RESEARCH – 9/10/08

*** Midterm and Final ****** 5 Assignments done by e-mail ****** Literature Review – 10-12 pages typically ****** Senior Research Project – You can have 5 people to perform an experiment.

DiabetesDiabetes will be the most expensive condition in the US in the future. This is a condition that can best be treated by conservative care.

Epistemology*** According to Wikipedia ***A branch of philosophy concerned with the nature and scope (limitations) of knowledge. The focus is on analyzing the nature of knowledge and how it relates to similar notions such as truth, belief, and justification. It also deals with the means of production of knowledge, as well as skepticism about different knowledge claims. In other words, epistemology primarily addresses the following questions: "What is knowledge?" "How is knowledge acquired?," "What do people know?," "How do we know what we know?."

Insurance companies often use knowledge, research and evidence refusing to pay claims. The burden of proof is on us as providers.

MD/DOSurgery/PillsDisease/Germ TheoryScience/Mechanistic Dualistic (law that makes mutually exclusive things separate and typifies science – control vs. experimental group are 2 very different categories)Specialist care (dermatologist, cardiologist, urologists, gynecologists, etc.)System has Primary Care Physicians, Specialties, Hospitals and Insurance CompaniesConsistency in teaching in Medical Schools (similar law for every states)MechanisticReductionisticEmpirical/Scientific Model: What defines scope of practice and standard of care is supposedly all based on science…Ex. Unnecessary angioplasties, hysterectomies, arthroscopies….What they have used is misrepresentation and the model. The consumers have also been sucked into the model

DCSMTSubluxation & numerous subluxation theories BiomechanicalVitalisticHolistic: Whole Body treatment and evaluationSystem has mostly general practitioners Lack of consistency in laws and training (laws are different for every state)Many techniques (Diversified, Activator, Gonstead, Thompson, SOT, BEST, Cox, Pro-Adjuster)InnateNeuromusculoskeletal Generalists/Specialists

If you can’t measure something, you cannot research it and you cannot have science.

Random Info Antidepressant medication is the most frequently prescribed medication. Co-management is often a good choice with conservative therapy the key.1/3 of adults have insomnia sufficient to interfere with ADL’sMost people who work for the FDA where former Drug company employees. After they leave the FDA, these employees go back to drug companies. The largest amounts of funds to the FDA come from drug companies. Average malpractice for anesthesiologist is 400-600,000 per year. Research is going to be right in the middle of the future of chiropractic.

There is a lot of evidence to support HVLA for acute back, sub-acute back conditions, and even some chronic conditions.

RESEARCH – 9/15/08

General Techniques and Treatment ApproachSMT:Physiotherapy: Laser, ART, PRT, PNF, Graston, MFRExercise:Nutrition/ Supplementation:Acupuncture/Acupressure: TCM predetermined point acupuncture in 12 weeks (customized vs. pre-determined vs. points in other areas to check blood pressure)…Blood pressure went down in each subject regardless of points used. Supportive Devices (lifts, belts, orthotics): Ergonomics:Socio-Occipito Advice:

CCECCE has said that if there is no evidence for what is being taught, that the schools will lose their accreditation.

Adverse Effects of Spinal Manipulation: A Systematic Review – Ernst (Journal of the Royal Society of Medicine)The author only lists the literature that supports the adverse effects but does not speak to other side of the equation. The journal is not peer reviewed. Peer reviewed means that unbiased experts review the article prior to publication. The editors decided what goes in the journal.

Results: The searches identified 32 case reports, four case series, 2 prospective series, 3 case controlled studies and 3 surveys in case reports or case series more than 200 patients were suspected to have been seriously harmed. The most common serious adverse effects were due to vertebral artery dissections. 2 prospective reports suggested that relatively mild adverse effects occur in 30% to 60% of all patients. The case-control studies suggested a causal relationship between spinal manipulation and the adverse effects. The survey data indicated that even serious adverse are rarely reported in the medical literature.

*** 1st assignment is due by e-mail 1 week from Wednesday 9/24/08…Google E. Ernst and collaborate…What is the Journal of the Royal Society of Medicine about…The article is from 2007 so what is that worth? Look at the title (systematic review) ***

Upper CervicalNot much evidence to substantiate it can be used to treat everything

Research Pyramid1. RCT2. Systematic Review of RCT’s

9/17/08

 *** Read the article, critique the method and article (how many times he refers to himself bashing chiropractic), find 3 contradictory sources (THIS IS THE CLASS ASSINGMENT) ***

9/22/08Mercy GuidelinesChiropractors set out to create guidelines about care. Unfortunately, chiropractors did not want to hear the message about care and treatment.

