You Ask #PEDroAnswers
You Ask #PEDroAnswers campaign to enhance searching skills:
About the campaign
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Portuguese and French versions of the campaign GIF
Portuguese version
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French version
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An essential element of evidence-based practice is searching to find the best high-quality research to answer your clinical questions. Despite the importance of searching, just one in three physiotherapists perform a database search each month. Skill is an obstacle to searching. Physiotherapists may do more searching if they could increase their competency and efficiency.
Throughout 2021 we ran the You Ask #PEDroAnswers campaign to help physiotherapists to improve their searching skills using the PEDro Advanced Search. The campaign was supported by World Physiotherapy, the Australian Physiotherapy Association, the Asociación Española de Fisioterapeutas, Physio Deutschland, the Società Italiana Fisioterapia and the Société Française de Physiothérapie.
Each month we shared short videos illustrating how to use the PEDro Advanced Search to find high-quality research to answer clinical questions submitted by the global physiotherapy community. You can watch all 10 search videos in the Short videos illustrating how to use the PEDro Advanced Search section, below.
Throughout 2021 we also shared 10 tips on how to use the PEDro Advanced Search. You can watch all 10 search tips in the Tips on how to use the PEDro Advanced Search section, below.
We hope the You Ask #PEDroAnswers campaign has helped you to develop your searching skills.
Short videos illustrating how to use the PEDro Advanced Search
Video 01: In older people living at home, does telephone motivational interviewing with a physiotherapist increase physical activity compared to providing written advice?
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Portuguese version
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Video 02: In stroke survivors, does mirror therapy improve upper limb function more than usual care?
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Video 03: In people with a cervical disc herniation, does computerised traction reduce pain more than exercise therapy?
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Video 04: In musicians with musculoskeletal injuries, does trigger point therapy decrease the time to return to playing an instrument compared to rest and advice?
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Video 05: In older people with urinary incontinence who live in residential aged care facilities, does pelvic floor muscle training combined with mobility training reduce episodes of incontinence compared to mobility training alone?
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Video 06: Does cooling decrease delayed onset muscle soreness following intense exercise in athletes compared to rest?
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Video 07: In people experiencing post-COVID-19 syndrome, does aerobic exercise improve exercise tolerance more than watchful waiting?
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Video 08: In people with stroke, does repetitive functional task practice improve mobility more than Bobath therapy?
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Video 09: In women with breast-cancer related lymphoedema, does adding upper limb strength training to usual care have more adverse events compared to usual care alone?
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Video 10: In children with cerebral palsy, does functional and repetitive training of sit-to-stand reduce disability more than usual care?
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Tips on how to use the PEDro Advanced Search
TIP 1: ask a PICO question before you search
As a clinician, you perform diagnostic tests, provide information on prognosis, and implement interventions on a daily basis. You may want to find out if the diagnostic test (or combination of tests) you are using is the best available considering your facilities and resources. You may want to discover the course of recovery for a condition you don’t see very often. You may also like to know if you are offering an intervention that is supported by the results of high-quality research. To do these you need to pose a clinical question.
In order to answer your clinical question, it is helpful to break it down into four essential components using the ‘PICO’ framework. In this memory aid, P stands for patient, I stands for intervention, C stands for comparison, and O stands for outcome. Taking the time to clearly define the question will help you work out the best search terms to use, which in turn will make finding the best research to answer your question less daunting or time-consuming.
For questions about the effects of interventions, your PICO question should include all four elements:
P (patient): what is the condition or population group of interest, are you interested in a particular subgroup (eg, acute stroke) or sociodemographic group (eg, workers)? Are you working with older people, children, athletes, people that have had a traumatic brain injury or stroke?
I (the intervention): what treatment are you interested in?
C (the comparison): are you interested in comparing your intervention to placebo, usual care, or another intervention (eg, aquatic versus land-based exercise)?
O (the outcome): what measurable outcome(s) are you interested in improving? Is the outcome important to patients? Outcomes could be events (eg, falls), symptoms (eg, pain), functional measures (eg, walking speed) and quality of life. Harmful effects and the cost of treatment are also important outcomes to consider.
An example of a PICO question about the effects of an intervention is: “In people with Parkinson’s disease, does training using visual or auditory cues reduce the risk of having a fall compared to usual care?”
PICO can also be used to frame diagnostic questions, but here “I” takes on a new meaning:
P (patient).
I (the “issue”): this could be a diagnostic test, a combination of physical tests, or a clinical prediction rule.
C (the comparison): what do you want to compare your diagnostic test to? This could be a reference test or the gold standard test.
O (for outcome): this is usually a measure of the test utility like specificity or sensitivity. This gives you an idea of both the rate of false positives (diagnosing the condition in those that do not have it) and false negatives (missing the diagnosis in those that do).
An example of a PICO question about a diagnostic test is: “In female soccer players with knee injuries, what is the accuracy of the anterior draw test compared to medical resonance imaging for detecting an anterior cruciate ligament injury?”
Elements of PICO can help you ask questions about the prognosis of a condition. With prognostic questions “I” takes on a new meaning and the “C” is dropped:
P (patient): when specifying this element it is useful to include the duration or severity.
I (for “time”): over what time span are you interested in, the short- or long-term?
O (for outcome): these should be both quantifiable and important to patient’s goals and priorities. Examples include the rate of disease progression or a positive outcome (eg, return to work or sport).
An example of a PIO question about prognosis is: “For people with an episode of back pain resulting in 4 weeks off work, what is the likelihood that they return to work in their previous role at 6 months?”
We’ve recently revised the PEDro video tutorial on posing clinical questions about interventions.
English version
Portuguese version
Turkish version
French version
TIP 2: don’t enter search terms for each element of the PICO question
In order to answer your clinical question, it is helpful to break it down into four essential elements using the ‘PICO’ framework. In this memory aid, P stands for patient, I stands for intervention, C stands for comparison, and O stands for outcome. Asking a PICO question gives you four options to choose from when selecting search terms, one potential search term for each PICO element. But you don’t need to enter terms for all four PICO elements when you perform your search. Usually just one or two are enough. A good starting point is to enter terms for the patient and intervention elements of your question.
The first search video for the “You Ask #PEDroAnswers” campaign illustrated how using terms for the patient and intervention can quickly identify relevant research. The question was: “in older people living at home, does telephone motivational interviewing with a physiotherapist increase physical activity compared to providing written advice?” The Search terms used were ‘gerontology’ in the Subdiscipline field for the patient and ‘motivational interview*’ in the Abstract & Title field for the intervention.
