97689_FM 12/07/10 5:41 PM Page i

RESEARCH METHODS
A Framework for Evidence-Based
Clinical Practice

Wendy L. Hurley, PhD, ATC, CSCS Associate Professor of Motor Behavior

Kinesiology Department
State University of New York College at Cortland
Cortland, New York

Craig R. Denegar, PhD, PT,

ATC, FNATA
Department of Physical Therapy
University of Connecticut
Neag School of Education
Storrs, Connecticut

Jay Hertel, PhD, ATC, FACSM, FNATA

Associate Professor of Kinesiology and
Physical Medicine & Rehabilitation
University of Virginia
Charlottesville, Virginia
97689_FM 12/07/10 5:41 PM Page ii

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Library of Congress Cataloging-in-Publication Data

Hurley, Wendy L.
Research methods : a framework for evidence-based clinical practice / Wendy L. Hurley, Craig R. Denegar, Jay
Hertel. — 1st ed.
p. ; cm.
Includes bibliographical references and index.
Summary: “This research methods textbook distinguishes itself from other textbooks by providing a unique frame-
work and perspective for users/students to establish the relevancy of research in their clinical practice. Many, if not
most, students in professional preparation allied health care programs view the research methods/statistics course
requirement of the curriculum as an obstacle to be overcome, or at best, as a necessary evil. Most research methods
textbooks promote these notions because of the way they are presented. Of course, most times they are written by
researchers or statisticians and are absolutely correct in presenting the theoretical underpinnings and mechanistic
applications of the scientific method. They correctly present explanations as to why one type of methodology re-
quires a certain type of statistical analysis based on the characteristics of the study population, the type of data col-
lected, or the underlying assumptions pertinent to a specific statistical model. So, while technically beyond re-
proach, their failure is in establishing how and why research activity and understanding is integral to a professional
practice”—Provided by publisher.
ISBN 978-0-7817-9768-9 (alk. paper)
1. Medicine—Research—Methodology. 2. Evidence-based medicine. I. Denegar, Craig R. II. Hertel, Jay. III. Title.
[DNLM: 1. Biomedical Research—methods. 2. Evidence-Based Medicine—methods.
3. Research Design. W 20.5]
R850.H87 2011
610.72—dc22 2010026652

DISCLAIMER
Care has been taken to confirm the accuracy of the information present and to describe generally accepted
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consequences from application of the information in this book and make no warranty, expressed or implied, with
respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information
in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described
and recommended may not be considered absolute and universal recommendations.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set
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Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA)
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97689_FM 12/07/10 5:41 PM Page iii

To Gram—When I was a child, you read to me as I sat on your lap, you

encouraged my curiosity, you allowed me to ask questions, you supported
my dreams and imagination, and you always showed me love and
acceptance. I miss you.To Dr. Bruce W. Young, Mr. David J.Tomasi,
Dr. Lori A. Michener, Dr. Bradley D. Hatfield, Dr.W.E. Buckley,
Dr. Craig R. Denegar, and Dr. Karl M. Newell—My beloved teachers,
respected mentors, and trusted professional role models.Your lessons con-
tinue to provide guidance and direction as I hear your words in my
mind’s ear and see your examples in my mind’s eye.This book would
never have been possible without your belief in me, and your lasting
influences on me both personally and professionally. It is my greatest
privilege to remain your humble and loyal student. I honor you with my
gratitude, love, and devotion.To my students—We learn together, and I
grow as you teach me what I need to do to become better at helping you
learn how to learn. I am fortunate to share my academic passions and
my favorite sagacious musings from the philosophies of Zen, Buddhism,
and Taoism with you.To Brent—You understand me, and I love you.
And, to Luka—Always.
WLH
To Sue, Charlie, and Cody for their love, support, and
daily inspiration.
CRD
To my parents, Jim and Kay Hertel, for providing the opportunity for
me to pursue a career in athletic training and sports medicine research,
and to all of the students I’ve had the opportunity to work with over
the past 15years. If I manage to teach others half of what you have
taught me, I’ll be satisfied.
JH
97689_FM 12/07/10 5:41 PM Page iv

