and a 2-item screening test for depression taken from the Primary Care Evaluation of Mental Disorders Procedure (PRIME-MD). Treating physical therapists used a 0 to 10 scale to judge whether each patient was depressed. Based on the short-form Depression Anxiety Stress Scales (DASS-21) depression scale score, each patient was categorized as exhibiting normal, mild, moderate, severe, or extremely severe depression symptoms, and receiver operating characteristic (ROC) curves were generated to describe test accuracy. Results. The 2-item screening test was more accurate in screening for depressive symptoms than the physical therapists' ratings were; for example, in detecting moderate depressive symptoms in the 2 areas under the ROC curve, values were 0.66 versus 0.79. Discussion and Conclusion. Because the therapists did not accurately identify symptoms of depression, even symptoms of severe depression, despite the common presentation in their clinics, we recommend that physical therapists managing patients with LBP use the 2-item depression screening test. Administration of this screening test would improve physical therapists' ability to screen for symptoms of depression and would enable referral for appropriate management.

Although there is a growing awareness of evidence-based practice among physical therapists, implementation of evidence-based practice has proved difficult. This article discusses barriers to access and interpretation of evidence. Some solutions are offered, including facilitating the publication of all research, use of an optimum format for reporting research, maximizing the efficient use of electronic databases, improving physical therapists' skills in critical appraisal of published research, and fostering consumer access to evidence. These strategies and others discussed in the article might facilitate implementation of evidence-based physical therapy.

Background and Purpose. Assessment of the quality of randomized controlled trials (RCTs) is common practice in systematic reviews. However, the reliability of data obtained with most quality assessment scales has not been established. This report describes 2 studies designed to investigate the reliability of data obtained with the Physiotherapy Evidence Database (PEDro) scale developed to rate the quality of RCTs evaluating physical therapist interventions. Method. In the first study, 11 raters independently rated 25 RCTs randomly selected from the PEDro database. In the second study, 2 raters rated 120 RCTs randomly selected from the PEDro database, and disagreements were resolved by a third rater; this generated a set of individual rater and consensus ratings. The process was repeated by independent raters to create a second set of individual and consensus ratings. Reliability of ratings of PEDro scale items was calculated using multirater kappas, and reliability of the total (summed) score was calculated using intraclass correlation coefficients (ICC [1,1]). Results. The kappa value for each of the 11 items ranged from .36 to .80 for individual assessors and from .50 to .79 for consensus ratings generated by groups of 2 or 3 raters. The ICC for the total score was .56 (95% confidence interval=.47–.65) for ratings by individuals, and the ICC for consensus ratings was .68 (95% confidence interval=.57–.76). Discussion and Conclusion. The reliability of ratings of PEDro scale items varied from “fair” to “substantial,” and the reliability of the total PEDro score was “fair” to “good.”

Background. The evidence that exercise intervention is effective for treatment of chronic low back pain comes from trials that are not placebo-controlled. Objective. The purpose of this study was to investigate the efficacy of motor control exercise for people with chronic low back pain. Design. This was a randomized, placebo-controlled trial. Setting. The study was conducted in an outpatient physical therapy department in Australia. Patients. The participants were 154 patients with chronic low back pain of more than 12 weeks' duration. Intervention. Twelve sessions of motor control exercise (ie, exercises designed to improve function of specific muscles of the low back region and the control of posture and movement) or placebo (ie, detuned ultrasound therapy and detuned short-wave therapy) were conducted over 8 weeks. Measurements. Primary outcomes were pain intensity, activity (measured by the Patient-Specific Functional Scale), and patient's global impression of recovery measured at 2 months. Secondary outcomes were pain; activity (measured by the Patient-Specific Functional Scale); patient's global impression of recovery measured at 6 and 12 months; activity limitation (measured by the Roland-Morris Disability Questionnaire) at 2, 6, and 12 months; and risk of persistent or recurrent pain at 12 months. Results. The exercise intervention improved activity and patient's global impression of recovery but did not clearly reduce pain at 2 months. The mean effect of exercise on activity (measured by the Patient-Specific Functional Scale) was 1.1 points (95% confidence interval [CI]=0.3 to 1.8), the mean effect on global impression of recovery was 1.5 points (95% CI=0.4 to 2.5), and the mean effect on pain was 0.9 points (95% CI=-0.01 to 1.8), all measured on 11-point scales. Secondary outcomes also favored motor control exercise. Limitation. Clinicians could not be blinded to the intervention they provided. Conclusions. Motor control exercise produced short-term improvements in global impression of recovery and activity, but not pain, for people with chronic low back pain. Most of the effects observed in the short term were maintained at the 6- and 12-month follow-ups.

