PHYS THER
Vol. 83, No. 2, February 2003, pp. 123-131
A Quantitative Analysis of Research Publications in Physical Therapy Journals
Patricia A Miller,
K Ann McKibbon and
R Brian Haynes
PA Miller, PT, MHSc, is Assistant Clinical Professor, School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada, and Chief of Physiotherapy Practice, Hamilton Health Sciences, Hamilton, Ontario, Canada. When this article was written, she was a graduate student in the Health Research Methodology Program at McMaster University. Address all correspondence to Ms Miller at 5 Undercliffe Ave, Hamilton, Ontario, Canada L8P 3G9 (pmiller{at}mcmaster.ca)
KA McKibbon, BSc, MLS, is currently on leave from the Department of Clinical Epidemiology and Biostatistics, McMaster University, for PhD studies at the Centre for Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pa
RB Haynes, MD, PhD, is Professor of Clinical Epidemiology and Medicine, McMaster University. He is Editor of ACP Journal Club
Submitted December 12, 2001;
Accepted August 6, 2002
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Abstract
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Background and Purpose. Many physical therapists depend on their professional journals for high-quality evidence. The purpose of this study was to evaluate the rigor of research and review articles in 4 national physical therapy journals. Subjects and Methods. All articles in 6 consecutive issues of the Australian Journal of Physiotherapy, Physical Therapy, Physiotherapy, and Physiotherapy Canada, published between January 2000 and June 2001 (N=179), were reviewed. One trained reviewer identified the type and purpose of each article and assessed the rigor of treatment and review articles according to explicit criteria. Results. The majority of articles reviewed were original studies (56%). The majority of the research articles that dealt with human health care (66%) addressed topics that were not directly applicable to the provision of patient care such as measurement topics and studies on subjects without identified pathologies or impairments. Of the 179 journal articles, 19 met the standards for rigor (11%). The majority of these articles dealt with treatment. The pass rate per journal was as follows: Australian Journal of Physiotherapy, 10% (4/42); Physical Therapy, 15% (7/47); Physiotherapy, 12% (4/34); and Physiotherapy Canada, 7% (4/56). Discussion and Conclusion. Because such a small percentage of articles in these professional journals were identified as having direct application to patient care, physical therapists should attempt to access other sources of information to find additional high-quality evidence. A larger sample with a greater number of issues per journal may have yielded different results and indicated different trends, and further research appears to be warranted.
Key Words: Clinical research • Evidence-based practice • Publications and audiovisual materials
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Introduction
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Evidence-based medicine or health care means integrating the "best research evidence with clinical expertise and patient values."1(p1) Herbert et al2 suggested that evidence-based practice is the best model of clinical practice that is currently available to physical therapists and the one most likely to produce the best outcomes in patients because it leads to use of the best evidence, evidence that arises from carefully-conducted research, and combines it with the needs and preferences of the patient in determining the appropriate intervention. The practice of evidence-based health care is usually thought to involve 5 steps: defining the question, collecting the best evidence related to a question, critically appraising the evidence, integrating the evidence with clinical expertise and patient factors to carry out the decision, and finally evaluating the process so that it can be improved the next time.1,3
Some authors2 have suggested that engaging in evidence-based practice is too time-consuming. Evidence is now being organized in new ways to make it easier for physical therapists and other health care professionals to access information that is valid and directly applicable to patient care.3,4 For example, secondary publications such as systematic review articles or distilled clinical research literature found on the Internet or in abstract journals are easily accessible and offer synthesized information to clinicians. The Cochrane Collaboration produces the Cochrane Library, consisting of systematic reviews of randomized controlled trials (RCTs). It is available on CD-ROM and via the Internet (available at: http://www.update-software.com/cochrane/). Abstracts can be viewed for free there; yearly subscriptions are US$235.00. Internet sites such as "PEDro," produced by the Centre for Evidence-Based Physiotherapy in Australia (available at: http://ptwww.cchs.usyd.edu.au/pedro/), which presents a database of RCTs and systematic reviews of RCTs, and DARE (Database of Abstracts of Reviews of Effectiveness) (available at: http://nhscrd.york.ac.uk/darehp.htm) are just 2 examples of Web sites that physical therapists can use to look for evidence. Both of these Web sites can be accessed free of charge.
