Reliability and validity of the AGREE instrument used by physical therapists in assessment of clinical practice guidelines

BACKGROUND: The AGREE instrument has been validated for evaluating Clinical Practice Guidelines (CPG) pertaining to medical care. This study evaluated the reliability and validity of physical therapists using the AGREE to assess quality of CPGs relevant to physical therapy practice. METHODS: A total of 69 physical therapists participated and were classified as generalists, specialist or researchers. Pairs of appraisers within each category evaluated independently, a set of 6 CPG selected at random from a pool of 55 CPGs. RESULTS: Reliability between pairs of appraisers indicated low to high reliability depending on the domain and number of appraisers (0.17–0.81 for single appraiser; 0.30–0.96 when score averaged across a pair of appraisers). The highest reliability was achieved for Rigour of Development, which exceeded ICC> 0.79, if scores from pairs of appraisers were pooled. Adding more than 3 appraisers did not consistently improve reliability. Appraiser type did not determine reliability scores. End-users, including study participants and a separate sample of 102 physical therapy students, found the AGREE useful to guide critical appraisal. The construct validity of the AGREE was supported in that expected differences on Rigour of Development domains were observed between expert panels versus those with no/uncertain expertise (differences of 10–21% p = 0.09–0.001). Factor analysis with varimax rotation, produced a 4-factor solution that was similar, although not in exact agreement with the AGREE Domains. Validity was also supported by the correlation observed (Kendall-tao = 0.69) between Overall Assessment and the Rigour of Development domain. CONCLUSION: These findings suggest that the AGREE instrument is reliable and valid when used by physiotherapists to assess the quality of CPG pertaining to physical therapy health services

The short-term effect of a rollator on functional exercise capacity in individuals with severe chronic obstructive pulmonary disease

grantor: University of Toronto'Purpose'. This study was conducted to examine the effect of a rollator on functional exercise capacity in individuals with severe COPD and to determine which individuals would benefit most from using a rollator. ' Methods'. 40 subjects were studied on two separate days in the same week. Two six-minute walk tests (6MWTs) were performed on each day. One 6MWT was performed unaided and the other using a rollator, with the order of the test randomized on the first day and reversed on the second. 'Results '. There was a significant reduction in modified Borg rating of dyspnea (p < 0.001) and duration of rest (p = 0.001) with use of the rollator. For subjects who walked less than 300 meters unaided, there was also a significant improvement in distance walked (p = 0.02). Requirement of a rest during the unaided 6MWT was the only significant predictor variable for improvement in functional exercise capacity with use of the rollator (p < 0.005). ' Conclusions'. Rollators are effective in improving functional exercise capacity by reducing perception of dyspnea and rest duration in individuals with severe COPD. Individuals who walk less than 300 meters and/or who require a rest during an unaided 6MWT will benefit most from using a rollator in terms of reductions in breathlessness and rest time and an improvement in distance walked.M.Sc

A Survey of Suctioning Practices among Physical Therapists, Respiratory Therapists and Nurses

OBJECTIVE: To assess the current tracheal and oropharyngeal suctioning practice variability within and among the professions of physical therapy, respiratory therapy and nursing.DESIGN: A mail survey of physical therapists, respiratory therapists and registered nurses who perform suctioning. The survey instrument consisted of questions about professional characteristics, clinical suctioning practice and sociodemographics.SETTING: The survey was restricted to professionals practising within the province of Ontario.PARTICIPANTS: Random samples (n=448) were drawn from membership of the regulatory boards of all three professions.MAIN RESULTS: Fifty-eight per cent of respondents returned completed questionnaires. There was large variation in reports of gloving procedure (eg, double clean: 26% for physical therapists, 5% for respiratory therapists, 55% for registered nurses, Pud_less_than0.0001) and technique of catheter use (sterile, inline or clean, Pud_less_than0.01). There was also discrepancy in the techniques used to minimize harmful effects, ie, prelubrication with gel (83% for physical therapists, 54% for respiratory therapists, 17% for registered nurses, Pud_less_than0.0001), use of hyperinflation (12% of physical therapists, 25% of respiratory therapists, 39% of registered nurses never hyperinflate) and use of instillation (7% of physical therapists, 0% of respiratory therapists, 19% of registered nurses never instill). However, there was agreement about the routine application of hyperoxygenation (74% or more) and there was almost perfect agreement (99% or more) within and across the three professions that secretion removal was the main indication for suctioning.CONCLUSIONS: The results of this study indicate a wide variation in suctioning techniques among physical therapists, respiratory therapists and registered nurses. Comparisons among professions revealed inconsistencies in some areas, such as the use of in-line catheters, gloving procedures, prelubrication and hyperinflation.Peer Reviewe