We wish that you could have been with us at our PTJ meeting following APTA's Combined Sections Meeting in Nashville. We have assembled an incredible group of talented Steering Committee members, Editorial Board members, and Reviewers, all of whom have worked diligently to reduce our time from submission to publication, to attract new authors, and to develop special features both in print and online. But we are never satisfied. For our meeting, we reviewed the randomized controlled trials (RCTs) that were published in PTJ between January 2007 and January 2008. Chris Maher pointed out that it was common to find reports of RCTs that did not include the kind of information that would allow readers to judge (1) the veracity of the results and (2) whether the results applied to their patients. Some of the problems he noted included an emphasis on P values rather than on effect sizes, the absence of a trial flow diagram, and insufficient information on how missing data were handled. Beck Craik's reaction to this report surprised her—she was delighted that we had 18 RCTs reported in a 1-year period! Her glee was short-lived, however, because Chris' report highlighted a gap between our standard of excellence and current practice in the reporting of RCTs published in PTJ . Others have written eloquently …

Clinical trial registration involves placing the protocol for a clinical trial on a free, publicly available, and electronically searchable register. Registration is considered to be prospective if the protocol is registered before the trial commences (ie, before the first participant is enrolled). Prospective registration has several potential advantages. It could help avoid trials being duplicated unnecessarily, and it could allow people with health problems to identify trials in which they might participate. Perhaps more important, however, it tackles 2 big problems in clinical research: selective reporting and publication bias. Selective reporting involves investigators reporting only the most favorable results when they publish a trial, instead of reporting the results for all the outcomes that were measured. Reporting only favorable outcomes can create a misleading appearance of the effect of a therapy in the published literature. For example, imagine that a completely ineffective intervention is tested across several trials, and each trial measures multiple outcomes. Most outcomes will show no significant effect of the intervention. However, occasionally an outcome will show significant benefit or harm simply by chance. If the researchers publish the positive outcomes but not all of the nonsignificant and negative outcomes, readers could interpret falsely that the intervention is beneficial. A similar problem could occur when outcomes are analyzed at multiple time points. Researchers may report that an intervention improves walking speed at 6 months, but fail to mention that it does not improve walking speed at 1, 2, 3, 9, 12, and 24 months. Prospective registration of clinical trials combats this problem in several ways. Journal editors and reviewers can compare the range of outcomes reported in a manuscript against those listed in the registered protocol, requesting that any discrepancies be resolved by following the protocol. Readers also can compare the outcomes in the registered protocol against …

Background and Purpose. The purpose of this study was to determine whether two versions of the posteroanterior (PA) pressure test provide similar stiffness information. Subjects. Twenty subjects were asked to judge the magnitude of five stiffness stimuli provided by a mechanical device. Methods. Subjects were required to rate the stiffness magnitude on a five-point scale using both the thumb-grip and pisiform-grip versions of the PA pressure test. Using signal detection theory methods, measures of both a subject's ability to discriminate between the stiffness stimuli and a subject's bias in perceived stiffness magnitude due to the testing method were obtained. These values were compared using analysis of trend within an analysis of variance framework. Results. The two methods of performing the PA central pressure had similar stimulus discriminability. With the thumb-grip method, however, a substantial bias occurred, making the mechanical stimuli appear to be stiffer than when the pisiform grip was used. Conclusion and Discussion. The method of performing the PA central pressure test affects the perceived magnitude of stiffness stimuli. This result suggests that the two versions of this clinical test should not be used interchangeably.