The best PICO elements to use to generate search terms will vary for different questions. Before you start your search think, which of the PICO elements will inevitably and uniquely be associated with the articles that I wish to find? Enter terms for those elements in your PEDro search.
We’ve recently revised the PEDro video tutorial on posing clinical questions about interventions.
English version
Portuguese version
Turkish version
French version
TIP 3: use the PEDro Advanced Search (not Simple)
PEDro has three search pages (Advanced, Simple and Consumer). We strongly encourage health professionals to use the Advanced Search option, which contains a series of fields to define search terms with precision. For this reason, the SEARCH buttons in the header and footer of the PEDro website and the SEARCH wedge of the navigation wheel on the PEDro homepage take you directly to the Advanced Search page.
The PEDro Advanced Search page has 13 fields that you can use to enter the search terms generated from your clinical question. But it is important to note that you do not need to enter search terms in EVERY field. Specifying terms in one to three fields is usually sufficient.
Six fields have pull-down lists that you can choose from (Therapy, Problem, Body Part, Subdiscipline, Topic and Method). These are indicated by the arrow symbol. For example, the pull-down list for the Body Part field contains the different anatomical regions that might be the focus of your intervention, from the head or neck down to the foot or ankle. This field is particularly useful if your clinical question relates to the treatment of a musculoskeletal condition. You can select a term by clicking on it. You can only select one term in a pull-down list.
Three fields let you enter numbers or dates. These let you identify articles that are published in or after a particular year, added to PEDro since a particular date or, for trials only, have a minimum cut-off value for the total PEDro score.
Four fields allow you to type text into them (Abstract & Title, Author/Association, Title Only and Source). For example, you can search for words that appear in the abstract or title of an article in the Abstract & Title field. Generally it is most efficient to search by typing one or two words into the Abstract & Title field.
You need to use English words in text fields because most of the database behind PEDro is in English. For example, searching for incontinência in the Abstract & Title field will return no articles. In contrast, searching for incontinence returns hundreds of articles. If you type non-English letters into text fields you will receive an error message reminding you to remove any non-English letters.
Those who are new to searching may like to begin with the Simple Search, which contains a single text field. Patients and other users of physiotherapy can access the Consumer Search, which has less technical language.
We’ve recently revised the PEDro video tutorial on how to perform an Advanced Search in PEDro.
English version
Portuguese version
Turkish version
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TIP 4: use wildcards (truncation)
Using wildcards refers to the replacement of a letter or letters of a word with a symbol in order to represent more than one version of that word. There are different wildcards for different purposes.
An asterisk (*) can be used to replace any number of letters (including no letters) that form part of the start or end of a word.
Truncation is most commonly used by placing an asterisk at the end of a full or shortened word to permit alternative endings. So searching with ambula* will retrieve articles that contain the words ambulate, ambulant or ambulation. Other examples include:
- Parkinson* will retrieve articles that contain Parkinson, Parkinson’s or Parkinsonism.
- cue* will retrieve articles that contain cue, cues or cueing.
- fall* will retrieve articles that contain fall, falls or falling.
Alternatively, an asterisk can be placed at the beginning of a word. So searching with *feedback will retrieve articles that contain biofeedback or myofeedback, as well as just feedback. Other examples include:
- *edema will retrieve articles that contain oedema, lymphedema or lymphoedema.
- *continence will retrieve articles that contain continence or incontinence.
Another type of wildcard is the @ symbol. It can be used in the place of one letter within a word, allowing any letter to fill that position. This can be useful for searching for words that have spelling variants in English. For example, searching with mobili@ation will retrieve articles that contain mobilisation or mobilization.
The @ wildcard can also be useful when searching for a particular article if you are unsure of the exact spelling of the author’s name. For example, searching with Peters@n would retrieve articles that contain Peterson or Petersen.
We’ve recently revised the PEDro video tutorial on how to perform an Advanced Search in PEDro.
English version
Portuguese version
Turkish version
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TIP 5: use phrase searching
Phrase searching is a strategy that combines two or more terms into a single term and is done by placing double quotation marks (" ") around the words. This is useful when a specific construct, like "lateral epicondylitis", involves more than one word. Phrase searching is a way of combining several search terms as if you were using the AND Boolean operator.
Let’s use lateral epicondylitis as an example. When you search for lateral epicondylitis without quotation marks, you will retrieve articles that contain both words (lateral AND epicondylitis) in their abstract or title, but not articles containing just lateral OR just epicondylitis.
Adding quotation marks ("lateral epicondylitis") will make your search more specific to the construct. You will retrieve articles that contain all words between the double quotation marks together and in that order (eg, ‘treatment of lateral epicondylitis’). You will NOT retrieve articles containing the words separately (eg, ‘treatment of epicondylitis’) or in a different order (eg, ‘treatment of epicondylitis of the lateral elbow’).
In other words, using phrase searching will make your search become more precise, as you will be looking specifically for articles that have two or more words combined in the abstract or title. However, you might end up missing articles that use a different nomenclature for lateral epicondylitis (eg, epicondylitis only or epicondylalgia).
Phrase searching cannot be combined with wildcards, such as * or @. If you want to use wildcards to identify articles that use different variants of the word epicondylitis (eg, epicond*), make sure you don’t use these wildcards in conjunction with phrase searching (eg, "lateral epicond*"). Using wildcards in conjunction with phrase searching will return no articles. More information on how to use wildcards is available in tip 3, above.
Phrase searching can be used in text fields in both the Simple Search and Advanced Search in PEDro. Three more examples of phrase searching are:
- "multiple sclerosis"
- "patellofemoral pain"
- "blood pressure".
We’ve recently revised the PEDro video tutorial on how to do an Advanced Search.
English version
Portuguese version
Turkish version
French version
TIP 6: don’t use Boolean operators
Boolean operators connect your search terms together to either narrow or broaden your results. There are three basic Boolean operators: AND, OR, and NOT. Boolean operators are useful when you are conducting a search that contains two or more terms.
If you need to narrow your results, AND is the Boolean operator you should look for. AND means all the terms you are searching for need to be present in the article. If you want to broaden your search, you should use OR instead. OR means that any search term in your strategy can be present in the article. NOT is designed to exclude words from your search by omitting any articles that contain certain terms.