Muscle relaxants for non-specific low-back pain

Background: The use of muscle relaxants in the management of non-specific low back pain is controversial. It is not clear if they are effective, and concerns have been raised about the potential adverse effects involved. Objectives: The aim of this review was to determine if muscle relaxants are effective in the treatment of non-specific low back pain. Search methods: A computer-assisted search of the Cochrane Library (Issue 3, 2002), MEDLINE (1966 up to October 2002) and EMBASE (1988 up to October 2002) was carried out. These databases were searched using the algorithm recommended by the Cochrane Back Review Group. References cited in the identified articles and other relevant literature were screened. Selection criteria: Randomised and/or double-blinded controlled trials, involving patients diagnosed with non-specific low back pain, treated with muscle relaxants as monotherapy or in combination with other therapeutic modalities, were included for review. Data collection and analysis: Two authors independently carried out the methodological quality assessment and data extraction of the trials. The analysis comprised not only a quantitative analysis (statistical pooling) but also a qualitative analysis ("best evidence synthesis"). This involved the appraisal of the strength of evidence for various conclusions using a rating system based on the quality and outcomes of the studies included. Evidence was classified as "strong", "moderate", "limited", "conflicting" or "no" evidence. Main results: Thirty trials met the inclusion criteria. Twenty-three trials (77%) were of high quality, 24 trials (80%) were on acute low back pain. Four trials studied benzodiazepines, 11 non-benzodiazepines and two antispasticity muscle relaxants in comparison with placebo. Results showed that there is strong evidence that any of these muscle relaxants are more effective than placebo for patients with acute LBP on short-term pain relief. The pooled RR for non-benzodiazepines versus placebo after two to four days was 0.80 [95% CI; 0.71 to 0.89] for pain relief and 0.49 [95% CI; 0.25 to 0.95] for global efficacy. Adverse events, however, with a relative risk of 1.50 [95% CI; 1.14 to 1.98] were significantly more prevalent in patients receiving muscle relaxants and especially the central nervous system adverse effects (RR 2.04; 95% CI; 1.23 to 3.37). The various muscle relaxants were found to be similar in performance. Authors' conclusions: Muscle relaxants are effective in the management of non-specific low back pain, but the adverse effects require that they be used with caution. Trials are needed that evaluate if muscle relaxants are more effective than analgesics or non-steroidal anti-inflammatory drugs

Muscle relaxants for nonspecific low back pain: A systematic review within the framework of the Cochrane Collaboration

Study Design. A systematic review of randomized and/or double-blinded controlled trials. Summary of Background Data. The use of muscle relaxants in the management of nonspecific low back pain is controversial. It is not clear if they are effective, and concerns have been raised about the potential adverse effects involved. Objectives. The aim of this review was to determine if muscle relaxants are effective in the treatment of nonspecific low back pain. Methods. A computer-assisted search of the Cochrane Library (Issue 2, 2002), MEDLINE (1966 up to October 2001), and EMBASE (1988 up to October 2001) was carried out. These databases were searched using the algorithm recommended by the Cochrane Back Review Group. References cited in the identified articles and other relevant literature were screened. Randomized and/or double-blinded controlled trials, involving patients diagnosed with nonspecific low back pain, treated with muscle relaxants as monotherapy or in combination with other therapeutic methods, were included for review. Two reviewers independently carried out the methodologic quality assessment and data extraction of the trials. The analysis comprised not only a quantitative analysis (statistical pooling) but also a qualitative analysis ("best evidence synthesis"). This involved the appraisal of the strength of evidence for various conclusions using a rating system based on the quality and outcomes of the studies included. Evidence was classified as "strong," "moderate," "limited," "conflicting," or "no" evidence. Results. Thirty trials met the inclusion criteria. Twenty-three trials (77%) were of high quality; 24 trials (80%) were on acute low back pain. Four trials studied benzodiazepines, 11 nonbenzodiazepines, and 2 antispasticity muscle relaxants in comparison with placebo. Results showedthat there is strong evidence that any of these muscle relaxants are more effective than placebo for patients with acute low back pain on short-term pain relief. The pooled relative risk for nonbenzodiazepines versus placebo after 2 to 4 days was 0.80 (95% confidence interval: 0.71 to 0.89) for pain relief and 0.49 (95% confidence interval: 0.25 to 0.95) for global efficacy. Adverse events, however, with a relative risk of 1.50 (95% confidence interval: 1.14 to 1.98) were significantly more prevalent in patients receiving muscle relaxants and especially the central nervous system adverse effects (relative risk 2.04; 95% confidence interval: 1.23 to 3.37). The various muscle relaxants were found to be similar in performance. Conclusions. Muscle relaxants are effective in the management of nonspecific low back pain, but the adverse effects require that they be used with caution. Trials are needed that evaluate if muscle relaxants are more effective than analgesics or nonsteroidal anti-inflammatory drugs