Background and Purpose. This study investigated whether the poor reliability of judgments of posteroanterior (PA) spinal stiffness is due to rater bias or is a consequence of raters each having individual concepts of PA stiffness. Subjects. Three pairs of manipulative physical therapists with a minimum of 5 years of experience took part in the study. Methods. The raters were required to make stiffness judgments of a series of metal springs, and their performance at this task was compared with that obtained when they rated the PA stiffness of patients with low back pain. A range of reliability indices were calculated and evaluated to establish whether rater bias contributed to poor reliability in either task. The relationship between each rater's estimates of the magnitude of the stimuli and the measured stiffness of the springs was also assessed using the Pearson Product-Moment Correlation Coefficient. Results. The average intraclass correlation coefficient (2,1) for rating spring stiffness was found to be .60, whereas for human spines it was found to be .19. There was no evidence of rater bias contributing to poor reliability for rating stiffness of human spines. The average correlation between the rater's estimates of the magnitude of the stimuli and the measured stiffness of the stimuli was .80. Conclusion and Discussion. Physical therapists demonstrated much better ability to judge spring stiffness than the PA stiffness of human spines. This difference in performance implies that mechanical stiffness is not equivalent to the clinical concept of PA stiffness. Posteroanterior stiffness may have more than one dimension, and individual interpretation of stiffness as a construct may lead to rater disagreement in the clinic. The reliability of judgments of PA spinal stiffness may be enhanced in the future if its dimensions can be identified, defined, and taken into account during clinical procedures. [ ARTICLE][1] [1]: /lookup/volpage/74/801?iss=9

BackgroundExercise interventions are often incompletely described in reports of clinical trials, hampering evaluation of results and replication and implementation into practice.ObjectiveThe aim of this study was to develop a standardized method for reporting exercise programs in clinical trials: the Consensus on Exercise Reporting Template (CERT).Design and MethodsUsing the EQUATOR Network's methodological framework, 137 exercise experts were invited to participate in a Delphi consensus study. A list of 41 items was identified from a meta-epidemiologic study of 73 systematic reviews of exercise. For each item, participants indicated agreement on an 11-point rating scale. Consensus for item inclusion was defined a priori as greater than 70% agreement of respondents rating an item 7 or above. Three sequential rounds of anonymous online questionnaires and a Delphi workshop were used.ResultsThere were 57 (response rate=42%), 54 (response rate=95%), and 49 (response rate=91%) respondents to rounds 1 through 3, respectively, from 11 countries and a range of disciplines. In round 1, 2 items were excluded; 24 items reached consensus for inclusion (8 items accepted in original format), and 16 items were revised in response to participant suggestions. Of 14 items in round 2, 3 were excluded, 11 reached consensus for inclusion (4 items accepted in original format), and 7 were reworded. Sixteen items were included in round 3, and all items reached greater than 70% consensus for inclusion.LimitationsThe views of included Delphi panelists may differ from those of experts who declined participation and may not fully represent the views of all exercise experts.ConclusionsThe CERT, a 16-item checklist developed by an international panel of exercise experts, is designed to improve the reporting of exercise programs in all evaluative study designs and contains 7 categories: materials, provider, delivery, location, dosage, tailoring, and compliance. The CERT will encourage transparency, improve trial interpretation and replication, and facilitate implementation of effective exercise interventions into practice.

Background and Purpose. The purpose of this study was to determine the intertherapist reliability of judgments of stiffness and pain at L-1 to L-5 made using posteroanterior (PA) central pressure testing. Subjects. Three pairs of manipulative physical therapists with a minimum of 5 years of experience were asked to rate pain and stiffness in a total of 90 patients with low back pain. Methods. Each pair of therapists assessed 30 patients within their own clinic, using their preferred technique to perform an examination using the PA central pressure test at the five lumbar levels. Each pair of therapists recorded their ratings of pain and stiffness. Reliability of judgments was evaluated by intraclass correlation coefficients (ICC) and percentage of exact agreement scores. Results. The ICC values for pain judgments for the group as a whole ranged from .67 to .72, with agreement scores ranging from 31% to 43%. The ICC values for stiffness judgments ranged from .03 to .37, with agreement scores ranging from 21% to 29%. Conclusion and Discussion. Judgments of stiffness made by experienced manipulative physical therapists examining patients in their own clinics were found to have poor reliability, whereas pain judgments had good reliability. Further investigation of this test is required in order to develop a more reliable method of assessing PA stiffness.