Although used in other databases, you do not need to use Boolean operators to conduct a PEDro search. When you run a search using two or more terms in one of the free-text fields (eg, ‘Abstract & Title’), PEDro automatically combines the terms with AND.
For example, let’s think about planning a search to identify articles evaluating the effects of exercise for shoulder pain. In PEDro you can simply type the words shoulder exercise into the ‘Abstract & Title’ field, because PEDro will automatically combine both words with AND. You should not use shoulder AND exercise. If you do use a search strategy that includes a Boolean operator, an error message will pop up prompting you to amend your search by removing Boolean operators from the text field.
We’ve recently revised the PEDro video tutorial on how to do an Advanced Search.
English version
Portuguese version
Turkish version
French version
TIP 7: if you get too many search results ...
After asking a question that contains all the PICO components, a good starting place for your search is to enter terms for the Patient and Intervention components of the question (see tip 1). However, in some cases this can lead to too many articles in the search results. In this blog we will suggest some strategies for narrowing down the number of articles if you get too many search results.
Let’s use this PICO question as an example: In people with subacromial shoulder pain, does resistance exercise reduce pain more than massage? One starting point for the search to answer this question would be to type shoulder pain into the Abstract and Title field and select strength training in the Therapy drop down list. If you do this you get over 400 articles, which is too many to read to answer the clinical question.
When you get too many articles in your search results, three strategies that can make your search more precise are:
- Make a search term more specific
For our search we used a very broad term for the Patient (shoulder pain). One strategy to reduce the number of articles in the search results is to make the term for the Patient more precise. A particular type of shoulder pain was included in the question, pain in the subacromial region. We could replace shoulder pain with subacromial shoulder pain in the Abstract and Title field. This would reduce the number of search results to around 65 articles.Phrase searching (where two or more words are combined into a single term by placing the words between double quotation marks) is another strategy to make a term like shoulder pain more specific. Changing shoulder pain to "shoulder pain" will reduce to number of search results to around 180 articles. A detailed explanation about phrase searching is in tip 5. - Change the field you use to enter a search term
We could also make the search more precise by using a different field to enter a search term. If we type subacromial shoulder pain in the Title Only field instead of in the Abstract and Title field, the number of search results is reduced to about 10 articles.You do need to carefully select which field(s) to use as, in some cases, changing where you enter the term might increase the number of search results. For example, removing shoulder pain from the Abstract and Title field and selecting upper arm, shoulder or shoulder girdle from the Body Part drop down list would increase the number of articles in the search results to over 900. Generally, typing terms in the Abstract and Title or Title Only fields retrieve less search results than using the drop down lists. - Add a term for another PICO component
We could add a term for another PICO component to our original strategy (typing shoulder pain into the Abstract and Title field and selecting strength training in the Therapy drop down list) in order to reduce the number of articles in the search results. A term for the Comparator component could be added by typing shoulder pain massage into the Abstract and Title field. This would reduce the number of search results to around 14 articles.You need to carefully select which PICO components to use in the search in order to use terms that are uniquely associated with the question being asked. In our example we avoided using a term for the Outcome (for example, selecting pain in the Problem drop down list) because this is an outcome used in many research articles and is likely to produce a large number of search results.
We’ve recently revised the PEDro video tutorial on how to do an Advanced Search.
English version
Portuguese version
Turkish version
French version
TIP 8: if you get too few search results ...
Let’s use this PICO (Patient-Intervention-Comparator-Outcome) question to illustrate what to do if you get too few (or even no) articles in the search results in PEDro: In people with femoroacetabular impingement syndrome, does joint mobilisation reduce pain more than rest? One starting point for the search to answer this question would be to enter terms for the Patient and Intervention by typing femoroacetabular impingement syndrome joint mobilisation into the Abstract and Title field. If you do this, you will get 0 results.
When you get too few (or even no) articles in your search results, four strategies that can make your search broader are:
- Check that you have spelt the terms correctly and in English if using text fields
- Remove the term for a PICO component
If you initially entered terms for more than one PICO component, you could remove the terms for one of these components. In the search for our example question we entered terms for both the Patient and Intervention components by typing femoroacetabular impingement syndrome joint mobilisation into the Abstract and Title field. We could make the search broader by removing the term related to the Intervention. If you delete joint mobilisation from the Abstract and Title field and rerun the search just using femoroacetabular impingement syndrome, the search results include around 7 articles. - Change the field you use to enter a search term
Another strategy to make the search broader is to use a different field to enter the term for a PICO component. In our question and search we typed the term for the intervention (joint mobilisation) into the Abstract and Title field. This could be problematic because there are a relatively large number of words that can be used in the abstract and title of an article to describe this intervention, including manual therapy, mobilisation, mobilization, manipulation and thrust. Using a code in one of the drop down lists could help overcome this problem. In this case we could use the stretching, mobilisation, manipulation, massage code in the Therapy drop down list. Deleting joint mobilisation but retaining femoroacetabular impingement syndrome in the Abstract and Title field and selecting stretching, mobilisation, manipulation, massage in the Therapy drop down list returns about 6 articles. Generally, entering terms in the Abstract and Title or Title Only fields will retrieve less search results than using a drop down list. - Make a search term less specific
For our example search we used a very specific term for the Patient (femoroacetabular impingement syndrome). One strategy to increase the number of articles in the search results is to make the term for the Patient less specific. We could replace femoroacetabular impingement syndrome with hip impingement in the Abstract and Title field. If you search for hip impingement in the Abstract and Title field and stretching, mobilisation, manipulation, massage in the Therapy drop down list there will be about 14 articles in the PEDro search results.
We’ve recently revised the PEDro video tutorial on how to do an Advanced Search.
English version
Portuguese version
Turkish version
French version
TIP 9: screen titles first, then look at abstracts
After you’ve run a search, it’s time to screen the articles listed on the "Search Results" page to find the article that best answers your clinical question.
The "Search Results" page displays the list of articles identified by your search. The results are displayed in a table which lists the title, the research method, and for randomised controlled trials, the total PEDro score (/10) for each article that fulfils your search criteria.
The "Search Results" are organised so that articles that use more rigorous methods appear closer to the top of the table. The articles are sorted by research method, with practice guidelines appearing before systematic reviews and then randomised controlled trials. Cochrane reviews are listed before systematic reviews published in other journals. Clinical trials are sorted by the total PEDro score, from the highest (10/10) to the lowest (0/10) score. Articles are also sorted by year of publication, from most to least recent, within each category.