FOREWORD

This research methods textbook distinguishes itself from other textbooks by provid-
ing a unique framework and perspective for users/students to establish the rele-
vancy of research in their clinical practice. Many, if not most, students in profes-
sional preparation allied health care programs view the research methods/statistics
course requirement of the curriculum as an obstacle to be overcome, or at best, as a
necessary evil. Most research methods textbooks promote these notions because of
the way they are presented. Of course, most times they are written by researchers or
statisticians and are absolutely correct in presenting the theoretical underpinnings
and mechanistic applications of the scientific method. They correctly present expla-
nations as to why one type of methodology requires a certain type of statistical
analysis based on the characteristics of the study population, the type of data col-
lected, or the underlying assumptions pertinent to a specific statistical model. So,
while technically beyond reproach, their failure is in establishing how and why re-
search activity and understanding is integral to a professional practice.
In this textbook, the authors appreciate professional realities that have rele-
vancy to professional preparation and the role of research within that preparation.
First, they promote that understanding research is a required competency in allied
health care preparation. That is, most allied health care professionals are going to
be consumers of research literature for the duration of their professional lives.
This is often enforced by continuing education requirements that reflect the un-
derstanding that medical and allied medical bodies of knowledge are ever ex-
panding and/or being refined and must be communicated to clinicians. Thus, at a
minimum, professional preparation programs must provide the opportunity for
the student to establish competencies in reading, critically evaluating, and synthe-
sizing research into their clinical practice.
The reality is that most medical and allied medical professions have accepted
that their disciplines need to follow an evidence-based best practice approach to
clinical practice and professional preparation in order to be effective today. Most
of their professional organizations actively promote through funding and dissem-
ination vehicles this research paradigm. This is not at the exclusion of other valu-
able research paradigms, but rather as an emphasis commensurate with current
disciplinary interest.
The authors have taken these realities and developed the research elements of
this textbook to be professionally relevant to clinical movement practitioners (e.g.,
physical therapists and certified athletic trainers). They use a commonsense-style
presentation of the conceptual and theoretical bases for the clinical research enter-
prise and provide clear examples of application, evaluation, and integration into
clinical practice.
iv
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Foreword v

Part I introduces the reader to the basic tenets of the research enterprise as it
relates to clinical practice. A wonderful chapter is presented on how to read and
evaluate research articles. This is a very pragmatic chapter that highlights the ele-
ments of an article so the reader can critically appraise the quality of the article.
The history of evidence-based clinical practice is presented along with a chapter
about how research can be used to establish best practices. The last chapter in this
section provides an overlay of ethical principles that need to be operative in re-
search and clinical practice enterprises.
Part II has seven chapters that effectively make the case that the conceptual,
elemental parts of research have a role in the reader’s effort to establish an
evidence-based practice. This is accomplished by describing how a reader could
have a clinical question and that the question is what dictates the research
methodology and analysis. One chapter provides the reader with a way to find re-
sources on clinical practice topics and evaluate the quality of the resources.
Another establishes that there is a hierarchy of evidence and the reader needs
to know what level or quality of evidence is important for them to use in their
clinical practice. Several chapters are nicely presented that introduce the most
common types of scientific inquiry and statistical analysis related to evidence-
based practice.
Part III carries this utilitarian presentation approach to the research enterprise
even further. The chapters are organized into clinical categories rather than re-
search method categories. That is, Chapter 13 presents what clinical research
methodology and analysis is appropriate when the reader is trying to find out
about the evaluation and diagnosis of orthopaedic conditions. Chapter 14 is about
screening and prevention of illnesses and injuries and what kinds of clinical re-
search and analysis are appropriate. Chapter 15 presents the research options that
clinical movement practitioners can use to develop evidence about the efficacy of
treatment/intervention options they may want to use. Chapter 16 further devel-
ops the concepts of treatment outcomes and broadens the focus to present com-
mon methods and relevant data analysis techniques. The last two chapters in this
part focus on how to extend research results to a clinical practice and how to or-
ganize many research results into a usable body of clinical evidence.
Parts IV and V provide sections that are unique to this text. But, again, the util-
itarian approach is taken. These sections are “how-to’s” for a clinical movement
practitioner to appreciate how clinical research results are disseminated. As a re-
search consumer, this is important for them to know. Also, the authors provide
some guidance on how to effectively write a funding proposal for a research proj-
ect. Again, many students in professional preparation programs begin to favor the
research element of their discipline and want to become actively involved in devel-
oping and answering their own clinical questions. Finally, the authors provide in-
sight into how clinical evidence can be used in clinical learning and teaching.
The genius of this text is that it is written for clinical professionals to under-
stand and appreciate research elements that are going to positively affect their
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vi Foreword

