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Confidence intervals give the reader critical information about the precision of an effect estimate reported in a trial
The Journal of Orthopaedic and Sports Physical Therapy publish a regular feature called “evidence in practice”. The latest evidence in practice article provides a great overview of confidence intervals.
Confidence intervals span a range of values above and below an effect estimate. The confidence interval is the range of effects that will most likely contain the true mean effect of treatment, compared to the control. The reader can be confident about the size of the mean effect of treatment when the confidence interval is narrow, but unsure when the confidence interval is wide.
The concept of minimal clinically important difference is also relevant when interpreting confidence intervals. If the confidence interval includes the minimal clinically important difference, it is possible that the treatment does not have a worthwhile benefit, regardless of the size of the effect estimate. When a confidence interval crosses the line of no effect (ie, contains the value of zero when assessing between-group differences), it is possible that the treatment is not more effective than the control. The article includes a graphic for interpretting confidence intervals based on their location with respect to the minimal clinically important difference and line of no effect.
Kamper SJ. Confidence intervals: linking evidence to practice. J Orthop Sports Phys Ther 2019;49(10): 763-4
#MyPTArticleOfTheMonth – what is Mireille Landry reading?
Mireille Landry has a BScPT from Queen’s University, an MSc from the University of Toronto, a Diploma in Sport Physiotherapy from Sport Physiotherapy Canada, and is a Registered International Sports Physical Therapist through the International Federation of Sports Physical Therapy. She has broad clinical expertise in cardiorespiratory, musculoskeletal and exercise physiotherapy in acute care, private practice and ambulatory care settings. As an Academic Lead in the Department of Physical Therapy at the University of Toronto, Mireille is involved in student teaching in various capacities and across units in the curriculum. She enjoys splitting her time between teaching, clinical care, and providing physiotherapy support and on-field management for sporting events. Mireille has travelled and worked at many national and major games supporting amateur athletes, including the 2016 Paralympic Games in Rio de Janeiro, Brazil.
Mireille has recently read two articles to inform her teaching and clinical work.
Oldham JR, et al. Efficacy of tandem gait to identify impaired postural control after concussion Med Sci Sports Exerc 2018;50(6):1162-8.
This study evaluated the diagnostic test accuracy and minimal detectable change of three field tests for concussion: the Tandem Gait Test, Balance Error Scoring System, and Modified Balance Error Scoring System. 76 National Collegiate Athletic Association student athletes, 38 acutely after concussion and 38 controls, were evaluated at two time points using the field tests and the reference standard for concussion evaluation (Concussion Assessment, Research, and Education Consortium Clinical Study Core Protocol). The Tandem Gait Test had higher sensitivity and specificity than both the Balance Error Scoring System and Modified Balance Error Scoring System. Tandem Gait Test time increased after concussion, but there was no difference in the number of errors recorded for the Balance Error Scoring System and Modified Balance Error Scoring System. Mireille says: “this study is interesting as the field tests were assessed at baseline and acutely after concussion, so we can determine how a concussion affects performance on each of the tasks. The results are useful for physiotherapy as, in addition to being more accurate than the other field tests, the Tandem Gait Test is easier to administer. It’s important to note that the Tandem Gait Test was performed in a quiet environment within 48 hours of the concussion, so we can’t extrapolate the results to a sideline concussion assessment.”
Esculier J-F, et al. Is combining gait retraining or an exercise programme with education better than education alone in treating runners with patellofemoral pain? A randomised clinical trial. Br J Sports Med 2018;52(10):659-66
Recreational running is a popular activity and patellofemoral pain is among the most common reasons why runners seek physiotherapy management. This randomised controlled trial compared three 8-week rehabilitation programs on symptoms and functional limitations of recreational runners with patellofemoral pain. All groups received education on symptom management and training modifications. One group received the education program alone (education), the second received an exercise program in addition to education (exercises), and the third received gait retraining in addition to education (retraining). The trial was well-designed and -reported, scoring 8/10 on the PEDro scale. There were not between-group differences for the primary outcome (Knee Outcome Survey of the Activities of Daily Living Scale) after the intervention – the mean difference between the education and exercise group was 0.7 (95% confidence interval -6.0 to 7.4) and the mean difference between the education and retraining group was -3.4 (-10.4 to 3.5). Mireille says: “adding exercises or gait retraining did not provide additional benefits compared to education alone. Empowering runners with self-management strategies on symptoms and training loads should be a priority of treatment in runners with patellofemoral pain syndrome.”