Background Many bibliographic databases index research studies evaluating the effects of health care interventions. One study has concluded that the Physiotherapy Evidence Database (PEDro) has the most complete indexing of reports of randomized controlled trials of physical therapy interventions, but the design of that study may have exaggerated estimates of the completeness of indexing by PEDro. Objective The purpose of this study was to compare the completeness of indexing of reports of randomized controlled trials of physical therapy interventions by 8 bibliographic databases. Design This study was an audit of bibliographic databases. Methods Prespecified criteria were used to identify 400 reports of randomized controlled trials from the reference lists of systematic reviews published in 2008 that evaluated physical therapy interventions. Eight databases (AMED, CENTRAL, CINAHL, EMBASE, Hooked on Evidence, PEDro, PsycINFO, and PubMed) were searched for each trial report. The proportion of the 400 trial reports indexed by each database was calculated. Results The proportions of the 400 trial reports indexed by the databases were as follows: CENTRAL, 95%; PEDro, 92%; PubMed, 89%; EMBASE, 88%; CINAHL, 53%; AMED, 50%; Hooked on Evidence, 45%; and PsycINFO, 6%. Almost all of the trial reports (99%) were found in at least 1 database, and 88% were indexed by 4 or more databases. Four trial reports were uniquely indexed by a single database only (2 in CENTRAL and 1 each in PEDro and PubMed). Limitations The results are only applicable to searching for English-language published reports of randomized controlled trials evaluating physical therapy interventions. Conclusions The 4 most comprehensive databases of trial reports evaluating physical therapy interventions were CENTRAL, PEDro, PubMed, and EMBASE. Clinicians seeking quick answers to clinical questions could search any of these databases knowing that all are reasonably comprehensive. PEDro, unlike the other 3 most complete databases, is specific to physical therapy, so studies not relevant to physical therapy are less likely to be retrieved. Researchers could use CENTRAL, PEDro, PubMed, and EMBASE in combination to conduct exhaustive searches for randomized trials in physical therapy.

BackgroundClinical prediction rules (CPRs) for treatment selection in musculoskeletal conditions have become increasingly popular.PurposeThe purposes of this review are: (1) to critically appraise studies evaluating CPRs and (2) to consider the clinical utility and stage of development of each CPR.Data SourcesPertinent databases were searched up to April 2009. Studies aiming to develop or evaluate a CPR for treatment response in musculoskeletal conditions were included. Two independent reviewers assessed eligibility and extracted methodological data, stage of development, and effect size information.Study Selection/Data Extraction and SynthesisEighteen studies, evaluating 15 separate CPRs, were included. Fourteen CPRs were at the derivation stage, and all CPRs had been evaluated using a single-arm trial design, thus it is not possible to determine whether the CPRs identify prognosis (regardless of treatment) or specifically response to treatment. The CPR at the validation stage investigated spinal manipulative therapy (SMT) for low back pain and had been evaluated in 2 separate well-conducted randomized controlled trials. The first trial demonstrated a clinically meaningful effect of the SMT CPR; the additional effect from SMT in patients “positive-on-the-rule” was 15 Oswestry disability units at week 1 and 9 units at week 4. The second trial showed that the CPR did not generalize to a different clinical setting, including a modified treatment.LimitationsDue to differences in methods of reporting and journal publication restraints (eg, word count restrictions), some quality assessment items may have been completed in the included studies, but not captured in this review.ConclusionsThere is, at present, little evidence that CPRs can be used to predict effects of treatment for musculoskeletal conditions. The principal problem is that most studies use designs that cannot differentiate between predictors of response to treatment and general predictors of outcome. Only 1 CPR has been evaluated within an RCT designed to predict response to treatment. Validation of these rules is imperative to allow clinical application.

Staying up to date as a physical therapist is a challenge because the research underpinning the science and practice of our profession is growing exponentially.1 The growth is well illustrated by the history of randomized controlled trials (RCT). In 1929, there was only 1 RCT evaluating a physical therapy treatment; by 1972, there were 100; by 1986, 1,000; by 2005, 10,000; and today, there are more than 12,000 RCTs. As a consequence, a “mid-career” physical therapist (who graduated in 1980) now has access to 25 times more RCTs compared with when they graduated. Even with the advent of physical therapy–specific databases such as Hooked on Evidence and PEDro, it has become impossible to keep up to date by reading primary research papers: the job has just gotten too big. An efficient way for physical therapists to keep up to date is to read recent systematic reviews. For people with little spare time, systematic reviews …