A variety of evidence-based journals also present distilled clinical research. These journals present the research findings in a systematic and condensed way in order to make the findings more "digestible and manageable."5(p180) Using distilled or secondary publications can be a time-efficient choice for busy clinicians looking for the best evidence. ACP Journal Club and Evidence-Based Medicine are examples of evidence-based abstract journals for physicians, produced by a team at the Health Information Research Unit (HIRU) at McMaster University in Hamilton, Ontario, Canada. ACP Journal Club is published by the American College of Physicians and is targeted to internists, and Evidence-Based Medicine is jointly published by the American College of Physicians and the BMJ Publishing Group in the United Kingdom and is targeted to primary care general practice.
The BMJ Publishing Group also produces Evidence-Based Nursing and Evidence-Based Mental Health. The editorial staff for these journals have established review criteria that are used to identify "studies and reviews that warrant immediate attention by physicians attempting to keep pace with important advances."6(pA15) Each publication comprises a selection of systematic review articles and original studies of prevention or treatment, diagnosis, differential diagnosis, prognosis, causation, quality improvement and continuing education, economics of health care programs or interventions, and clinical prediction guides. These articles are identified following a standardized review process applied to more than 150 journals. When an article is presented as an abstract in any of the journals, it is accompanied by a commentary from an expert in the content area, who provides comments on the quality, clinical context, and appropriate application of the research. The accumulated contents since 1991 are on the Web as a database (available at: http://acpjc.org), which can be accessed free of charge at present, and also as part of Ovid's Evidence-Based Medicine Reviews (available at: http://www.ovid.com), available through many institutional libraries; the database contains a considerable amount of content of relevance to physical therapists.
Recently, the HIRU evidence-based journals team undertook a project to develop MEDLINE search strategies to retrieve articles that meet the standards of ACP Journal Club and the other evidence-based journals. This project, known as the Hedges Project, is funded by the National Library of Medicine in Washington, DC. Interrater reliability for assessments of these standards has been shown to be high (a level of agreement at least 80% greater than that expected by chance, as determined with the Kappa statistic).7 Simple guidelines for critical appraisal of health care research evidence are widely available in print and on the Internet (eg, http://www/cche.net/usersguides/main.asp).
Optimal study designs differ for determining cause, course, diagnosis, prognosis, prevention, therapy, and rehabilitation, so the rules for assessing validity differ according to the questions being studied. For example, randomized allocation of participants to intervention and control groups is held to be better than nonrandom allocation for controlling bias in intervention studies. This is not merely a matter of logic, common sense, or faith: nonrandom allocation usually results in larger and more variable estimates of the effects of an intervention than does random allocation.8 Similarly, in observational study designs for assessing the accuracy of diagnostic tests, independent interpretation of the tests that are being compared is known to result in less optimistic reports on test performance.9 Qualitative articles that are included in Evidence-Based Nursing and Evidence-Based Mental Health, but not in ACP Journal Club, also were evaluated using the established criteria. The criteria were applied to all issues of more than 170 journals during the year 2000. These journals did not include any physical therapy professional journals, such as the 4 journals we studied. The project that we describe in this article is an extension of this work to assess the quality of the literature in 4 prominent physical therapy professional journals.
We reviewed the contents of 4 physical therapy professional journals with large circulations (American, Australian, British, and Canadian) to identify the proportion of articles that meet the HIRU evidence-based journal standards for high-quality evidence suitable for direct application to clinical practice. The applicability of these scoring criteria for physical therapy's professional literature and different sources of high-quality evidence for physical therapist practice will be discussed.
