CHAPTER 1 Geriatric Physical Therapy in the 21st Century 13 pro the eralizability .h the exclusion criteria include rization of evidence to qualify the recommendations the findings to.It is fairly common for studies to exclude nerocohthefind subjects older than age 70 or 75 years,those with com ings of the systematic review provided good,fair,eak monly occurring comorbid conditions,or individuals wh everyone wh draw any conclusions from a study involvin se?In a g ofolder adult Applicability to a Specific Patient.Although examining this requirement would likely exclude at least half of the a study for the applicability of the hndings of the study to es.Consider the ity of the subiects of the study and the clinicale The te specific patients and clin r this que n an ho chose to participatein the stu dy should he Are these subjects reasonably similar to the patient spur uggest that the aim of an efficacy study is to determin ring the clinician's search for evidence?Or are the ces too arge to apply the nce deal pat nt,is th sary to apply the findings of the to your clinical world?Is this feasible?If the conclusion is typical patients including all their variability ular clinic, the studies are particularly applicable to every physica day practice an are worthy c smade that the ed f likely differ between the current cohort of older adults (on which cur refe h approach is required or for dults.Muc de of the curren evidenc stu he cap. lity or the equipment to pro 040 The olde Generalizing findings across broad groups of olde same older adult we anticipate in the next 20 vears.Baby adults can be particularly difficult in geriatrics.As stated boomers are approaching old age with a different per tieialteradhssagropaeewaordnalyaiabl spective and set of experie ices with s must ess w prior the are the confounding factors to mask real change.However. conditions and increased the likelihood of other condi the greater the number of exclusion criteria,the narrower tions associated with a longer life span. B0X1-4 One F rk for Ass mendations Emerging from a Systematic Review gth to Reco Good evidence n any im ortant v Fair evidence ings fro applicability Alth is support for the rec endation,there is a Weak evidence bly cons stent findings from primarily foundational studie CHAPTER 1 Geriatric Physical Therapy in the 21st Century 13 ranking systems and others fairly simple. Box 1-4 pro￾vides this author’s suggestion for a simple and useful cat￾egorization of evidence to qualify the recommendations. Using this system, a reviewer could conclude that the find￾ings of the systematic review provided good, fair, or weak evidence to support or refute an outcome, or one could conclude that there is insufficient evidence to allow one to draw any conclusions. Applicability to a Specific Patient. Although examining a study for the applicability of the findings of the study to particular patients is very straightforward, it is a step that is often forgotten. A thoughtful comparison of the similar￾ity of the subjects of the study and the clinical environment in which the care is delivered to the target conditions of specific patients and clinical environment will allow you to answer this question. The inclusion and exclusion criteria for a study as well as the general characteristics of subjects who chose to participate in the study should be reviewed. Are these subjects reasonably similar to the patient spur￾ring the clinician’s search for evidence? Or are the differ￾ences too large to apply the findings with confidence? What equipment, specialized knowledge, or availability of resources was necessary to apply the findings of the study to your clinical world? Is this feasible? If the conclusion is that the approach is not feasible in a particular clinic, the physical therapist should continue to look for alternative approaches with similar outcomes. If, indeed, a determina￾tion is made that the outcomes achieved from this ap￾proach are far superior to the alternatives available at your clinic, then a mechanism should be adopted to either refer the patient out when this approach is required or for the clinic to obtain the capability or the equipment to provide the approach. Generalizing findings across broad groups of older adults can be particularly difficult in geriatrics. As stated earlier, older adults as a group are extraordinarily variable. Researchers must balance inclusiveness with homogeneity. The more homogeneous the subjects in a study, the fewer are the confounding factors to mask real change. However, the greater the number of exclusion criteria, the narrower the generalizability. Often, the exclusion criteria include those patients the clinician is most interested in applying the findings to. It is fairly common for studies to exclude subjects older than age 70 or 75 years, those with com￾monly occurring comorbid conditions, or individuals who have any cognitive impairment. Was everyone who had heart disease, diabetes, or high blood pressure excluded from a study involving exercise? In a group of older adults, this requirement would likely exclude at least half of the patients treated in physical therapy practices. Consider the impact of the exclusion criteria on the ability to apply the findings to your typical patient world. The terms efficacy and effectiveness are frequently used to describe the aim of a study, particularly an inter￾vention study. These terms give you a clue to the expec￾tations of the researchers about the generalizability of the findings. The terms, commonly used in conjunction with the four levels of clinical trials as described by NIH, suggest that the aim of an efficacy study is to determine if a given intervention can work. Meaning, given an ideal situation and ideal patient, is the intervention successful? An effectiveness study is one that aims to determine if the intervention will work in the typical clinical world with typical patients including all their variability. Effectiveness studies are particularly applicable to every￾day clinical practice and, therefore, are worthy of particularly close review and consideration. A challenge, and reality check, is the likely differences between the current cohort of older adults (on which cur￾rent research is based) and the next generation of older adults. Much of the current evidence is based on studies that emerged from landmark investigations completed 20 to 40 years ago. The older adult of prior years is not the same older adult we anticipate in the next 20 years. Baby boomers are approaching old age with a different per￾spective and set of experiences with physical activity and exercise than prior generations of older adults. Medical science has decreased the impact of many chronic health conditions and increased the likelihood of other condi￾tions associated with a longer life span. Good evidence Reasonably consistent findings from several high-quality definitive studies of clinical applicability. Unlikely that further research will change the recommendation in any important way. Fair evidence Reasonably consistent findings from several moderate-quality studies (initial studies evaluating foundational concepts) or one definitive study of clinical applicability. Although there is support for the recommendation, there is a reasonable possibility that further research will modify the recommendation in some important way. Weak evidence Reasonably consistent findings from primarily foundational studies with findings not yet rigorously tested on relevant patient groups. It is quite likely that further research will modify the recommendation in some important way. Inconclusive evidence There is insufficient or markedly conflicting evidence that does not allow a recommendation to be made for or against the intervention. BOX 1-4 One Framework for Assigning Strength to Recommendations Emerging from a Systematic Review