BackgroundRehabilitative ultrasound imaging (RUSI) measures of abdominal wall muscles are used to indirectly measure muscle activity. These measures are used to identify suitable patients and to monitor progress of motor control exercise treatment of people with low back pain.PurposeThe purpose of this study was to systematically review reproducibility studies of RUSI for measuring thickness of abdominal wall muscles.Data SourcesEligible studies were identified via searches of MEDLINE, EMBASE, and CINAHL. The authors also searched personal files and tracked references of the retrieved studies via the Web of Science Index.Study SelectionStudies involving any type of reliability and or agreement of any type of ultrasound measurements (B or M mode) for any of the abdominal wall muscles were selected.Data ExtractionTwo independent reviewers extracted data and assessed methodological quality.Data SynthesisDue to heterogeneity of the studies’ designs, pooling the data for a meta-analysis was not possible. Twenty-one studies were included, and these studies were typically of low quality and studied subjects who were healthy rather than people seeking care for low back pain. The studies reported good to excellent reliability for single measures of thickness and poor to good reliability for measures of thickness change (reflecting the muscle activity). Interestingly, no studies checked reliability of measures of the difference in thickness changes over time (representing improvement or deterioration in muscle activity).ConclusionsThe current evidence of the reproducibility of RUSI for measuring abdominal muscle activity is based mainly on studies with suboptimal designs and the study of people who were healthy. The critical question of whether RUSI provides reliable measures of improvement in abdominal muscle activity remains to be evaluated.

Many researchers and clinicians believe the effectiveness of existing physical therapy interventions can be improved by targeting the provision of specific interventions at patients who respond best to that treatment. Although this approach has the potential to improve outcomes for some patients, it needs to be implemented carefully because some methods used to identify subgroups can produce biased or misleading results. The aim of this article is to assist readers in assessing the validity and generalizability of studies designed to identify subgroups of responders to physical therapy interventions. The key messages are that subgroups should be identified using high-quality randomized controlled trials, the investigation should be limited to a relatively small number of potential subgroups for which there is a plausible rationale, subgroup effects should be investigated by formally analyzing statistical interactions, and findings of subgroups should be subject to external validation.

BackgroundPrevious systematic reviews have concluded that the effectiveness of motor control exercise for persistent low back pain has not been clearly established.ObjectiveThe objective of this study was to systematically review randomized controlled trials evaluating the effectiveness of motor control exercises for persistent low back pain.MethodsElectronic databases were searched to June 2008. Pain, disability, and quality-of-life outcomes were extracted and converted to a common 0 to 100 scale. Where possible, trials were pooled using Revman 4.2.ResultsFourteen trials were included. Seven trials compared motor control exercise with minimal intervention or evaluated it as a supplement to another treatment. Four trials compared motor control exercise with manual therapy. Five trials compared motor control exercise with another form of exercise. One trial compared motor control exercise with lumbar fusion surgery. The pooling revealed that motor control exercise was better than minimal intervention in reducing pain at short-term follow-up (weighted mean difference=−14.3 points, 95% confidence interval [CI]=−20.4 to −8.1), at intermediate follow-up (weighted mean difference=−13.6 points, 95% CI=−22.4 to −4.1), and at long-term follow-up (weighted mean difference=−14.4 points, 95% CI=−23.1 to −5.7) and in reducing disability at long-term follow-up (weighted mean difference=−10.8 points, 95% CI=−18.7 to −2.8). Motor control exercise was better than manual therapy for pain (weighted mean difference=−5.7 points, 95% CI=−10.7 to −0.8), disability (weighted mean difference=−4.0 points, 95% CI=−7.6 to −0.4), and quality-of-life outcomes (weighted mean difference=−6.0 points, 95% CI=−11.2 to −0.8) at intermediate follow-up and better than other forms of exercise in reducing disability at short-term follow-up (weighted mean difference=−5.1 points, 95% CI=−8.7 to −1.4).ConclusionsMotor control exercise is superior to minimal intervention and confers benefit when added to another therapy for pain at all time points and for disability at long-term follow-up. Motor control exercise is not more effective than manual therapy or other forms of exercise.

This perspective provides an overview of the randomized controlled trials, systematic reviews, and evidence-based clinical practice guidelines in physical therapy. Data from the Physiotherapy Evidence Database (PEDro) are used to describe key events in the history of physical therapy research and the growth of evidence of effects of interventions used in the various subdisciplines of physical therapy. The 11,494 records that were identified reveal a rich history of physical therapy research dating back to the first trial in 1929. Most of the randomized controlled trials, systematic reviews, and evidence-based clinical practice guidelines in physical therapy have been published since the year 2000. This rapid growth presents a challenge for physical therapists who want to keep up to date in clinical practice.