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Methods
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The review was conducted by one individual (PAM). All articles published in 6 consecutive issues of the Australian Journal of Physiotherapy, Physical Therapy, Physiotherapy, and Physiotherapy Canada between January 2000 and June 2001 were reviewed. Each article was categorized using the Hedges Project scoring criteria (Appendix). Using the Hedges Project criteria, all studies were classified according to format: an original study reporting firsthand observations, a review or meta-analysis of the literature on a particular topic, a general or miscellaneous article that presents a general or philosophical discussion of a topic without original observation, or a case report. For all articles except those determined to be general and miscellaneous articles, we then determined whether the article was of interest to health care providers (it meets this criterion if it deals with information relevant to patient care). Only reviews or studies that dealt with patient care issues were evaluated in greater detail. For these articles, the purpose (eg, etiology, prognosis, diagnosis, treatment, prevention, continuing education, quality improvement, economics, clinical prediction guide, qualitative study) was identified. Articles that were relevant to patient care but did not fit into one of these categories were labeled "Something Else." All articles other than those labeled "Something Else" were then evaluated by standards for rigor and assigned a pass or fail score. The article must meet all of the defined criteria in order to pass. The Figure presents a flowsheet of the review process.
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Reliability of Reviewer's Assessments
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The reviewer (PAM) attended the training sessions on the Hedges Project criteria presented to new HIRU staff members. These sessions included a review of criteria and application of the criteria to journal articles, guided by experienced staff. Following training, the contents of 6 journal issues representing 3 of the 4 journals were scored in collaboration with an experienced evaluator from the HIRU staff (KAM) in order to practice the application of the criteria to physical therapy publications. The reviewer then proceeded to review the journals in this study on her own, flagging articles where she was uncertain about the scoring, as is the practice in the Hedges Project. The appropriate scoring of these articles was then determined in consultation with the experienced staffperson (KAM). Table 1 lists the journal issues that were reviewed.
The test-retest reliability of the reviewer's assessments was determined by a blind reclassification of all of the articles (n=29) that had previously been evaluated for rigor as passing or failing to the meet the Hedges Project criteria. The purpose of the article (treatment [original study], treatment [review], clinical prediction guide, qualitative study) also was identified. This reassessment was conducted 8 weeks following the initial scoring by the same reviewer (PAM). The articles were evaluated in random order, as determined using a random numbers table. Using the formula for sample size determination reported by Walter et al10 to test the hypothesis that the reliability is greater than .80 (generally regarded as an excellent level of agreement) and to compare it with the alternative hypothesis that it is not less than .50, with an alpha of .05 and a beta of .20, the required sample size would be 22 articles. Intraclass correlation coefficients (3,1)11 for agreement between the original classification and the reclassification were .92 for evaluation of passing or failing and .93 for the articles' purpose. Robertson12 reported a coefficient of agreement of .93 in the reclassification of 27 articles according to methods (n=8), and Klassen et al13 reported an agreement of 91.9% in the reclassification of 62 articles in earlier studies reviewing journal content.
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Results
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A total of 179 articles were reviewed in 25 issues. One additional issue of Physical Therapy was required because one entire issue was devoted to a professional document (volume 81, number 1, January 2001).
The format of the articles determined for the 6 issues of each publication is shown in Table 2. The majority of the articles in 3 journals (Australian Journal of Physiotherapy, Physical Therapy, and Physiotherapy Canada) were categorized as original studies reporting firsthand observations (62%, 57%, 61%, respectively). The highest proportion of articles in Physiotherapy were categorized as "General and Miscellaneous" (47%) and the second most frequent format used was "Original Study" (38%).
For articles of interest to human health care, the majority of articles in the Australian Journal of Physiotherapy, Physical Therapy, Physiotherapy, and Physiotherapy Canada were determined to be "Something Else" (75%, 67%, 50%, and 65%, respectively). Articles in this category included investigations of the psychometric properties of new and existing measures and studies involving subjects without known impairments or disabilities. Reviews or studies of interventions were the second most common purpose identified for all publications. One prediction study and one qualitative study dealing with patient care issues also were identified. There were no studies dealing with etiology, prognosis, diagnosis, prevention, continuing education, quality improvement, or economics. Table 3 provides a summary of the results.