As you read down the list of articles, from practice guidelines, systematic reviews, and higher-quality trials, pay close attention to the title as your first point of reference. Screening the titles first before looking at the abstracts can help save time by ignoring articles that don’t answer your question. This is because the title should generally provide enough information to inform you whether the article is related to your clinical question or not.
Once you identify a title which looks promising, clicking on the title hyperlink will take you to the “Detailed Search Results” page. This page provides more detailed information about the article, including the citation, abstract (when available), links to full text and, for randomised controlled trials, a breakdown of the PEDro score.
Reading the abstract will help to confirm whether the article answers your clinical question, if the methods used were rigorous and if there is clear reporting of the results. Some tips on how to quickly appraise the quality of evidence-based clinical practice guidelines, systematic reviews and randomised controlled trials are available in previous PEDro blogs.
When you decide on the best article to read, you can access a full text copy of the article (sometimes free) using the links under the abstract on the "Detailed Search Results" page.
We’ve recently revised the PEDro video tutorial on how to do an Advanced Search.
English version
Portuguese version
Turkish version
French version
TIP 10: access full text using links in PEDro
Access to full-text copies of research articles is essential for translating research into practice. Full-text articles are needed to appraise the quality and applicability of research for a clinical question. They are also needed for a detailed description of the intervention. Access to full-text articles is crucial for all health professionals trying to provide evidenced-based care.
When a PEDro search locates an article of interest, clicking on the title hyperlink brings up its "Detailed Search Results" page. We have recently estimated the percentage of articles in PEDro that have free full-text access via these links. Access to free full text was available for 60% (95% confidence interval 53% to 67%) of the articles sampled. This is higher than the free full-text access that was available via PubMed (47%, 95% confidence interval 40% to 54%).
We provide up to 5 links to full text for each article in PEDro. The number of links will depend on whether the article is indexed in PubMed or PubMed Central, if the article has a DOI number, and if the journal has a website. These links may be to free full text, or you may need a subscription to the journal or to pay to view the article. Access to free full text is determined by the journal publishers. The links to full text in PEDro are listed in order of likelihood for accessing free full text. With links at the top of the list being more likely to link to free full text than the links at the end of the list. The links are:
- PubMed Central. PubMed Central is a free full-text archive of biomedical journal literature produced by the United States National Institutes of Health's National Library of Medicine. It contains over 6 million full-text articles that have been published in journals that have an agreement with PubMed Central to archive their content. Clicking on the "PubMed Central" link on the PEDro "Detailed Search Results" page will take you directly to the article in PubMed Central. You may be able to view the full-text article on this website or open the article in Portable Document Format (PDF) by clicking on a link.
- DOI. This is the acronym for Digital Object Identifier, a unique alphanumeric string assigned by the International DOI Foundation to identify content and provide a persistent link to its location on the internet. Clicking on the "DOI" link on the PEDro "Detailed Search Results" page will take you directly to the article on the journal’s website. Not all journals will allow you to access full text free of charge. In this case you may be asked to login or to pay to access the article. If a subscription is required, you may be able to access the article via your local medical library.
- PubMed. Produced by the United States National Institutes of Health's National Library of Medicine, PubMed is a free database containing over 33 million citations and abstracts of biomedical literature. The "PubMed" link on the PEDro "Detailed Search Results" page will take you to the PubMed entry for the article. This PubMed entry may contain links to full text from other sources.
- PDF locator. Some search engines on the internet are designed to find free PDF documents. In PEDro we have created a link that uses PDFSearchEngine.net to search for PDF copies of the article. Clicking on the "PDF locator" link on the PEDro "Detailed Search Results" page will take you to the search results generated by PDFSearchEngine. These results are ranked for relevance using a built-in algorithm. You will need to scan down the list of search results to see if a link to full text is available for your article of interest. We suggest that you look at the first two pages of search results.
- Publisher. The last option for accessing full text is via the website of the journal using the "publisher" hyperlink on the PEDro "Detailed Search Results" page. Accessing full text will require additional navigation through the journal website in order to locate the issue that your target article is published in. Not all journals will allow you to access full text free of charge. In this case you may be asked to login or to pay to access the article.
#PEDroTacklesBarriers to EBP
The #PEDroTacklesBarriers to evidence-based physiotherapy campaign to tackle the four biggest barriers to evidence-based physiotherapy:
About the campaign
About the campaign. Portuguese version
Portuguese version
About the campaign. French version
French version
About the campaign. Italian version
Italian version
La campagna #PEDroTacklesBarriers alla pratica della fisioterapia è disponibile in italiano
Welcome to the #PEDroTacklesBarriers to evidence-based physiotherapy campaign. The campaign will help you to tackle the four biggest barriers to evidence-based physiotherapy.
This campaign was inspired by a recent systematic review by Matteo Paci and colleagues that investigated the barriers to evidence-based physiotherapy. The review included 29 studies reporting the opinions of nearly 10,000 physiotherapists. Lack of time was the most frequently encountered barrier and was reported by 53% of physiotherapists. This was followed by language (36%), lack of access (34%), and lack of statistical skills (31%).
From May 2022 to April 2023, the campaign will delve into each of the four biggest barriers to evidence-based physiotherapy. You will hear from physiotherapists who have encountered these barriers and developed strategies to overcome them. You will also learn more about the methods used to conduct, analyse, report and interpret randomised controlled trials, to help you tackle the barrier of lack of statistical skills.
Each month we will release tips on how to tackle a particular barrier to evidence-based physiotherapy. We encourage physiotherapists from around the globe to work collaboratively to implement the most relevant strategies into your practice.
The campaign will conclude with some real-world examples of how physiotherapists have overcome these barriers and used evidence to make positive changes to their practice and improve the outcomes of their patients.
#PEDroTacklesBarriers is supported by World Physiotherapy, Australian Physiotherapy Association, Società Italiana di Fisioterapia, Société Française de Physiothérapie, and Koninklijk Nederlands Genootschap voor Fysiotherapie.
Please join us in the ‘PEDroTacklesBarriers to evidence-based physiotherapy’ campaign to help tackle the biggest barriers to evidence-based physiotherapy. You can follow the campaign on this webpage or via the PEDro blog, Twitter or Facebook.
Time
Lack of time is the most common barrier to evidence-based physiotherapy. Many factors contribute to this, including a high workload, competing priorities, efficiency in all 5 steps of evidence-based physiotherapy (Ask, Acquire, Appraise, Apply, Assess), lacking resources, lacking confidence, and being overwhelmed by the amount of evidence and the process of changing practice.