Depression is a condition that worsens the prognosis of low back pain (LBP) and is under-recognized and undertreated in primary care. The purpose of this study was to evaluate the accuracy with which physical therapists screen for depressive symptoms among their patients with LBP.Sixty-eight physical therapists and 232 patients with nonspecific LBP from 40 physical therapy clinics participated.Patients completed the reference standard (Depression Anxiety Stress Scales [DASS]) and a 2-item screening test for depression taken from the Primary Care Evaluation of Mental Disorders Procedure (PRIME-MD). Treating physical therapists used a 0 to 10 scale to judge whether each patient was depressed. Based on the short-form Depression Anxiety Stress Scales (DASS-21) depression scale score, each patient was categorized as exhibiting normal, mild, moderate, severe, or extremely severe depression symptoms, and receiver operating characteristic (ROC) curves were generated to describe test accuracy.The 2-item screening test was more accurate in screening for depressive symptoms than the physical therapists' ratings were; for example, in detecting moderate depressive symptoms in the 2 areas under the ROC curve, values were 0.66 versus 0.79.Because the therapists did not accurately identify symptoms of depression, even symptoms of severe depression, despite the common presentation in their clinics, we recommend that physical therapists managing patients with LBP use the 2-item depression screening test. Administration of this screening test would improve physical therapists' ability to screen for symptoms of depression and would enable referral for appropriate management.

Although there is a growing awareness of evidence-based practice among physical therapists, implementation of evidence-based practice has proved difficult. This article discusses barriers to access and interpretation of evidence. Some solutions are offered, including facilitating the publication of all research, use of an optimum format for reporting research, maximizing the efficient use of electronic databases, improving physical therapists' skills in critical appraisal of published research, and fostering consumer access to evidence. These strategies and others discussed in the article might facilitate implementation of evidence-based physical therapy.

Assessment of the quality of randomized controlled trials (RCTs) is common practice in systematic reviews. However, the reliability of data obtained with most quality assessment scales has not been established. This report describes 2 studies designed to investigate the reliability of data obtained with the Physiotherapy Evidence Database (PEDro) scale developed to rate the quality of RCTs evaluating physical therapist interventions.In the first study, 11 raters independently rated 25 RCTs randomly selected from the PEDro database. In the second study, 2 raters rated 120 RCTs randomly selected from the PEDro database, and disagreements were resolved by a third rater; this generated a set of individual rater and consensus ratings. The process was repeated by independent raters to create a second set of individual and consensus ratings. Reliability of ratings of PEDro scale items was calculated using multirater kappas, and reliability of the total (summed) score was calculated using intraclass correlation coefficients (ICC [1,1]).The kappa value for each of the 11 items ranged from.36 to.80 for individual assessors and from.50 to.79 for consensus ratings generated by groups of 2 or 3 raters. The ICC for the total score was.56 (95% confidence interval=.47-.65) for ratings by individuals, and the ICC for consensus ratings was.68 (95% confidence interval=.57-.76).The reliability of ratings of PEDro scale items varied from "fair" to "substantial," and the reliability of the total PEDro score was "fair" to "good."

Background and Purpose. The reliability and criterion-related validity of ratings of posteroanterior (PA) spinal stiffness made using reference values for comparison have not been investigated. In this study, mechanical reference stimuli for points on an 11-point rating scale were used to determine whether using a reference scale may be feasible. Subjects. Five different raters took part in 2 studies in which they rated 40 subjects who were asymptomatic for low back pain. Methods. The interrater reliability of ratings was evaluated with intraclass correlation coefficients (ICCs) and standard errors of the measurement (SEMs). Criterion-related validity was evaluated by correlating judgments of PA spinal stiffness assessed manually with measurements of PA spinal stiffness provided by a mechanical device, the “Stiffness Assessment Machine” (SAM). Results. Although the reliability indices were generally high, with ICCs reaching .77 and with SEMs as low as 0.72 points, the evidence for criterion-related validity (ie, the ability of the examiner to judge spinal stiffness levels) was not strong, with correlations reaching only .56. Conclusion and Discussion. The reference-based protocol allows for more reliable measures of PA stiffness judgments than previous protocols have; however, the human ratings are not highly correlated with the SAM measures. The protocol will have clinical value if judgments made using it are shown to be reliable in clinically relevant subjects and to have validity for clinical management of patients.

