8 CHAPTER 1 Geriatric Physical Therapy in the 21st Century eviden e phy apy manag ment suppo atic re Searching the Literature and stron mendations.More commonly,best evidence consists of the integration of the finding of one or several individ nto secondar al studies varying quality s wh The d sed p able dgm and analyses of these primary studies.The ideal evidence locate,categorize,int rpret,and svnthesize the available that is readily available evidence and also judge its relevance to the particular easily acces rmatte st bons hncratey Phys 1-5 and Bos an organi portance,and applicability of primary research arti mid with foundational studies at the bottom of the cles as well as being able to choose appropriate second ary sources Geriatric physic top of th is from truste rapof kr area requ ule high-aualiry ythe rly)clin ndies (the firs a wide variety of evidence sourc Foundationalstudiesprovideehcof As depicted in Box 1-1,each piece of evidence falls heor to the rom foundation ramewrkand obervations thatpr ons c o with gn-qu direct and vide direction to future research and sug where a specific type of evidence falls within the con and a clo r review is o answers to search to answer lguecsti9ehnitiveiniaec tion (i. mos certainty about the ications of the findings)is patients under typically derived from the recommendations emerging hehad typical conditions and provide sufficiently long follow rev e most valuable in ou 1-qu2 directly are the search for best primary ence.These stuc les,terme es.are BOX 1-1 Continuum of Evide nce studies Rep senting Early Foundational Concepts Through Integration of Findings Across Multiple Studies Aggr epts Evidence riptivestudies wi油hig Syst dea rs (based on theorie ility validity: Evider 59 afaty and notential for .D and ll Clinical trialsphase ll and IV ed c xper se l et narketing studies delineate additional information incuding the documented risks,benefits,and optimal use.8 CHAPTER 1 Geriatric Physical Therapy in the 21st Century impairments and functional activity than participa￾tion and quality of life. Searching the Literature Sources of Evidence. The scientific literature is divided into two broad categories: primary and secondary sources. The primary sources are the original reports of research studies. Secondary sources represent reviews and analyses of these primary studies. The ideal evidence source is a trusted resource that is readily available, easily accessed, and formatted to answer your specific questions quickly and accurately. Physical therapists must be competent in finding and assessing the quality, importance, and applicability of primary research arti￾cles as well as being able to choose appropriate second￾ary evidence from trusted sources. Geriatric physical therapy is a broad specialty area requiring an expansive range of knowledge and clinical expertise and, therefore, a wide variety of evidence sources. As depicted in Box 1-1, each piece of evidence falls along a continuum from foundational concepts and theories to the aggregation of high-quality and clinically applicable empirical studies. On casual review of pub￾lished studies, it is sometimes difficult to determine just where a specific type of evidence falls within the con￾tinuum of evidence and a closer review is often required. The highest quality research to answer a clinical ques￾tion (i.e., providing the strongest evidence that offers the most certainty about the implications of the findings) is typically derived from the recommendations emerging from a valid systematic review that aggregates numerous high-quality studies directly focusing on the clinical question. However, only a very small proportion of evidence associated with the physical therapy manage￾ment of older adults is well enough developed to support systematic reviews yielding definitive and strong recom￾mendations. More commonly, best evidence consists of the integration of the findings of one or several individ￾ual studies of varying quality by practitioners who incorporate this evidence into their clinical judgments. The evidence-based practitioner must be able to quickly locate, categorize, interpret, and synthesize the available evidence and also judge its relevance to the particular situation. Figure 1-5 and Box 1-1 provide an organizational schematic depicting the scientific literature as a pyra￾mid with foundational studies at the bottom of the pyramid and the systematic integration and synthesis of multiple high-quality studies at the top of the pyramid. The literature is replete with both foundational and initial (early) clinical studies (the first two levels of the pyramid). Foundational studies provide theories, frameworks, and observations that spur empirical in￾vestigations of topics with clinical applicability but, in and of themselves, have little direct and generalizable clinical applicability. Similarly, early empirical studies provide direction to future research and suggest poten￾tial impact but, by themselves, do not provide definitive answers to clinical questions. Studies with a more definitive influence on clinical decisions are higher up on the pyramid. High-quality primary studies that examine typical patients under typical conditions and provide sufficiently long follow￾up are the most valuable in our search for best primary evidence. These studies, termed effectiveness studies, are BOX 1-1 Continuum of Evidence: Studies Representing Early Foundational Concepts Through Integration of Findings Across Multiple Studies *Clinical trials: Foundational Concepts and Theories Initial Testing of Foundational Concepts Definitive Testing of Clinical Applicability Aggregation of the Clinically Applicable Evidence Descriptive studies Case reports Idea papers (based on theories and observations) “Bench research” (cellular or animal model research for initial testing of theories) Opinions of experts in the field (based on experience and review of literature) Single-case design studies Testing on “normals” (no real clinical applicability) Small cohort studies (assessing safety and potential for benefit with real patients) Clinical trials,* phase I and II Well-controlled studies with high internal validity and clearly identified external validity: • Diagnosis • Prognosis • Intervention • Outcomes • Clinical trials,* phase III and IV Systematic review and meta-analysis Evidence-based clinical practice guideline Phase I: examines a small group of people to evaluate treatment safety, determine safe dosage range, and identify side effects. Phase II: examines somewhat larger group of people to evaluate treatment efficacy and safety. Phase III: examines a large group of people to confirm treatment effectiveness, monitor side effects, compare it to commonly used treatments, and further examine safety. Phase IV: postmarketing studies delineate additional information including the documented risks, benefits, and optimal use