Ten clinicians share some strategies they use to tackle the barrier of lack of time in the #PEDroTacklesBarriers to evidence-based physiotherapy campaign.
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Nosipho Zumana Mtotoba Mafikeng Provincial Hospital, South Africa Nosipho emphasises quality over quantity. She says that “everybody in life does not have time, but we try to accommodate and do what we can within the time that we are given.” |
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Kate Scrivener Concentric Rehabilitation Centre, Australia A key strategy to tackle the time barrier suggested by Kate is to use synthesised research. Kate says “guidelines provide the most important evidence for clinical practice” and that “systematic reviews have the potential to be strong enough to change what we do in clinical practice.” |
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Nicholas Draheim Movement Solutions, Australia Nick suggests making evidence part of your staff meetings by “identifying areas that the team need to develop knowledge and skills in and task staff with bringing relevant high-quality clinical research to the meeting”. |
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Michele Marelli Università degli Studi del Molise, Italy Michele dedicates time to reading new articles. He says that “specialising in specific fields in musculoskeletal care” has also helped him tackle the time barrier. |
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Daniel Treacy South Eastern Sydney Local Health District, Australia Daniel suggests a journal club that is focused on a practice or question over a period of time will facilitate implementation. Daniel emphasises “that, in addition to reading relevant research, journal clubs should include planning and testing how the new practices are implemented in the clinic’s busy work schedule.” |
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Nehal Shah Bhopal Memorial Hospital and Research Centre, Bhopal, India Being in a routine of reading articles has made Nehal more efficient. Every morning she puts an article in her pocket so that it is on hand when she has some spare time. |
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Govinda Nepal Kathmandu University Hospital, Nepal Like many physiotherapists, Govinda has a long commute to work. He uses this travel time to read high-quality research. |
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Yvette Black Bloomfield Hospital, Orange Health Service, Australia A mentor once said to Yvette “it’s not that you don’t have time, you need to reframe it and make time.” She suggests using your diary to make considering evidence a normal part of your routine. |
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Sean Kaplan Home visiting physiotherapist, South Africa Sean seeks to “know what you don’t know.” You can collaborate with colleagues or friends to take action on this using relevant evidence. |
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Laura Crowe-Owen Therapy for Life, Australia Laura provides some great tips for the strategic use of social media. Suggestions include “following researchers who produce meaningful articles, rather than the loudest person in the room, and always read the articles.” |
This month seven more clinicians talk about how they tackle the time barrier for the #PEDroTacklesBarriers to evidence-based physiotherapy campaign.
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John Tan Singapore General Hospital, Singapore John recommends finding like-minded colleagues that spur you on to help tackle the time barrier. He says “it is important to stay curious and committed plus develop the habit of inquiry.” |
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Fairuz Boujibar Rouen University Hospital, France Fairuz thinks that spending 30 minutes per day thinking about evidence is within reach of many physiotherapists. She says “having physiotherapy students in your department is an opportunity for mutual learning.” |
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Francesco Ferrarello Azienda Usl Toscana Centro, Italy Francesco suggests that “Reading regularly will make it easier and increase confidence”. If you are new to reading research, start by reading one relevant article per month. |
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Alison Hoens University of British Columbia, Canada Alison is a Physical Therapy Knowledge Broker, a position partly funded by the Physiotherapy Association of British Columbia. She says “get involved in your professional association in order to access resources and meet people who are deeply engaged.” |
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Ruth Chua Singapore General Hospital, Singapore Ruth reminds us that evidence-based practice will help ensure that treatment is effective and will benefit your patients. Ruth says that “enrolling in a residency program provides lots of opportunities for implementing evidence into practice.” |
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Matt Jennings South Western Sydney Local Health District, Australia Matt provides some system-level guidance to use the time you do have to make a difference. He says that “the culture around time is really important, what you prioritise and how you support teams to provide the best care is critical.” |
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Harriet Shannon University College London, United Kingdom Harriet thinks that team ethos is critical for making time available. She says “it starts with a team decision that we are going to be the change makers who are going to implement evidence-based practice.” |
Language
Language is an important barrier to accessing and implementing evidence-based physiotherapy in many countries, with English being the dominant language used to publish and disseminate evidence-based research and guidelines.
Five physiotherapists and physiotherapy groups share how they have tackled the language barrier for the #PEDroTacklesBarriers to evidence-based physiotherapy campaign.
Tiê Parma Yamato, Brazil
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Tiê Parma Yamato is a researcher where English is her second language. Tiê prioritised learning English to overcome the language barrier as most research is disseminated in English. Initially, she relied heavily on translation services (i.e. Google translate), took English courses, and read a lot in English. She travelled to Australia to further immerse herself in the English language. As she became more familiar with the language, she engaged with more complex vocabulary and discussion, giving her more in-depth understanding of the literature and evidence-based practice. |
Zbyszek Wroński, Poland
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PEDro was recently translated into Polish, which has led to a large increase in PEDro-related searches from Poland and increased the accessibility of evidence-based practice among Polish physiotherapists. The PEDro resource is now used in physiotherapy courses in Poland to teach and promote evidence-based practice. Accessibility to research has improved with this resource, however language continues to be a barrier since most research articles are published in English. |
Cynthia Srikesavan, India
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A small group of Tamil speaking physiotherapists trained from Tamil Nadu in Southern India have been running a monthly virtual journal club since 2020. One strategy they use to overcome the language barrier is to use both English and Tamil during their journal clubs. For example, they introduce initial article structure and concepts in Tamil, have their more formal presentations in English, and end with broader group discussions back in Tamil. This, amongst other strategies, improves their English and understanding of evidence-based physiotherapy. |
Anne-Kathrin Rausch, Germany
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Physioscience is a platform that publishes research in the German language and is the Official publication of Germany’s Society for Physiotherapy Science. To make research more accessible, Physioscience publishes work in both German and English. In every issue, Physioscience publishes three ‘Gelesen & Kommentiert’ articles. These articles are in German and include a summary (abstract) of the published work, followed by a critical appraisal and comment to discuss the topic within the context of physiotherapy in Germany, Austria and Switzerland. |
Nynke Swart, the Netherlands
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Nynke Swart says KNGF (Royal Dutch Society for Physical Therapy) have developed 16 clinical guidelines that are relevant for physiotherapy practice in the Netherlands. When developing guidelines, they mainly focus on Dutch and English studies. The evidence together with other considerations is translated into easy-to-use recommendations for physiotherapists by a group of experts. KNGF disseminate their guidelines in both Dutch and English to increase accessibility. |
Lack of access
Evidence-based physiotherapy cannot be implemented if there are barriers to accessing research. Below are two videos on strategies to tackle the barrier of accessing full text articles. The first focuses on accessing full text using the links in PEDro. The second outlines strategies that use other non-PEDro methods.