clinical practice. All the research methodology and analysis contained herein is
within the context of improving clinical outcomes. In other words, the authors il-
lustrate how clinical practice should drive the research enterprise rather than the
converse. In this way, the information becomes relevant to something clinical pro-
fessionals value and are therefore willing to accept and incorporate research com-
petencies in their clinical practice.

W.E. Buckley, PhD, MBA, ATC

Professor of Exercise and Sport Science, and Health Education
Department of Kinesiology
The Pennsylvania State University
97689_FM 12/07/10 5:41 PM Page vii

PREFACE

Process transforms any

journey into a series of small
steps, taken one by one, to reach
any goal. Process transcends
time, teaches patience, rests
on a solid foundation of careful
preparation, and embodies trust
in our unfolding potential.
~Dan Millman (Millman D.
The Laws of Spirit: Simple,
Powerful Truths for Making
Life Work. Tiburon, CA:
H J Kramer Inc; 1995.)

PURPOSE AND AUDIENCE

The purpose of this book is to provide a theoretical framework that will enable
students and practitioners to interpret and apply research into an evidence-based
best practice model. This book will serve as a primary course textbook in upper-
level undergraduate and graduate allied health programs for clinical movement
practitioners in both athletic training education programs and physical therapy
programs. The focus of this book is research methods, with emphasis on applica-
tion to evidence-based best practice for clinical allied health programs.
This book is intended to fill the void that exists in medical professions for a
textbook on research methods for evidence-based clinical practice for movement
practitioners. We’ve been teaching research methods for a combined 30 years to
both undergraduate and graduate students in allied health programs that empha-
size evidence-based clinical practice, and throughout this time, there has contin-
ued to be a void in existing research methods textbooks to address the specific
needs of disciplines and educational programs that follow an evidence-based best
practice approach to clinical practice and clinical education. As a result, we’ve
been left to use our own personal notes on research methods supplemented by re-
search methods textbooks designed and intended for nonclinical programs such
as Physical Education, or nonmovement practitioners such as nurses.
Existing materials currently do not provide the breadth and depth of discipline-
appropriate informational substance necessary for application to evidence-based
vii
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viii Preface

clinical practice for movement practitioners in the professional practices of physical

therapy and athletic training. The approach to research methods is often dry and
theoretical. If examples are provided, they tend to be methodological and scientific
rather than practical. As a result, the texts are often uninteresting and read like in-
struction manuals. All too often, the unfortunate outcome has been that students re-
ject their research methods text or put it aside because they feel as though they can-
not connect with the material and the manner in which it is presented.
While the procedural methods of empirical research are consistent across dis-
ciplines, the examples and connections to clinical programs are left the responsi-
bility of the professor. Often this has resulted in feedback from students who
complain about the expense of buying a textbook that they don’t like and don’t
use because they prefer to use our lecture notes and examples rather than
purchase the course textbook. It has been our experience that with the lack of
targeted information in the textbook, students struggle to make application to
their core curriculum and all too often the result is that students disengage from
the learning process and often draw the erroneous conclusions that research is
not for them or their future profession. After years of students asking us why we
didn’t write our own textbook on this subject matter, we feel that it is time to offer
a discipline-appropriate course textbook in research methods for movement
practitioners in evidence-based clinical practice.
While the concept of evidence-based clinical practice is still relatively new, the
body of literature on this topic has grown considerably over the last 5 years. It seems
that perhaps this notion has been slow to catch on in the United States, but interna-
tionally it has seemed to be more widely recognized as a hot topic. As grant monies
become more available nationally to focus on this area in medicine and clinical prac-
tice, it is likely that the concept will become more widespread throughout colleges
and universities in the United States. (To this point, we felt it important to include a
chapter that specifically addresses the issue of grant writing and provides helpful
guidelines, examples, and suggestions for writing funding proposals.) This text ref-
erences much of this current literature and contemporary material with the sole pur-
pose of targeting this untapped audience of allied health professionals and clinical
movement practitioners (i.e., physical therapists and certified athletic trainers).