As shown in Table 4, a total of 19 articles (11% in all) met the Hedges Project criteria. The majority of these articles dealt with treatment (95%), as identified under the "Treatment (Original Study)" (14/19) and "Treatment (Review)" (4/19) headings. One qualitative study met the criteria. Physical Therapy had the greatest proportion of articles that met the criteria (7/7=100%).
Ten articles failed to meet the Hedges Project criteria for rigor. In 6 treatment studies, the design was not an RCT (n=5) or greater than 20% of the subjects were lost to follow-up assessment of a primary outcome (n=1). The 3 review articles dealing with treatment failed to meet the criteria because the authors did not provide a detailed outline of the search strategy that should identify the databases used (n=2) or the review did not include at least one RCT (n=1). In the one article in the "Clinical Prediction Guide" category, the predictive equation was not cross-validated in a second set of patients.
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Discussion
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The 4 journals in this study were selected because they are the publications of 4 professional physical therapy associations with large circulations. They delineate a group of well-established international journals for physical therapists and are distributed to more than 125,000 association members around the world. These journals have been included in similar previous studies where different review strategies have been used to quantify or rank physical therapy publications.13–15 Physical Therapy and the Australian Journal of Physiotherapy are the only journals indexed in Index Medicus (MEDLINE); all 4 journals are indexed in the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database. Six issues per publication were reviewed because of the time constraints of this project. However, Haynes16 has noted that this number is usually adequate to assess the quality of the evidence in a journal, giving a reasonable estimate of its performance over time.
Only 2 types of original and review articles were identified: those dealing with treatment (n=27) and clinical prediction (n=1). During the 6-issue period, there were no reviews or studies that would be classified as having an etiology, prognosis, diagnosis, or economics purpose using the Hedges Project criteria. One reason for this could be the small sample of issues that were reviewed. Our findings also may reflect the interests of those researchers who are submitting manuscripts to the journals, rather than being reflective of the values of practicing physical therapists. Perhaps the question of etiology or causation is not of primary interest to physical therapists, but analyzing the underlying problem (eg, diagnosis) and prognosis are 2 of the 5 integral elements of patient/client management as defined in the American Physical Therapy Association's (APTA) Guide to Physical Therapist Practice.17
Economic evaluation is becoming more relevant as health care professionals are asked to be more accountable for the services they provide and the outcomes that are achieved. In comparison, data from the Hedges Project research indicate that 28 of the 377 articles in 14 issues of the Archives of Physical Medicine and Rehabilitation during 2000 met the Hedges Project criteria. They dealt with treatment (15/377 [4%]), prognosis (8/377 [2%]), clinical prediction (3/377 [0.8%]), and diagnosis (2/377 [0.53%]). Twenty-five of the 623 articles in the 26 issues of Spine in 2000 met the Hedges Project criteria. They dealt with treatment (n=20), etiology (n=3), diagnosis (n=1), and prognosis (n=1). We would expect future publications in physical therapy journals to address a broader range of topics as well.
Only one qualitative research article was identified in our study. Although there are no qualitative studies abstracted in ACP Journal Club, each issue of Evidence-Based Nursing contains about 6 reports of qualitative studies. Ritchie18 stated that physical therapists need to include qualitative research methods in order to bring together evidence-based practice and client-centered care. We would anticipate seeing the results of more qualitative studies published in the future.
The Institute for Scientific Information impact factor (IF), reported in the 2000 Journal Citation Report,19 provides another way to address the quality of a journal. The Journal Citation Report covers over 6,000 multidisciplinary and international journals. The IF is the average number of times that a journal's recent articles (eg, those published within the 2 years proceeding the Journal Citation Report's cover year) were cited in other journals in the specific year. The larger the number, the more frequently other authors refer, in their own articles, to articles within the publication. In the 2000 Journal Citation Report,19 Physical Therapy and the Journal of Orthopaedic and Sports Physical Therapy (with an IF of 1.424) were the only physical therapy journals noted. Physical Therapy had an IF of 1.222, which was slightly less than the IF for the Archives of Physical Medicine and Rehabilitation (1.409). This finding suggests that the quality of the articles in Physical Therapy is relatively high and that other authors make reference to its content, the performance of other biomedical journals such as the New England Journal of Medicine, which has an IF of over 29, must be taken into account. Although Maher et al15 cautioned physical therapists not to accept the IF as a measure of the quality of physical therapy research or of a journal's prestige, it is a widely accepted manner of assessing the quality of journals used across many professions.
