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Return to Testing Your Knowledge In the following exercise, click an answer and a pop-up box should appear that contains feedback. Note: If you do not see a pop-up box, check your popup blocker settings in the browser. If that is not the problem, try closing the previous pop-up box or check to see if the pop-up box is behind your browser window.  If you still do not see the pop-up box, you may need to update your browser. Supplement: Case 2: Physical Therapy for the Knee The Patient 1. Start with the patient -- a clinical problem or question arises out of the care of the patient. George is an active 83 year old male. He used to swim three times a week for 45 minutes, garden, and walk to church. But for the last several months, he has had trouble walking and bending his knees. It has made gardening difficult and caused some discomfort. His family physician made the diagnosis of osteoarthritis and suggested that a course of physical therapy would be beneficial. George has had physical therapy before for his back and is very skeptical of this suggestion. He wants to know if there is any proof that physical therapy does any good for this problem. The Question 2. Construct a well-built clinical question derived from the case. Based on this scenario, choose the best, well-built clinical question: A. Can physical therapy help an elderly 83 year-old male? B. In elderly patients with osteoarthritis of the knee, can physical therapy improve mobility and reduce pain? C. Is physical therapy helpful for a painful knee? The Resource 3. Select the appropriate resource(s) and conduct a search Based on the best, well-built question, choose the best search strategy to address the question. These search examples were done using PubMed in October 2003. A. Search Most Recent Queries   Result  #1 Search physical therapy techniques 92828 #2 Search osteoarthritis knee 1519 #3 Search #1 AND #2 107 #4 Search #1 AND #2 Field: All Fields, Limits: Aged: 65+ years, Randomized Controlled Trial 28 B. Search  Most Recent Queries Result  1 Search physical therapy techniques 92828 2 Search physical therapy techniques Field: All Fields, Limits: 80 and over: 80+ years, English, Randomized Controlled Trial, Male, Human 278 3 Search physical therapy techniques Field: All Fields, Limits: 80 and over: 80+ years, English, Randomized Controlled Trial, Male, Human, Core clinical journals 86 C. Search  Most Recent Queries Result #1 Search knee 55426 #2 Search physical therapy 4140 #3 Search #1 AND #2 343 #4 Search #1 AND #2 Field: All Fields, Limits: English, Randomized Controlled Trial, Human 29 The Evaluation 4. Appraise the evidence for its validity (closeness to the truth) and its applicability (usefulness in clinical practice). Read the following article, then determine if the article addresses the issues of validity. As stated previously, evaluating the medical literature is a complex undertaking. You will find that the answers to the questions of validity may not always be clearly stated in the article and that you may have to use your own judgment about the importance and significance of each question. Deyle GD. Henderson NE. Matekel RL. Ryder MG. Garber MB. Allison SC. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Annals of Internal Medicine. 132(3):173-81, 2000 Feb 1. pdf version | html version Permission to reproduce parts of this article was given by American College of Physicians and American Society of Internal Medicine.   Validity Issues: Does the article address this: 1. Randomization:: Was the assignment of patients to treatment randomized? Yes No 2. Patient follow-up:  Were all patients who entered the trial properly accounted and attributed for at its conclusion? Yes No 3. Analysis of patients:  Were patients analyzed in the groups to which they were randomized? Yes No 4. Blinding:  Were patients, health workers, and study personnel "blind" to treatment? Yes No 5. Baseline characteristics of patients:  Were groups similar at the start of the trial? Yes No 6. Treatments:  Aside from the experimental intervention, were the groups treated equally? Yes No Are the results of this study valid? Yes No This covers the first aspect of evaluating the evidence. There are two additional questions that you, as clinicians, need to consider: What are the Results of the study? At 8 weeks, mean WOMAC scores decreased more in the intervention group than in the placebo group (P less than 0.05). Intervention-group patients increased their 6-minute walking distance more than did placebo-group patients (P less than 0.05). At 1 year, fewer intervention-group patients had knee surgery than did placebo-group patients (P = 0.039). Outcomes at 8 weeks PT + Ex (baseline) Placebo (baseline) Difference in mean change from baseline (95% CI) Mean WOMAC Score (MM) 462   (1047) 934   (1094) 425   (189 to 661) Mean 6 min walking distance (meters) 487   (431) 410   (403) 49   (19 to 79) In scrutinizing the study methods, it is notable that neither the sample size nor the anticipated dropout rate was justified in the text. It was not clear which of the 2 main outcomes reported was considered primary in testing the study hypothesis. Because of the unbalanced dropout rate, the use of a multiple imputation analysis to account for missing data might have been helpful. Any loss of outcome data regardless of how it occurs clearly reduces the statistical precision of a trial and may also introduce bias if the losses vary by treatment group. This trial showed that control patients had statistically significant higher rates of surgeries and intra-articular steroid injections at 1 year. On the basis of this finding, physicians treating patients with osteoarthritis might improve pharmacologic management by referring patients earlier rather than later to physical therapists. This small change could diminish the burden of disability and reduce the presumably higher cost of invasive surgery and postsurgical rehabilitation. Reprinted with permission from the American College of Physicians (ACP Journal Club 133(2):57, Sep/Oct 2000) Are the Results applicable to your patient? Do these patients match George for age, physical conditioning, or previous treatment? Note that the mean age of patients in this study was 60 years. The Patient 5. Return to the patient -- integrate the evidence and clinical expertise, patient preferences and apply it to practice. Think about George, your treatment recommendation for him and what you would discuss with him on his next visit. If you are not going on to another test case, please take a few minutes to give us feedback about this tutorial. Thank you! Return to Testing Your Knowledge updated 11/28/06