APPROACH
The focal point of our approach to research methods is to provide guidance and
direction for students, instructors, and practitioners on how to acquire, read, in-
terpret, assess, and apply research as evidence in clinical practice has not been
provided in traditional research methods textbooks. We tend to view statistical
analysis as the flip side of research methodology, or two sides of the same coin.
We approach the subject matter conceptually and practically. Using a common-
sense style, conceptual and theoretical frameworks are introduced and discussed
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Preface ix

with clear application and integration to evidence-based clinical research. While

much research methodology is known this information will be restated in a clear,
detailed manner targeting practitioners in evidence-based clinical care and stu-
dents in professional preparation allied health care programs. Discipline-specific
vocabulary, examples, and case studies will be used to help the target audience bet-
ter understand the role and process of research in evidence-based clinical practice.

CHAPTER FEATURES
Each chapter of Research Methods provides the following elements to enhance the
usability of the text and offers a fresh approach to research methods for clinical
movement practitioners and students interested in learning about evidence-based
clinical practice:

• Key terms and concepts are bolded throughout the chapter to help the
reader focus their attention on scientific nomenclature and vocabulary es-
sential to a basic understanding of the chapter content and context.
• Chapter objectives detail what the reader will learn in the chapter and
highlight important pedagogical outcomes while also serving as a three-
fold self-assessment for readers (What are some important reasons for me
to read this chapter? How does this knowledge help me prepare to read it?
And, after reading this chapter, can I satisfy this list of learning outcomes?).
Readers are encouraged to make use of the chapter objectives to help guide
their reading and assess their level of reading comprehension.
• Concept checks reinforce important chapter content and purposefully reit-
erate noteworthy theory and viewpoints.
• Examples throughout chapters make concepts easier to grasp and apply to
real-life research and clinical decision-making situations.
• A chapter summary at the end of each chapter provides a comprehensive
review of the chapter and provides a take-home message for the readers.
• A list of key points further elucidates concepts, theories, and viewpoints
presented and elaborated throughout the chapter as both foundation to the
current chapter and groundwork to subsequent chapters, thus presenting a
full-circle approach by reinforcing the importance of key terms, chapter ob-
jectives, concept checks, examples, and the chapter summary within the
textbook.
• Chapter references and suggested readings are provided to aid the reader
with supplemental materials for breadth and depth of knowledge, and
demonstrate appropriate use and formal citation of original sources in em-
pirical research.
• Figures and tables offer illustrations to provide the reader with visual ex-
amples that help support important information detailed in the text.
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x Preface

• End-of-chapter critical thinking questions and thought-provoking discussion-

based problem-solving questions serve as necessary opportunities for dis-
cussion, review, assessment, and critical appraisal to help organize and
guide readers’ thought processes as we lead them through the thought-
structured progression of problem-solving, which is a foundational re-
quirement for learning to apply research methodology and follow an
evidence-based model of clinical practice.

By providing consistent features in each chapter, this approach guides the

reader as they encounter new vocabulary and learn to interpret and apply content
knowledge in a way that makes sense to them. In this manner, the text is both a
learning tool and an informational resource for research methods.