This review of these 4 physical therapy publications produced a low yield of articles that met the Hedges Project criteria. When each publication was examined individually and all of the articles in the 6 issues of each publication were included, the percentage of articles that met the ACP Journal Club criteria was 10% (4/42) for the Australian Journal of Physiotherapy, 15% (7/47) for Physical Therapy, 12% (4/34) for Physiotherapy, and 7% (4/56) for Physiotherapy Canada. For comparison, 7% (28/377) of articles published during 2000 in the Archives of Physical Medicine and Rehabilitation met the criteria. McKibbon et al3 identified the "big four" journals (ie, British Medical Journal, Journal of the American Medical Association, The Lancet, and New England Journal of Medicine) as those where the majority of important advances in many health care disciplines are published. Bohannon14 has argued that these 4 journals are also part of the core journals in physical therapy. The percentages of articles that met the ACP Journal Club standards in these 4 journals in 1999 were 14%, 22%, 25%, and 34%, respectively.
Haynes16,20 noted that there is a small yield of articles of clinically useful and strong evidence in peer-reviewed clinical journals. He identified 4 forms of communication that journals support: (1) scientist-to-scientist information, where preliminary studies are reported; (2) scientist-to-practitioner communication, conveying information about studies that are ready for clinical application; (3) practitioner-to-practitioner communication such as review articles; and (4) practitioner-to-scientist information, which includes case reports and case series research.20 The 4 journals that we studied would appear to comprise all 4 forms of communication. Haynes suggested that journals that include all 4 types of articles are a "hazard to clinicians and their patients"20(p725) because most clinicians do not have the necessary skills to critically appraise these articles and understand if and how they apply to clinical practice. He suggested that publications need to clearly outline their purpose in determining the audience they will serve and that clinicians must cultivate excellent skills to critically appraise the literature. Journal editors can assist the readers by describing the purpose of articles. For example, when journals such as Physical Therapy identify their articles in the index as "research reports" and "case reports" and discussion articles are labeled as "viewpoints" as in Physiotherapy Canada, the purpose of the article is clearly identified for the clinician, possibly eliminating inappropriate application of the article's content. Haynes16,20 suggested that the practicing clinician can benefit most from abstract journals such as ACP Journal Club that concentrate clinically useful information relevant to practice.
One reason for a low proportion of articles meeting the criteria is that the standards for evidence have been set at a high level. For example, for treatment articles, the design, according to the criteria we used, must be an RCT. This is in keeping with level I and level II of Sackett's levels of evidence.21 If the article is a review, according to the criteria, it must have explicit information about the sources of data and the results must contain at least one study that meets the criteria for an original study (eg, includes at least one RCT if the review is about a therapeutic approach or about quality improvement or continuing education). All articles regarding intervention published in Physical Therapy met the Hedges Project criteria for treatment, whereas only one third of the articles in Physiotherapy Canada met them.
In another study conducted to examine the rigor of research articles, Maher et al15 used the PEDro quality rating to evaluate the quality of RCTs. The intraclass correlation coefficient (1,1) for reliability of the consensus ratings for the total PEDro score has been shown to be .68 (95% confidence interval=.57–.76) (Christopher Maher, PT, PhD; personal communication; April 2002). Four PEDro scale items (randomization, concealed allocation, blinding, and adequacy of follow-up) have been validated in the medical literature,22 but these scale items have yet to be validated for RCTs in the physical therapy literature. Maher and colleagues' results yielded a different ranking of these 4 journals. When RCTs since 1990 were considered, the Australian Journal of Physiotherapy had the highest mean score, followed by Physiotherapy Canada, Physical Therapy, and Physiotherapy. The differences in ranking of these 4 journals may be due to a number of different methodological considerations, including the dates of the journals reviewed and the scoring standards. Furthermore, Maher et al considered only RCTs, and we included research that addressed more than interventions.