Risk of Vertebrobasilar Stroke and Chiropractic Care – Results of a Population Based Case Control and Case Crossover Study*** A good article with good information about chiropractic induced stroke ***

General Critique of Ernst Article1. A credible systematic review uses a specific, standard review template. 2. The use of tricky phrases and bad statistics3. Case reports, case series, 4. Referring to his own publications

5. Bait and switch (referring to chiropractors as therapists instead of doctors0*** This is all info that can be used for Homework #1 ***

*** ASSIGNMENT #2...Alarm Rings in Louisiana – Time for Profession ***

Laser Research = Good for fibrotic tissue…Insurance doesn’t pay for laser.

Soft Tissue Techniques = No real good research for soft tissue treatment.

Ultrasound = Not much good according to the literature

9/24/08

Impact FactorThe impact factor of JMPT is .8. The impact factor of Spine is 4.8. The impact factor of NE Journal of Medicine is 5.0. Impact factor is the total # of times the journal is cited by other sources.

Peer ReviewedExperts, not employees of the journal (not members of editorial journal) review the works to be published in the article. The peer review tries to guarantee a level of quality for the journal. The reviewers critique the article. Some reviewers like the article and some don’t but the point is to get feedback and critical analysis to make the paper as scientific as possible.

Chiro EconomicsNot peer reviewed. The mission is to promote chiropractic (mostly from a financial point of view).

Acupuncture Research and BPAcupuncture on points not on the meridians did the exact same at points on the meridians regarding drop in blood pressure. So the actual points that needed to be stimulated weren’t any more effective.

JMPTJMPT has an impact factor of .8. It is just chiropractors reading it, not other practitioners.

IndexingJournal is listed on sources where others can find it (ex. PubMed). Index means is the information is accessible to databases and large search engines. The Journal of Chiropractic Education has recently become indexed.

Abstracts printed in Journal of Chiropractic Education can be submitted elsewhere. In other journals, you must sign a copyright. This is unique, since most journals wish to retain original research.

*** Google Ralph Gay for 10 Pts….DC, MD ****** Google How Much money is spent on research for 10 pts ****** Google Impact Factor JMPT, Spine, Pain, Manual Therapy for 10 pts ****** Who is buried in Grant’s Tomb ****** Which journal has highest impact factor ***

Low Back Pain90% expect to be pain free after a couple of weeks. A high percentage (35-75% may have pain up to 4 weeks and 10-75% may have pain up to and longer than 4 weeks).

*** Test Question ***70% of all hot low backs are symptom free in 8 weeks and 80% in 12 weeks…What is the future impact of this statement? Standard medical care, PT, Chiro Care (HVLA) get equivalent results with acute LBP according to a journal. How does it confound Low back research if most gets better on its own in 8-12 weeks? How could you identify acute LBP who wasn’t going to get better? How do you know what the predictors are?

DiscsDiscs are not good predictors of back pain. We cannot classify back pain and the results of back pain from MRI’s of disc injuries.

9/29/08

Before You Begin Your Research ProjectReliabilityThe importance of reliability in any research project cannot be overstated but it becomes particularly important

Measurement ErrorLow reliability means increased error

Reliability of Measurement InstrumentsIt is important to use measures that have demonstrated reliability in other studiesIt is critical to report reliability coefficient for YOUR study

A measure that has been deemed reliable with a certain sample individuals, in a particular testing situation, will not necessarily be reliable in your study. Establishing reliability in your study allows you to make more solid conclusions about your findings.

Determining the reliability of the instrument you are using AND the rater making the measurements must be undertaken.

Pilot TestingPilot testing your study protocol30 is the magic #

Limit the Number of Dependent and Independent VariablesRemember that including multiple dependent and independent variables will ultimately mean multiple comparisonsIncreased probability of rejecting the Null Hypothesis can occur with too many variables.

After Data CollectionAlways check data before beginning analysisLook at the distributions for each variable. Get to know your data!If you are planning to use parametric statistical analyses then you must ensure that your data meets certain statistical assumptions regarding the distribution, homogeneity of variance.Also, be sure to check your data for outliers

Statistical Significance Testing is a ToolStatistical Significance testing should be used as a tool, not an end to interpretation of results.

T TestThe T test assesses whether the means of two groups are statistically different from each other.This analysis is appropriate when you want to compare the means of the two groups, and especially appropriate as the analysis for the posttest-only two-group randomized experimental design.

Clinical SignificanceStatistical significance does not equal clinical significanceDiscussion of the significance of clinical change in rehabilitation research

Review of the history and use of the concept of clinical significance in psychotherapyA variety of methods for assessing clinical significance are found in the psychotherapy literature

3 Options for Research1. Project2. Lit Review3. Research Assistant

Efferent Transmission MeasurementsEMG measurements measures the myoelectric event associated with muscle contraction. Efferent EMG use and interpretation requires an understanding of as much as possible the sources of each of these elements and their influences on EMG signals. The sampling rate is an important factor determined by the type of test and area tested. Surface EMG data needs to be sampled at 1000 Hz. Other data should be sampled at highest rates (2000 Hz).

Nerve Conduction Testing

Motion Capture EquipmentMotion capture equipment utilizes a microcontroller to sample and average movement data from accelerometers attached to the body. The data is then transmitted serially to a windows PC where the data is reconstructed and displayed to the user in real time.