#MyPTArticleOfTheMonth #PhysicalTherapy #physio
#MyPTArticleOfTheMonth – how to use a diagnostic test accuracy paper
Last month we explained the logic of studies of diagnostic test accuracy. Studies of diagnostic test accuracy involve comparing the findings of the index test to a reference test. The degree of concordance of the findings of the index and reference tests provides a measure of the accuracy of the index test.
How can the accuracy of a diagnostic test be quantified? Somehow we have to come up with some numbers that say something about the concordance between the findings of the index test and the reference test. This task is easiest when each of the index test and the reference test can generate just one of two findings: a positive finding or a negative finding. Here we will restrict consideration to these sorts of tests, as they are the most common sorts of diagnostic tests. We say the test is positive when its findings suggest the person who was tested has the condition of interest, and we say the test is negative when its findings suggest the person who was tested does not have the condition of interest.
The most frequently reported measures of diagnostic test accuracy are sensitivity and specificity. Sensitivity is the probability that a person who has the condition of interest will test positive. We can estimate sensitivity by first identifying all of the people in the study who tested positive to the reference test (i.e., the people who really do have the condition of interest) and then calculating the proportion of these people who tested positive with the index test. Specificity is the probability that a person who does not have the condition of interest will test negative. We can estimate specificity by identifying all of the people in the study who tested negative with the reference test (the people who really do not have the condition of interest) and then calculating the proportion of these people who tested negative with the index test.
To find out more about how to use the findings of a diagnostic test accuracy paper visit the DiTA tutorials.
PEDro indexes 45,000 reports
We are pleased to announce that PEDro has just achieved a new milestone for the amount of evidence. There are now 45,000+ reports of trials, reviews and guidelines indexed on PEDro.
PEDro update (4 November 2019)
PEDro contains 45,191 records. In the 4 November 2019 update you will find:
- 35,285 reports of randomised controlled trials (34,489 of these trials have confirmed ratings of methodological quality using the PEDro scale)
- 9,242 reports of systematic reviews, and
- 664 reports of evidence-based clinical practice guidelines.
PEDro update (November 2019)
PEDro was updated on 4 November 2019. For latest guidelines, reviews and trials in physiotherapy visit Evidence in your inbox.
PEDro Top 5 Trials from 2014-2019 announced!
To celebrate PEDro’s 20th birthday we have identified the five most important randomised controlled trials in physiotherapy published in the years 2014-2019. The trials were nominated by PEDro users, and an independent panel of international trialists judged the nominations received.
We are excited to announce the PEDro Top 5 Trials! These ground-breaking trials are from a broad cross-section of physiotherapy practice. The trials answer important clinical questions that will change the way people are treated for a variety of conditions seen by physiotherapists and other healthcare professionals. All of them mark important milestones in the evolution of physiotherapy treatment.
The trials are listed below in no particular order. We have produced short videos to summarise each trial.
Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial
Boden I, Skinner EH, Browning L, Reeve J, Anderson L, Hill C, Robertson IK, Story D, Denehy L
BMJ 2018 Jan 24;360:j5916
Exercises to improve function of the rheumatoid hand (SARAH): a randomised controlled trial
Lamb SE, Williamson EM, Heine PJ, Adams J, Dosanjh S, Dritsaki M, Glover MJ, Lord J, McConkey C, Nichols V, Rahman A, Underwood M, Williams MA, on behalf of the Strengthening and Stretching for Rheumatoid Arthritis of the Hand Trial (SARAH) Trial Team
Lancet 2015 Jan 31;385(9966):421-429
Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial
Griffin DR, Dickenson EJ, Wall PDH, Achana F, Donovan JL, Griffin J, Hobson R, Hutchinson CE, Jepson M, Parsons NR, Petrou S, Realpe A, Smith J, Foster NE, on behalf of the FASHIoN Study Group
Lancet 2018 Jun 2;391(10136):2225-2235
Effect of inpatient rehabilitation versus a monitored home-based program on mobility in patients with total knee arthroplasty: the HIHO randomized clinical trial
Buhagiar MA, Naylor JM, Harris IA, Xuan W, Kohler F, Wright R, Fortunato R
JAMA 2017 Mar 14;317(10):1037-1046
Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial
The AVERT Trial Collaboration group
Lancet 2015 Jul 4;386(9988):46-55
You will be hearing more about these trials over the coming months, including podcasts with the lead authors produced by PT Pintcast.