Background and Purpose. This study determined the test-retest reliability of measurements of responses to posteroanterior (PA) forces made using a recently developed instrument. Subjects. Twenty-two subjects with nonspecific low back pain participated. Methods. The length of the low-stiffness or “toe“ region and the slope of the linear portion of the force-displacement curve were measured on two occasions. Reliability of repeated measurements was evaluated by intraclass correlation coefficients and percentage-of-agreement scores. The presence of a systematic change in the response to PA forces was evaluated by a paired-samples t test. Results. High reliability coefficients were obtained for both indices of the response to PA forces. The t test revealed no systematic change with repeated testing. Conclusion and Discussion. The new device provides highly reliable measurement of the lumbar PA force-displacement relationship and may prove useful in evaluating theories that have suggested a relationship between spinal symptoms and abnormal PA stiffness.

We encourage Journal readers to respond to articles in “Evidence in Practice.” E-mail your contribution to the dialogue to steveglaros@apta.org.? We would like to suggest an alternate search strategy for the “Evidence in Practice” article in the March issue written by Charles Ciccone, PT, PhD. Dr Ciccone selected the CINAHL database because he wanted “to focus on journals that might deal specifically with physical therapy interventions.” CINAHL is not restricted to physical therapy interventions. In contrast, the Physiotherapy Evidence Database (PEDro) (ptwww.cchs.usyd.edu.au/pedro/) is a database that is restricted to systematic reviews and randomized controlled trials (RCTs) of physical therapy interventions. We believe, therefore, that it might offer a potentially more efficient method to search for external evidence on the effectiveness of physical therapy interventions than generic databases, such as CINAHL or MEDLINE, could. In our opinion as the developers of PEDro, PEDro is a much more complete database of RCTs and systematic reviews in physical therapy than either MEDLINE or CINAHL are. A search of PEDRO was conducted on March 6, 2002. By typing lymphedema in the abstract search box, 6 records …

We commend the authors for undertaking a systematic review on this topic, but we have seriousreservations about their methodsand conclusions. Clinical prediction rules (CPRs) or clinical decision rules can be used to make a diagnosis, predict disease progression, predict prognosis, or select therapy. Benecuiket al reviewed CPRs that were developed to select therapy but then evaluated the quality of these CPRs using criteria designed for prognosis studies. This is unfortunate because the optimal design and analysis strategies for a prognosisstudy are not the same as for an intervention study. Refereed/Peer-reviewed

Stuart Warden is correct in pointing out that the search strategy used by Richter and colleagues1 means that they have likely underestimated the research productivity of physical therapists. I did a quick check on Web of Science (http://scientific.thomson.com), which allows you to search the affiliation field of …

Background Tai chi is recommended for musculoskeletal conditions; however, the evidence for its clinical effectiveness is uncertain. Purpose The aim of this study was to determine whether tai chi is beneficial for clinical outcomes in people with musculoskeletal pain. Data Sources Seven databases were searched: Embase, PEDro, AMED, MEDLINE, CINAHL, SPORTDiscus, and the Cochrane Central Register of Controlled Trials. Study Selection Randomized controlled trials of tai chi for people with a chronic musculoskeletal condition were included. Data Extraction Two reviewers extracted data and rated risk of bias. Standardized mean differences (SMDs) and 95% confidence intervals (CI) were calculated for individual trials and pooled effect sizes were calculated using a random-effects model. Data Synthesis Fifteen studies were identified; these studies included people with osteoarthritis (80%), back pain (13%), and headache (7%). Using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach, moderate-quality evidence was found that tai chi was more effective than no treatment or usual care at short term on pain (SMD=−0.66 [95% CI=−0.85, −0.48]) and disability (SMD=−0.66 [95% CI=−0.85, −0.46]). The evidence for other outcomes was of low or very low quality and there was little information regarding long-term effects. Thus, although the number of publications in this area has increased, the rigor has not, hindering physical therapists' ability to provide reliable recommendations for clinical practice. Limitations The evidence provided in this review is limited by trials with small sample sizes, low methodological quality, and lack of long-term assessment. Conclusions In order for tai chi to be recommended as an effective intervention, more high-quality trials with large sample sizes assessing tai chi versus other evidence-based treatments at short term and at long term are needed.