ORGANIZATION
The book is organized into five parts. Part I (Chapters 1 to 5) is structured as an
opening presentation of underlying conceptual frameworks and theoretical un-
derpinnings in clinical research and evidence-based practice, and an introduction
to the skills for critiquing and analyzing research is introduced. Chapter 1 covers
the concept of empirical research and the basic tenants of research methodology
as a collective paradigm. Chapter 2 provides a guide for how to read research and
offers a framework for evaluating research articles. Chapter 3 introduces the no-
tion of evidence-based clinical practice and explains how to distinguish best prac-
tices. Chapter 4 addresses the historical perspective of evidence-based medicine to
provide lead into the necessity of ethics in research and practice (covered in
Chapter 5).
Part II (Chapters 6 to 12) is organized around the research process in terms of sta-
tistical analyses and the idea of research as evidence. More specifically, this section
addresses how the question drives the methods when seeking answers to clinical
questions, because we are of the pedagogical and theoretical perspectives that it is
difficult to “teach” research methods without simultaneously addressing statistics.
Chapter 6 covers informational sources, search strategies, and critical appraisal of re-
search as evidence. Chapter 7 addresses the issue of hierarchy of evidence. Chapter 8
deals with qualitative inquiry, while Chapter 9 begins to sort out quantitative inquiry.
Chapters 10 and 11 describe research designs and data analysis while introducing the
statistical perspective of research methods. Chapter 10 discusses the fundamentals of
statistical analysis, focusing on validity and reliability of measures. Chapter 11 cov-
ers tests of comparison. Chapter 12 highlights measures of association.
The concepts that are introduced in Parts I and II and then developed and elab-
orated in Part III focuse on clinical research diagnosis, prevention, and treatment. In
this way, Part III (Chapters 13 to 18) is ordered to describe research designs and data
analysis for each type of study, and then provide some examples to illustrate its
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Preface xi

application. Our goal is to address and apply concepts of research methods into pre-
vention, diagnostics, and intervention outcomes. We are of the perspective that
these are the issues at the heart of evidence-based medicine—why disease and in-
jury occur (epidemiology) and what can I, as a clinician, do to prevent the condition
in the patient in my office (clinical epidemiology), etc. Chapter 13 addresses evalu-
ation and diagnosis from the perspective of research methods and data analysis.
Chapter 14 looks at screening and prevention of illness and injuries, again from the
perspective of research methods and data analysis. Chapter 15 explores the notion
of treatment outcomes across the disablement spectrum. Chapter 16 expands on this
and looks at treatment outcomes from the perspective of research methods and data
analysis. Chapter 17 covers the topics of clinical prediction rules and practice guide-
lines. And, Chapter 18 explores the application and usefulness of systematic review
and meta-analysis in evidence-based clinical practice.
Parts IV and V are unique to our book on several levels. The topics covered in
these chapters are uncommon in most traditional textbooks and are even rarely
mentioned in a book on research methods. Part IV (Chapters 19 and 20) is concen-
trated on the dissemination of research. Specifically, Chapter 19 offers guidelines
and suggestions for presenting research findings; and, Chapter 20 offers a detailed
guide with examples for writing the funding proposal. Part V (Chapters 21 and 22)
covers the integration of evidence-based medicine into the education experience.
Chapter 21 explores the notion of evidence in learning and teaching. Chapter 22
wraps up the discussion and comes full circle to revisit the topic of evidence in the
context of the clinical experience.

ADDITIONAL RESOURCES
Research Methods includes additional resources for both instructors and students
that are available on the book’s companion website at http://thePoint.lww.com/
Hurley.

Instructor Resources
Approved adopting instructors will be given access to the following additional
resources:

• Answers to the critical thinking problems found in each chapter

• One to two example assignments for each chapter
• A chapter assignment template—with accompanying guidelines, directions,
and suggestions—that can be used by instructors to create their own chapter
assignments
• PowerPoint slides for each chapter
• An image bank of all the figures and tables in the book
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xii Preface

Student Resources
All purchasers of the textbook can access the searchable Full Text On-line by going
to the Research Methods website at http://thePoint.lww.com/Hurley. See the in-
side front cover of this textbook for more details, including the passcode you will
need to gain access to the website.

ACKNOWLEDGMENTS
No book is the result of any one person’s efforts, yet we accept any mistakes as
ours alone. We would like to thank the following people whose efforts were essen-
tial to this project:

• Our product manager, Meredith Brittain, and her editorial staff for their tal-
ents, continued hard work, patience, and assistance in bringing this vision
to fruition.
• Our reviewers, for their time, feedback, and suggestions for improvement.
• Our contributing authors for their time, expertise, and generous participa-
tion. These include the coauthors of Chapter 20, Amy Henderson-Harr
(Assistant Vice President, Research and Sponsored Programs, State
University of New York College at Cortland) and Allan Shang (Assistant
Professor of Anesthesiology, Duke University School of Medicine, and
Senior Research Scientist, The Fitzpatrick Institute for Photonics, Duke
University Pratt School of Engineering).
• We would also like to acknowledge the following individuals who con-
tributed suggestions for the text: Timothy J. Bryant (Lecturer III, Kinesiology
Department, State University of New York College at Cortland), for his
help with Chapters 5 and 8; Brent Thomas Wilson (Assistant Professor,
Communication Disorders and Sciences Department, State University of
New York College at Cortland), for his help with Chapters 5 and 8; and,
Amy Henderson-Harr, for her help with Chapter 5.
• Our students and patients, past and present. We offer special acknowledg-
ment to the following students for their assistance in this project: Caitlin
Latham, Lauren Lenney, Patrick Sullivan.
• Our contemporaries in education, research, and medicine.
• The many past generations of teachers, clinical researchers, and medical
practitioners who came before us. We have benefited from your countless,
sometimes unrecognized, sacrifices, and your successes and failures paved
the way for evidence-based practice.

We would also like to thank our families and friends for their understanding
and support throughout the many hours during which our work keeps us away
from those most precious parts of our lives: the persons, the times, and the occa-
sions that we cannot recover after they are missed or gone.
97689_FM 12/07/10 5:41 PM Page xiii

CONTENTS

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

PART I
INTRODUCTION TO CLINICAL RESEARCH 1
1 Research: An Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Introduction 4
What Research is and What Research is Not 4
The Role of Theory in Research 7
The Research Process 7
Research and the Clinical Practitioner 14
Chapter Summary 15
Key Points 15
Critical Thinking Questions 16
Applying Concepts 16
REFERENCES 16
SUGGESTED READING 17

2 How to Read Research: Evaluating

Research Articles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Introduction 19
Whereabouts 20
Navigating Scientific Writing 22
Chapter Summary 26
Key Points 26
Critical Thinking Questions 27
Applying Concepts 27
SUGGESTED READING 27

3 Evidence-Based Clinical Practice:

Distinguishing Best Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Introduction 29
What is Evidence-Based Practice? 30
The Role of Theory: Definition and Basic Tenets 32
The Role of Research in EBP 35
How Does the Clinical Practitioner Use Research and EBP? 35
Chapter Summary 40
xiii
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xiv Contents

Key Points 40
Critical Thinking Questions 41
Applying Concepts 41
REFERENCES 41
SUGGESTED READING 42

4 EBM: A Historical Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Introduction 44
History and Direction of Clinical Fields 45
Research in Medicine 46
Clinical Research 47
Clinical Research and Evidence-Based Practice 48
Chapter Summary 49
Key Points 50
Critical Thinking Questions 50
Applying Concepts 51
REFERENCES 51

5 Ethics and Responsible Conduct in Research

and Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Introduction 53
General Background 54
Model of Interpretative Practice 55
Historical Context 58
Ethical Principles and Human Participation Protections 61
Medical Research Combined with Medical Care 67
Military and Other Special Interest Research 68
Chapter Summary 70
Key Points 71
Critical Thinking Questions 71
Applying Concepts 71
REFERENCES 73
SUGGESTED READING 73

PART II
SEEKING ANSWERS: HOW THE QUESTION
DRIVES THE METHODS 75
6 Finding the Evidence: Informational Sources,
Search Strategies, and Critical Appraisal . . . . . . . . . . . . . . . . . . 77
Introduction 78
Informational Sources and the Reference Librarian 78
Electronic Sources and Databases 79
Search Strategies 80
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Contents xv

Critical Review and Appraisal 81

Chapter Summary 86
Key Points 86
Critical Thinking Questions 87
Applying Concepts 87
REFERENCES 88

7 The Hierarchy of Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Introduction 90
Evidence Across Patient Care 91
Is All Evidence Equal? Levels of Evidence 92
Relevance of Evidence to Problem 103
Chapter Summary 104
Key Points 105
Critical Thinking Questions 106
Applying Concepts 106
REFERENCES 106

8 Qualitative Inquiry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Introduction 109
What is Qualitative Inquiry? 109
Objectives of Qualitative Research 110
Types of Qualitative Research 111
Methods of Qualitative Inquiry 113
Types of Qualitative Data Collection 114
Perspectives and Theoretical Traditions 115
Validity in Qualitative Research (Credibility) 119
Reliability of Qualitative Research (Dependability) 119
Health Professional As Being “On” While On the Job 120
The Health Profession and Professionals as a Community with Multiple Roles 120
Qualitative and Quantitative Integration 121
Chapter Summary 121
Key Points 122
Critical Thinking Questions 122
Applying Concepts 122
ACKNOWLEDGMENT 122
REFERENCES 123