Congratulations to the teams who produced the PEDro Top 5 Trials. Your contributions to physiotherapy are highly valued and appreciated. PEDro would also like to thank all the users who nominated trials and those who served on the independent judging panel.
Next PEDro update (November 2019)
The next PEDro update is on Monday 4 November 2019.
Systematic review found that interventions using activity trackers improve physical activity levels and mobility among older people
A recent systematic review sought to determine the effect of interventions using activity trackers on physical activity levels and mobility compared with usual care or another physical activity intervention in older people. The review searched eight databases to identify randomised controlled trials involving participants aged 60 years and older. Trials enrolling healthy older adults or older adults with health conditions were eligible. The primary outcome was physical activity quantified as steps per day and measured using an activity tracker or accelerometer. Other types of objective measures of physical activity (e.g., time in moderate-to-vigorous physical activity) or self-reported physical activity measures were excluded. Secondary outcomes included mobility. The methodological quality of the trials was measured with the PEDro scale. The quality of the evidence was assessed with the GRADE approach.
Twenty-three randomised trials including 2,766 participants, with publication dates ranging from 2003 to 2017, were included in the review. There is low quality evidence that participants allocated to activity tracker interventions increased their physical activity levels by 1,558 steps per day (95% confidence interval (CI) 1,099 to 2,018) more than control participants after the intervention. At 12 months post-intervention, the differences between activity tracker and control interventions were not sustained (1 trial, 571 participants; mean difference 210 steps 95% CI -148 to 567). There was moderate quality evidence that activity tracker interventions improved mobility compared to control interventions (3 trials, 218 participants, standardised mean difference 0.61, 95% CI 0.31 to 0.90). Meta-regression did not find any differences in physical activity levels between: trials conducted in healthy populations (9 trials, standardised mean difference 0.61, 95% CI 0.25 to 0.96) versus populations with health conditions (14 trials, standardised mean difference 0.54, 95% CI 0.25 to 0.82)); trials using accelerometers (7 trials, standardised mean difference 0.24; 95% CI -0.15 to 0.63) versus trials using pedometers (16 trials, standardised mean difference 0.69; 95% CI 0.45 to 0.93); or trials with small (< 100 participants) sample sizes (15 trials, standardised mean difference 0.72; 95% CI 0.42 to 1.01) versus large sample sizes (8 trials, standardised mean difference 0.40; 95% CI 0.10 to 0.70). In contrast, a significant interaction between intervention duration and effect size was found, with longer interventions (12 or more weeks) having a larger impact on increasing physical activity levels (18 trials, standardised mean difference 0.70, 95% CI 0.47 to 0.93) compared to shorter interventions (5 trials, standardised mean difference 0.14; 95% CI -0.26 to 0.54).
Oliveira JS, et al. Effect of interventions using physical activity trackers on physical activity in people aged 60 years and over: a systematic review and meta-analysis. Br J Sports Med 2019 Aug 9:Epub ahead of print
Read more on PEDro.
Infographic for systematic review that found that neuromuscular training reduces anterior cruciate ligament injury in female athletes
Last month we summarised the Petushek et al systematic review. The review concluded that neuromuscular training reduces anterior cruciate ligament injury in female athletes. Data from the meta-regression were used to produce a best-practice checklist that can be used to evaluate neuromuscular training programs.
You can evaluate how beneficial the injury prevention programs you provide are using this infographic. The algorithm illustrated in the infographic is based on data from the meta-regression analysis in the review.
Petushek EJ, et al. Evidence-based best-practice guidelines for preventing anterior cruciate ligament injuries in young female athletes: a systematic review and meta-analysis. Am J Sports Med 2019;47(7):1744-53
Read more on PEDro.