The Hedges Project criteria exclude a number of research articles that could assist in the advancement of physical therapist practice. For example, articles are excluded because they do not include information about patients or patient care. These articles include studies that looked at subjects without known impairments or disabilities and that would heighten our understanding of basic mechanisms, thereby allowing us to make hypotheses about patients in future studies. Surveys and research regarding professional practice issues such as students and quality monitoring also are excluded. Original studies that deal with measurement issues of new or existing measures are not judged for rigor. Rothstein, the editor of Physical Therapy, noted that, although the physical therapy profession appears to have a "fixation on measurement studies,"23(p775) he encourages members of the profession to commit to a careful and scientific use of measurement in our research, as described in APTA's Standards for Tests and Measurements in Physical Therapy Practice.24 If the application of the Hedges Project criteria to our professional journals were considered, the criteria would need to be modified to take into account the contemporary practice and research topics within the rehabilitation professions. As noted earlier, physical therapy journals serve to communicate a broad range of clinical and professional topics and research findings to their readers.
Where is high-quality evidence that may change physical therapist practice published? Physical therapy professional journals do contain high-quality evidence, although these articles do not appear in great numbers (ie, approximately 1 article per issue). This is also the same in medicine.16 Robertson25 noted that that authors in physical therapy journals place a high degree of reliance on literature sources other than physical therapy publications, including those of medicine and sports science. In searching the abstracted database of ACP Journal Club for the year 2000 using the search words "physiotherapy" and "physical therapy," 5 articles were identified. All 5 articles dealt with "treatment/therapeutics." These articles were published in the following journals: BMJ (2 articles), Lancet (2 articles), and Annals of Internal Medicine (1 article). It may be that when physical therapists complete RCTs and other important studies, they choose a medical journal that serves a larger multidisciplinary audience rather than a professional one. McKibbon et al3 recommended that today's health care professionals need to make use of a combination of health care journals, sampling from their own professional discipline, from the "big four" journals, and from secondary journals to access appropriate journal coverage of important clinical information.
A limitation of our study was the small number of issues of each journal that were reviewed. A larger number of issues may have produced different results and indicated different trends in professional research activities. Further research with a larger sample size appears to be warranted.
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Conclusion
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Evidenced-based medicine or practice is defined as "the conscientious, explicit, and judicious use of current best-evidence in making decisions about the care of individual patients."26(p71) The greatest percentage of articles in the 4 physical therapy journals reviewed (N=179) were original research (56%) and general discussion and miscellaneous articles (33%), as defined by the Hedges Project criteria. When the original research articles were examined, many articles addressed topics that were not directly applicable to the provision of health care (eg, studies on subjects without known impairments or disabilities, research addressing measurement topics). Only 19 (11%) of the 179 articles in the 4 journals met the Hedges Project criteria of high-quality evidence suitable for direct application to patient care. The majority of these research articles dealt with treatment. In our study, we demonstrated that there were a small number of articles in this sample of physical therapy journals that can be utilized by the evidence-based practitioner. Clinicians who are looking for high-quality evidence to change patient care practices need to supplement their professional journal readings by accessing other sources of research findings, including medical journals, abstract journals, and resources on the Internet. A larger sample with a greater number of issues per journal may have yielded different results, and further research appears to be warranted.
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Appendix
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Footnotes
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Ms Miller provided concept/idea/research design and project management. All authors provided writing and consultation (including review of manuscript before submission). Ms Miller and Ms McKibbon provided data collection, and Ms Miller and Dr Haynes provided data analysis. Ms McKibbon provided training materials, and Dr Haynes provided facilities/equipment and institutional liaisons. The authors acknowledge the statistical assistance of Dr Stephen Walter and the editorial comments provided by Dr Mary Law.
The material in this article was the basis for a podium presentation at the National Congress of the Canadian Physiotherapy Association; July 11–14, 2002; Halifax, Nova Scotia, Canada.
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Introduction
Methods