9 Quantitative Inquiry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

Introduction 125
Characteristics of Quantitative Inquiry 125
Chapter Summary 136
Key Points 137
Critical Thinking Questions 137
Applying Concepts 137
SUGGESTED READING 138
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10 Validity and Reliability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Introduction 140
Types of Quantitative Data 140
Validity 141
Reliability, Agreement, and Precision of Measures 145
Chapter Summary 153
Key Points 153
Critical Thinking Questions 153
Applying Concepts 154
REFERENCES 154
SUGGESTED READING 154

11 Tests of Comparison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155

Introduction 156
Selecting Statistics and Types of Data 157
Analysis of Variance 160
Interpreting F 165
Alpha Values and Types of Error 167
Complex Designs and Terminology 169
Interaction 170
Levels of Variables 172
Planned Comparison and Post-Hoc Analysis 173
Analysis of Covariance 174
T-Tests 175
Significance and Confidence Intervals 178
Effect Sizes 183
Nonparametric Statistics 184
Mann—Whitney U Example Scenario 187
A Note on Parametric Analysis of Ordinal Data 189
Chapter Summary 190
Key Points 191
Critical Thinking Questions 192
Applying Concepts 192
REFERENCES 193
SUGGESTED READING 193

12 Measures of Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194

Introduction 195
Purpose and Methods 195
Data Analysis 197
Regression 198
Interpreting p and R2 205
Managing Ordinal and Nominal Data 207
Association versus Cause 210
Chapter Summary 211
Key Points 211
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Critical Thinking Questions 212

Applying Concepts 212
REFERENCES 212
SUGGESTED READING 212

PART III
CLINICAL RESEARCH: DIAGNOSIS, PREVENTION, AND TREATMENT 213
13 Evaluation and Diagnosis: Research Methods
and Data Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Introduction 216
Physical Examination Procedures 217
How Can Clinical Research Improve Patient Evaluation? 218
Design of Studies of Diagnostic Testing 219
Assessing Research of Diagnostic Instruments 222
Statistics and Interpretations 224
The Basics—Sensitivity and Specificity 226
Likelihood Ratios 229
Chapter Summary 236
Key Points 236
Critical Thinking Questions 237
Applying Concepts 237
REFERENCES 237
SUGGESTED READING 238

14 Screening and Prevention of Illness and Injuries:

Research Methods and Data Analysis . . . . . . . . . . . . . . . . . . . 239
Introduction 240
Model of Injury Prevention 240
Risk Identification: Research Design Issues 242
Estimating Injury Rates and Risks 248
Statistical Analysis 251
Chapter Summary 255
Key Points 257
Critical Thinking Questions 257
Applying Concepts 257
REFERENCES 258

15 Treatment Outcomes Across the Disablement Spectrum . . . 259

Introduction 260
Types of Outcomes Measures 260
Disablement Models 261
Clinician-Derived Measures 265
Patient Self-Report 266
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xviii Contents

Global Health Measures 266

Condition-, Region-, or Dimension-Specific Measures 267
Single Item Outcomes Measures 268
Choosing the Appropriate Outcomes Instruments 269
Chapter Summary 271
Key Points 271
Critical Thinking Questions 271
Applying Concepts 272
REFERENCES 272

16 Treatment Outcomes: Research

Methods and Data Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Introduction 274
Building an Infrastructure to Measure Treatment Outcomes 274
Study Designs 275
Data Analysis: Statistical Significance versus Clinical Meaningfulness 282
Clinical Prediction Rules 289
Comprehensive Data Analysis 291
Chapter Summary 291
Key Points 291
Critical Thinking Questions 292
Applying Concepts 292
REFERENCES 293
SUGGESTED READING 293

17 Clinical Practice Guidelines and Clinical Prediction Rules . . . 294

Introduction 295
Clinical Prediction Guides 295
Data Analysis 297
Clinical Practice Guidelines 299
Levels of Evidence 302
Diagnostic Practice Guidelines and Grade of Recommendation 302
Additional Considerations 303
Chapter Summary 303
Key Points 304
Critical Thinking Questions 304
Applying Concepts 304
REFERENCES 305