Access to full-text articles is crucial for all health professionals trying to provide evidenced-based care. Full-text articles are needed to appraise the quality and applicability of research for a clinical question. They are also needed for a detailed description of the intervention.
When a PEDro search locates an article of interest, clicking on the title hyperlink brings up its “Detailed Search Results” page. In 2022 we have recently estimated the percentage of articles in PEDro that have free full-text access via these links. Access to free full text was available for 60% (95% confidence interval 53% to 67%) of the articles sampled. This is higher than the free full-text access that was available via PubMed (47%, 95% confidence interval 40% to 54%).
We provide up to 5 links to full text for each article in PEDro. The number of links will depend on whether the article is indexed in PubMed or PubMed Central, if the article has a DOI number, and if the journal has a website. These links may be to free full text, or you may need a subscription to the journal or to pay to view the article. Access to free full text is determined by the journal publishers. The links to full text in PEDro are listed in order of likelihood for accessing free full text. With links at the top of the list being more likely to link to free full text than the links at the end of the list.
The links are:
1. PubMed Central
PubMed Central is a free full-text archive of biomedical journal literature produced by the United States National Institutes of Health’s National Library of Medicine. In January 2022 it contained over 7.6 million full-text articles that have been published in journals that have an agreement with PubMed Central to archive their content. Clicking on the “PubMed Central” link on the PEDro “Detailed Search Results” page will take you directly to the article in PubMed Central. You may be able to view the full-text article on this website or open the article in Portable Document Format (PDF) by clicking on a link.
2. DOI
This is the acronym for Digital Object Identifier, a unique alphanumeric string assigned by the International DOI Foundation to identify content and provide a persistent link to its location on the internet. Clicking on the “DOI” link on the PEDro “Detailed Search Results” page will take you directly to the article on the journal’s website. Not all journals will allow you to access full text free of charge. In this case you may be asked to login or to pay to access the article. If a subscription is required, you may be able to access the article via the library provided by your university or health service your local medical library.
3. PubMed
Produced by the United States National Institutes of Health’s National Library of Medicine, PubMed is a free database containing over 34 million citations and abstracts of biomedical literature. The “PubMed” link on the PEDro “Detailed Search Results” page will take you to the PubMed entry for the article. This PubMed entry may contain links to full text from other sources.
4. PDF locator
Some search engines on the internet are designed to find free PDF documents. In PEDro we have created a link that uses PDFSearchEngine.net to search for PDF copies of the article. Clicking on the “PDF locator” link on the PEDro “Detailed Search Results” page will take you to the search results generated by PDFSearchEngine. These results are ranked for relevance using a built-in algorithm. You will need to scan down the list of search results to see if a link to full text is available for your article of interest. We suggest that you look at the first two pages of search results.
5. Publisher
The last option for accessing full text is via the website of the journal using the “publisher” hyperlink on the PEDro “Detailed Search Results” page. Accessing full text will require additional navigation through the journal website in order to locate the issue that your target article is published in. Not all journals will allow you to access full text free of charge. In this case you may be asked to login or to pay to access the article.
Saurab Sharma, Nepal
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As a physiotherapist, researcher, and educator in Nepal, Saurab Sharma often faced barriers to accessing full-text research articles that are behind a “paywall”. Saurab provides some innovative solutions on how to access full-text articles freely in low and middle-income countries where resources are scarce. For example, digital archives like PubMed Central or Hinari provide options to search for articles in specific languages and can provide free access to full-text articles. Other good resources for accessing free full-text articles are journals or publishers that publish ‘open-access’ articles such as Journal of Physiotherapy, PLoS and BMC. The Physiotherapy Evidence Database also provides links to accessing full-text articles, some of which are freely available. Research published in 2022 showed that PEDro provides access to 60 % of the articles sampled from the PEDro database, compared to PubMed which provides access to 47% of full-text articles. In this video, Saurab explores these resources and other strategies to address the barrier of access. |
Lack of statistical skills
A lack of statistical skills is a common barrier to interpreting evidence and implementing evidence-based physiotherapy. Three clinician-researchers including the Scientific Editor of the Journal of Physiotherapy, tackle the barrier of lack of statistical skills by discussing the methods used to conduct, analyse, report, and interpret randomised controlled trials.
This topic will be covered between October 2022 and January 2023.
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Aidan Cashin Exercise Physiologist and researcher, University of New South Wales, Australia Area of practice: Comparative effectiveness of interventions for people with chronic pain |
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Kate Scrivener Physiotherapist, educator and researcher, Macquarie University, Australia Area of practice: Post-stroke physiotherapy intervention and research |
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Mark Elkins Scientific Editor of Journal of Physiotherapy Area of practice: Physical and pharmacological therapies in respiratory disease and improving the understanding and application of published research by clinicians |
Interpreting comparative effects in trials
High-quality randomised controlled trials are a great source of evidence to support clinical decisions about which treatment may be best for the patients you work with. When interpreting the findings from trials, it is important to consider both how the outcomes are reported and what the treatment is being compared to.
Trial outcomes are often measured and reported as the ‘within-group’ change in outcomes or as the ‘between-group’ difference in outcomes. The distinction between within-group comparison and between-group comparison is critical when interpreting the results of trials. The between-group difference represents the treatment effect because it does not include natural history, regression to the mean, and nonspecific effects of receiving care which are included in the within-group change.
The treatment effect in trials is always comparative, meaning that the treatment benefit (or harm) is interpreted relative to the other treatment(s) in the trial. This is an important issue because the choice of comparison group will have a big influence on the interpretation of the size of the effect and whether the comparison was a fair test of the treatment.
Choosing the ideal comparison group is not straightforward and is heavily influenced by the research question (spanning the spectrum of efficacy to effectiveness research). For example, guideline-based care may be a suitable comparator if researchers were interested in investigating if the treatment was better than current practice.
The choice of comparison group is also important when trials are synthesised in systematic reviews. It is important that meta-analyses of systematic reviews combine trials with similar treatments, and trials that have similar comparison groups.
