Critical Evaluation of Research in Physical Rehabilitation; Toward Evidence-Based Practice,
A. Helewa, J. Walker, Philadelphia, Pa, WB Saunders, 1999, softcover, 271 pp. $35.00.
Sara J. Smiley MHS, PT, Marshfield, Wisconsin
The purpose of this text is to assist physical rehabilitation students and clinicians in understanding the rudiments of evidence-based practice, at any stage of their education or careers. Toward that end, the authors provided an overview of research design and methods, as well as the tools required to conduct a search of the available literature to evaluate the literature critically.
The book is divided into nine chapters and four appendices as well as a glossary and index. It includes figures and tables which are illustrative and examples of evaluation tools that can be used to evaluate research literature. %In chapter one, the authors discussed the places a clinician can look to find a published paper. A variety of computer-based tools are available to search for information, and several of the most useful are listed. A definition of the criteria to look for is also included. To discern the quality of published literature, the authors urge the reader to look for peer-reviewed articles. The different types of articles such as research, review, textbook sources, and case reports are discussed at length, and the differences between them are clearly explained. The first chapter is extremely useful and instructive and contains much of the “meat” of the text.
In the second chapter, the authors describe how to locate potentially useful articles. This was introduced in the first chapter and thoroughly discussed here. Most, if not all of the journals of interest to rehabilitation professionals are outlined here, including Canadian and European journals. This is probably the most useful information contained in the chapter. A logarithm for performing searches can be found in this chapter, and may be helpful for those unfamiliar with performing a computer-based search. The strength of the book is the fact that the authors do not assume any prior knowledge, but most students will have had some of this information in today’s computer-based world.
The third chapter elaborates on the computer search and the authors are instructive in pointing out high vs low quality articles. The authors point out that the low number of randomized clinical trials in the rehabilitation literature unfortunately leaves us little to draw from. In addition, the studies showed treatment benefit in general have had lower methodological scores when compared with negative studies. Any systematic search for evidence leading to changes in clinical practice must be based on a critical review of the scientific methodology of the studies in question, according to the authors.
In chapter four, the authors discuss review strategies for outcome measures and diagnostic tests. “Clinical research often involves the evaluation of outcome measure or diagnostic tests; both use designs that are compatible, but their goals and statistical analyses are different. In this chapter, we point out these differences and show how they influence the general approach to the critical evaluation of such studies.” The concepts of error, accuracy, and diagnosis are explored at length. Chapter five is focused on review of articles about treatment efficacy and effectiveness. The authors point out that those two terms are often used interchangeably. In fact, efficacy refers to a beneficial result under ideal conditions, whereas effectiveness lists results of all subjects in the trial, including those that are noncompliant. Thus effectiveness is more reflective of reality. The size of the study group and applicability of outcomes to specific populations are discussed. Some very practical concepts are outlined here and are food for thought in applying techniques to a given population.
Chapter six introduces healthcare economics. “This chapter will deal with the economic evaluation of studies that take into account treatment effectiveness, and its economic impact and evaluation in terms of a treatment’s cost and its utility. ” As healthcare dollars are limited, clinicians must sometimes choose which treatments will give the greatest benefit, and to which patients those treatments will be given.
Using meta-analysis is the focus of chapter seven. Because there is a paucity of good literature in the rehabilitation field, the authors advocate reviewing the previous literature for commonalities, but urge caution in data abstraction that may artificially inflate the results of the analyses. Future use of meta-analysis on emerging literature “will be needed to demonstrate the benefits of physical rehabilitation interventions.”
In chapter eight, international collaborations in healthcare that are focused on evidence-based practice are reviewed. These include the Cochrane Collaboration, the centers for evidence-based medicine, the Agency of Health care Policy and Research (AHCPR), and journal clubs. The purpose of these groups is to improve the health outcomes of the world’s populations. Clinicians today must rely in part on the information gathered by agencies involved in the evidence-based practice movement. This information must be continuously updated and revised, to ensure true benefit to the healthcare customer, and wise allocation of the healthcare dollar. This chapter is more of an “FYI,” than the nuts-and-bolts information presented in chapters one, two, and nine.
In the final chapter, the authors review the progress during the last 50 years of healthcare, and predict how the change in patterns of health and disease will impact the delivery of healthcare into the next century. The implication of this on the physical rehabilitation field rounds out the chapter. Models of healthcare and the focus on computerized medicine and exchange of information are emphasized. This chapter was one of the strongest in general information, which is appropriate for students and advanced clinicians alike.
This text is most suitable for students engaged in a first look at research, literature searches, and evidence-based practice. The initial chapter is especially informative and the authors did an excellent job of defining terms and research concepts in a way that would be useful for any student of physical rehabilitation. Although physical therapists will benefit from this book, many rehabilitation professionals will gather useful information as well. Actually, the text is not especially geared for physical therapists alone. Others who will benefit from this text are those people who have been out of the classroom and practicing for 10 to 20 years, those who graduated without an initial master’s degree, and those who base their practice on “feel-good” methods for which no published literature is available. The text is well-organized and is an instructive manual, which refers us back to using literature to support our practice.