18 Systematic Review and Meta-Analysis . . . . . . . . . . . . . . . . . . 306

Introduction 307
Systematic Review 309
Traditional Literature Review versus Systematic Review 311
Systematic Review as a Research Process 313
Data Synthesis 314
Meta-Analysis 317
Considerations for Applying the Results from Systematic
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Review to the Care of the Individual Patient 317

Chapter Summary 324
Key Points 324
Critical Thinking Questions 325
Applying Concepts 325
REFERENCES 326

PART IV
DISSEMINATION OF RESEARCH 327
19 Presentation of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329
Introduction 330
Types of Presentations 330
Chapter Summary 344
Key Points 344
Critical Thinking Questions 344
Applying Concepts 345
REFERENCES 345

20 Writing the Funding Proposal . . . . . . . . . . . . . . . . . . . . . . . . . . 346

Introduction 346
History and Culture of Grants 347
Grant versus Contract 348
Sources of Funding 350
Grant Writing for the Twenty-First Century:
A Recipe for Success 353
Grant Writing versus Publication Authorship 357
Preparing a Budget 370
Chapter Summary 375
Key Points 377
Critical Thinking Questions 378
Applying Concepts 378
REFERENCES 378
SUGGESTED READING 379

PART V
INTEGRATING EVIDENCE-BASED MEDICINE INTO
THE EDUCATIONAL EXPERIENCE 381
21 Evidence in Learning and Teaching . . . . . . . . . . . . . . . . . . . . . 383
Introduction 384
Learning Critical Appraisal 385
Learning and Teaching from a Body of Evidence 387
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Problem-Based Learning 388

Promoting Learning and Assessing Outcomes 390
Chapter Summary 391
Key Points 393
Critical Thinking Questions 394
Applying Concepts 394
REFERENCES 394

22 The Clinical Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396

Introduction 397
Case Reports 397
Grand Rounds 400
Chapter Summary 403
Key Points 403
Critical Thinking Questions 404
Applying Concepts 404
REFERENCES 404

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 415
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Reviewers xxi

Reviewers
Diane P. Brown, PhD, OTR
Associate Clinical Professor
School of Occupational Therapy
Texas Woman’s University
Denton, TX

Allyn Byars, PhD, CSCS, *D

Associate Professor
Department of Kinesiology
Angelo State University
San Angelo, TX

Mary Ellen Camire, PhD

Professor
Food Science and Human Nutrition
University of Maine
Orono, ME

D. Scott Davis, PT, MS, EdD, OCS

Associate Professor
Department of Human Performance and Exercise Science
West Virginia University
Morgantown, WV

Dawn M. Hankins, PhD, ATC, LAT

Associate Professor and Curriculum Director for Athletic Training
Athletic Training, School of Nursing and Health Professions
McKendree University
Lebanon, IL

Patti Kalvelage, MS, OTR/L

Senior Lecturer, MOT Program
Department of Human Health and Services
Governors State University
University Park, IL

Suh-Jen Lin, PT, PhD

Associate Professor
School of Physical Therapy
Texas Woman’s University
Dallas, TX
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xxii Reviewers

Elizabeth Rink, PhD

Assistant Professor
Health and Human Development
Montana State University
Bozeman, MT

Barbara Sanders, PT, PhD, SCS

Professor and Chair, Department of Physical Therapy
Associate Dean, College of Health Professions
Texas State University
San Marcos, TX

Hal Strough, PhD, ATR, ATC

Department Chair/Assistant Professor
Athletic Training
The College of St. Scholastica
Duluth, MN

Laura K. Vogtle, PhD, OTR/L

Professor and Director, Postprofessional Master’s Program
Department of Occupational Therapy
University of Alabama at Birmingham
Birmingham, AL

Bruce Watkins, PhD

Associate Professor
Sport Management
University of Michigan
Ann Arbor, MI

Barbara Prudhomme White, PhD, OTR/L

Associate Professor
Occupational Therapy, College of Health and Human Services
University of New Hampshire
Durham, NH