Understanding the importance of blinding in trials
There are numerous stakeholders involved in any clinical trial. These include patients and participants, therapists, researchers, outcome assessors and statisticians. Stakeholders are a source of bias in trials. This is because they can consciously or subconsciously influence procedures or results based on knowing whether a patient has been allocated to the intervention or control group. To minimise biases, a trial can ‘blind’ the stakeholders to which group participants are allocated. Blinding is considered successful if the stakeholder is unable to distinguish between the treatments applied to the groups.
Three important people or groups to be blinded in clinical trials include the:
1. Patient or participant: where the patient is unaware if they are receiving the intervention or control
2. Therapist: where the therapist is unaware if they are delivering the intervention or control
3. Assessor: where outcome assessor(s) are unaware if the participant being assessed had received the intervention or control
In most physiotherapy trials, it is very difficult to blind participants and therapists. For example, if interventions are physical or active (e.g. exercise), participants will know they are receiving the intervention and therapists will know if they are delivering it. In regard to blinding the assessor, blinding is successful if the assessor does not know which group the patient has been allocated to and outcome measures are objective (e.g. passive range of motion). However, when outcome measures are patient-reported or self-reported (e.g. pain), the assessor is considered blind if the patient was blinded.
Studies frequently report the occurrence of blinding in the title or abstract using terms such as ‘single blinded’ or ‘double blinded’. However, there is inconsistent use of these terms. For example, one ‘double blinded’ trial may have blinded the therapists and outcome assessors, while another may have blinded the patients and statisticians. Readers should investigate which elements of a clinical trial have been blinded and authors should avoid this ambiguous terminology and explicitly state who was blinded.
Some clinical trials attempt to blind patients to their allocated group by providing control interventions that are similar to active interventions. To assess the perceived similarity of the control and active intervention, some studies report the ‘treatment credibility’, where patients are asked ‘How convinced are you that you have received an active therapy?’. Similar treatment credibility between the active and control interventions usually indicates successful blinding.
Many people in a clinical trial can be blinded. Although blinding helps minimise biases, it is often difficult to blind every person. Readers need to assess how a lack of blinding could influence the conduct and reporting of a trial.
Understanding intention-to-treat analysis in a trial
Intention-to-treat is an approach to analysing results in randomised controlled trials. Intention-to-treat means that all participants who are randomized are included in the statistical analysis and analysed according to the group they were originally assigned, regardless of what treatment (if any) they received. Intention-to-treat is the recommended approach to analysing randomised controlled trial data.
Example:
In a hypothetical randomised trial, 100 participants with acute back pain were randomised to receive advice to stay active or bed rest. The primary outcome was back pain, assessed at baseline and at 4 weeks. Participants’ demographic and clinical characteristics (e.g. age, sex, pain scores, duration of pain, etc.) were similar in both groups at baseline.
At 4 weeks, 10 participants could not be contacted (7 in the bed rest group) and therefore they had no data at follow-up. An additional 10 participants did not adhere to the intervention they were initially allocated to – 3 patients randomised to advice to stay active group rested in bed and 7 participants in the bed rest group remained active.
There is a misconception that the best way to analyse data from this hypothetical trial would involve excluding participants who did not contribute to data at follow-up and those who did not adhere to the intervention. That approach is wrong as it introduces bias in results of the trial and does not represent what happens in everyday clinical practice.
Why is intention-to-treat important in a trial?
Both groups in the hypothetical trial were similar in relation to key demographic and clinical characteristics. Excluding participants who were lost to follow-up may create imbalance in these important characteristics, which in turn will bias the results of the trial. For example, perhaps the participants who were lost to follow-up had more severe pain and did not see any benefit with the recommended treatments and decided to ignore the researchers’ requests for data. Excluding them from the analysis would unbalance in a key clinical characteristic (pain intensity), as there were more participants with more severe pain who were lost to follow-up in the bed rest group. This is likely to generate biased treatment effects. Intention-to-treat analysis avoids this problem by preserving the original groups.
In clinical practice, it is common for patients not to do what clinicians recommend them to i.e. adherence is rarely perfect. Excluding trial participants who did not adhere to the assigned interventions (also known as ‘per protocol analysis’) creates an artificial scenario of perfect adherence that does not represent clinical practice and introduces bias to the results, which are typically overestimated. If adherence to treatments is poor, analyses by intention-to-treat may underestimate the magnitude of the treatment effect that will occur in patients who adhered to the treatment.
Understanding confidence intervals
How precise is the reported effect of an intervention in a trial for my patient?
The point of studies that compare the effects of treatments is to give readers an idea about what would happen if a patient received one treatment versus another. The study does this by producing an ‘effect estimate’. For continuous measures this is the between-group difference; the mean outcome score for the intervention group minus the mean outcome score for the control group. Note that we are not talking about p-values here, for a range of reasons p-values are not useful for informing treatment decisions.
It is important to recognise though that the effect in the study comes from a study sample. One implication of this is that the best the researchers can do is provide an estimate of the effect in the whole population. All estimates are imprecise, and it matters how imprecise they might be. The most important and useful tool researchers have to describe the precision of an effect estimate is the confidence interval.
Confidence intervals are often misinterpreted. They do not represent the range of effects that 95% of patients will experience, or the largest and smallest effects an individual patient can expect.
The technical explanation of a confidence interval is quite complicated but there is a way to interpret them that is close enough for clinical purposes. The confidence interval is the range of values that the population effect most likely falls into. So, if a trial has a mean between-group difference of 2 points, with a confidence interval from 1 to 3, then the best estimate of the treatment effect is 2 points, but it could be anywhere from 1 point to 3 points.
For a clinician, the range of plausible effects (values within the confidence interval) can form part of the discussion with a patient about treatment options in coming to a shared decision.
Putting it all together
The final two months of the campaign will showcase success stories of how physiotherapists have overcome different barriers to ensure patients receive evidence-based care. This month we cover success stories from an individual clinician-perspective in the fields of stroke rehabilitation and oncology.
Kate Scrivener (consultant physiotherapist Sydney, Australia) presents how implementing guidelines on stroke rehabilitation helped her patient (Sharon) gain significant function after a stroke.
- The context: Sharon was a stroke survivor in her 40s who was initially very disabled and discharged to an aged care facility. Fortunately, the facility had a rehabilitation centre on site.
- The evidence: Evidence-based clinical practice guidelines on stroke rehabilitation recommend high-intensity, intensive and task specific practice.
- The barriers to implementation: Sharon had several impairments, including motor planning issues and severe spasticity, which made implementing guideline recommendations very challenging. As a result, she initially needed two people to stand and couldn’t walk.
- The solution: With a lot of problem solving and trial and error, Kate and her team found a way to ensure Sharon performed intensive, task specific practice. Key strategies included using whole (vs. part) task practice linked to meaningful daily activities to overcome the motor planning issue and using a zimmer split to ensure her knee stayed extended during standing and walking practice.
- The outcomes: Between 6 and 12 months after her stroke, Sharon transitioned from walking with an aid, to without, and then to walking outside the facility. She eventually left the aged-care facility and now lives on her own in supported accommodation.
Rohit Raykar (first year graduate physiotherapy, Sydney, Australia) presents how evidence increased a cancer survivor’s motivation to exercise.
- The context: Rohit was a student on placement and treating a woman in her 60s who had ovarian cancer. Due to her chemotherapy, she was suffering from severe fatigue.
- The barriers to implementation: The patient had a hysterectomy to remove the ovaries affected by cancer and Rohit was seeing her to encourage her to exercise post-operatively. The patient was very reluctant to engage in an exercise program due to the fatigue and past negative experiences of exercising when fatigued.
- The evidence: Rohit had been told exercise was beneficial for people with cancer but wanted to see the evidence for himself. Using his searching and appraisal skills, he found a high-quality systematic review on the effects of exercise for people with cancer. The review showed that exercise has numerous benefits including reducing weight gain, cognitive dysfunction, lymphedema, and the risk of cancer relapse and secondary cancers just to name a few.
- The solution: Rohit communicated this evidence to his patient at the next session and she was astounded by the benefits. Rohit reassured her that any amount of exercise was a good starting point and that she could gradually increase this over time.
- The outcomes: Rohit referred the patient to an outpatient exercise physiologist where she was able to gradually increase her activity levels over time.
Asheigh (private practice physiotherapist in Toowoomba, Australia) presents how using guideline recommendations on stroke rehabilitation to modify her exercise program helped her patient (Wendy) improve her walking after a stroke. Wendy also shared her perspective on the changes to the exercise program and her improvement.
- The context: Wendy is in her 60s and had a stroke 5 years ago. She was walking 1km per day after a few years of rehabilitation but wanted to get back to 5km like before the stroke.
- The problem: Ashleigh noticed Wendy had plateaued with her improvements after a few years of rehabilitation. Wendy was mostly doing hydrotherapy and doing only 1-3 sets of exercises that were not task specific (e.g. leg extensions, sit to stand). Ashleigh decided to look for evidence to see if there’s anything she could do differently.
- The evidence: The most recent evidence-based clinical practice guideline on stroke rehabilitation recommends high-intensity, intensive and task specific practice. Ashleigh found the guideline easy to use to help adapt Wendy’s program to have more task-specific exercises relevant to her goals.
- The barriers to implementation: Ashleigh suggested Wendy needed to do more land-based training instead of hydrotherapy. However, Wendy enjoyed hydrotherapy and had made a lot of new friends there. There was a need to find a balance between what Wendy wanted to do, and what she needed to do to reach her goals.
- The solution: It was agreed that Wendy would continue hydrotherapy but she would also practice the land-based high-repetition exercises which were specific to her goals of walking more (e.g. 400-600 repetitions of moving the leg faster during the swing phase of gait).
- The outcomes: Walking speed improved from 0.8m/s to 1.3m/s over the course of a few months and walking distance improved from 1km to 2km per day.
Our final month features how a physiotherapy team implemented evidence-based physiotherapy in their service.
Nicole Stockill (physiotherapist at Toowoomba Hospital, Australia) presents the changes made to a balance class to bring it in line with evidence-based practice.
- The context: Physiotherapists working in the geriatric and adult rehabilitation and stroke services team at Toowoomba Hospital, Australia read the best available evidence for falls prevention.
- The evidence: High-quality evidence from a systematic review found that high-challenge balance exercises performed 3 or more hours per week reduces the risk of falls by 39%. High-challenge balance exercises are those where upper limb support is removed, the base of support is reduced and the centre of gravity moves.
- The problem: The physiotherapists decided to evaluate their balance class to see if it aligned with this evidence. They found patients performed 2 hours of exercise a week compared to the recommended 3 or more hours and that only 31% of the exercise repetitions involved high-challenge balance exercises.
- The barriers to implementation: The class needed an overhaul but there were some barriers to implementing the evidence. These included time to plan the new class and educate staff on the class structure and evidence, additional resources such as minor equipment additions and new home exercise programs which included high-challenge exercises, and time management to ensure physiotherapists could get patients through all the new exercises within an hour session.
- The solution: The physiotherapy team tackled many of the barriers by restructuring the class to a circuit class format. Exercise stations with poster instructions allowed exercises to be tailored to individual abilities while maintaining the motivation for exercise gained through a group setting. Patients received goal-oriented instructions and feedback on their performance which improved their motivation to exercise. The result was a high challenge, high volume program which had little-to-no impact on staff requirements, resources and costs.
- The outcomes: The average number of repetitions increased from 101 to 894 per class, and the percentage of repetitions involving high-challenge exercise increased from 31% to 100%. This resulted in improved balanced outcomes as assessed by the physiotherapists over time.
Maddie Jaeger (physiotherapist at Toowoomba Hospital, Australia). Maddie shares her experience working in a physiotherapy team that implemented evidence-based care into their balance class service. Maddie describes the features of the class, how participants coped with the challenges and intensity of the class, the changes in participants’ measured outcomes, and their achievement of goals.
The ‘#PEDroTacklesBarriers to evidence-based physiotherapy’ campaign has now concluded. We hope you have enjoyed the strategies and tips shared to help you overcome barriers to evidence-based physiotherapy.
PEDro acknowledges Joshua Zadro for coordinating this campaign. We also acknowledge all campaign contributors, translation work from Mariana Nascimento Leite, Junior Vitorino Fandim (Portuguese), Leonardo Pellicciari, Francesco Ferrarello, Michele Marelli, Matteo Paci, Paolo Pillastrini (Italian), Elodie Louvion, Magda Costa Castany, Céline Lesage, Matthieu Guémann et Guillaume Galliou (French), the PEDro Education and training committee and PEDro production support from Geraldine Wallbank, Courtney West and Anne Moseley.