Cervical ROM EquipmentThe MCU was designed for the evaluation and rehabilitation for the cervical spine and to objectively measure and improve cervical ROM and strength in all planes of movement.

Identifies cervical function, physical limitations and capabilities, real time recording of C/S ROM and isometric strength.

Balance/Postural Control StudiesNeurocomm Balance Master: Postural control, balance and proprioception are measured

10/1/08

*** Assignment #2 ***Due on 10/13/08Email to Rodger.tepe@logan.eduUse header: your name(s) assignment #2Read the July 11, FCER announcement RE: Alarm Rings in Louisianahttp://www.nuhs.edu/research/Website_Files/WebstieMedia/WordDocs/FcerNewsReleaseJul2008.doc

Please give answers to the following questions:1. What is evidence based education?2. What is evidence based practice?3. What is evidence informed practice? How is this different from evidence – based practice? IN your answer,

emphasize the role of clinical judgment?4. How does the insurance industry use evidence in policy decisions?5. What evidence will be most important to chiropractic in the next 10 years?

EVIDENCE BASED CHIROPRACTIC PRACTICEThe best available research evidence combined with clinical expertise and patient values

EBC is Unique in Several Ways1. Chiropractic interventions (manipulation) are difficult to investigate by experimental methods

a. Difficult in designing an effective placebo b. It is difficult to blind both doctors and patients

As a Result, there are fewer chiropractic articles that use a placebo control group than other disciplines.

EBC is Unique (Cont.)Chiropractors commonly utilize multiple treatment modalities

A variety of manipulations, exercises, ergonomic advice, physiotherapy, and other methods are used to treat patientsIn contrast, clinical trials often utilize only one modality

In order to isolate it and compare it with a placebo or an alternative therapy, 1 thing must be tested

*** Test Question: What are the advantages of an RCT as compared to other research that is practice/patient based ***

A Unique Evidence BaseThe uniqueness of chiropractic research has produced or correspondingly unique evidenceStudies may appear to be less rigorous than for other forms of treatmentNonetheless, many studies are available to support and help direct

EBP is not a “Cookbook” Method of practiceIt is the integration of the best evidence with the past training and expertise of the clinician, which results in better care for the patients

Evidence is added to patient care to supplant outdated info

EBP SupportsEBP supports HVLA. HVLA is the standard of care, and after that support gets weaker and weaker. The next best studied treatment is Activator. The support thins further with other treatments.

Patient PreferencesPatient expectation:

The degree that patients accept a doctor’s recommendationsOften wide-ranging and can have a significant impact on clinical results

EBC (Evidence based care)Best Research Evidence ------ Clinical Expertise ------ Patient PreferencesEBC blends all 3 categories

Why EBP’s?Practitioners may not have enough information to answer clinical questionsBetter reimbursementPatient Specific: Patients who present for care with unusual conditions that are unknown to the practitioner can get best care

Is the patient a good candidate for chiro care?

When EBPSelf EducationAttending seminars and conferences

How Informed is the speaker and how accurate and current is the material?Practitioners gathering the best available evidence on their own

Journal articles

The Five Steps of EBPAsk a clinically relevant questionSearch the literature to find the best available evidence to answer your questionAppraise the evidence for validity and applicability to the clinical circumstancesApply the Relevant Evidence to the Clinical Situation

Hierarchy of Research Evidence1. Systematic Reviews2. RCT’s3. Cohort Studies4. Case-Controlled Studies5. Case Series6. Case Reports7. Editorials and Opinions8. Animal Research and Laboratory Studies

Systematic reviews of RCT’s are considered by most to be the “gold standard” for determining the highest level evidence.

A lower level study may be better evidence when…Studies rank higher on the hierarchy of evidence pyramid is not always betterFor instance, a single RCT that involved few subjects is not necessarily more credible than reliable results from a high-quality non-randomized trailSometimes RCTs are of little value because of design flaws

Evidence in EBPIs founded on ScienceThe science is: The observation

Evidence Rating SystemsUsed to rate the quality and class structure of evidenceExamples: Scottish Intercolllegiate Guidelines Network (SIGN), Agency for Healthcare Research (AHRQ), Oxford Center for Evidence Based Medicine (CEBM)

SIGN Levels of Evidence1++ High quality meta-analyses1+ = Good2 = Moderate3 = Non-analytic studies (eg case reports, case series)4 = Expert Opinion

SIGN Grades of RecommendationsA = at least one meta-analysis, systematic review or RCT as 1++ and directly applicable to the target population or a systematic review of RCT’s or a body of evidence consisting principally of studies rated as 1+ directly applicable to the target population and demonstrating overall consistency of results.

*** The #1 Referral from MD’s to DC’s is acupuncture ***

B = A body of evidence…

C = A body of evidence including studies rates as 2+ directly applicable to target population

D = Evidence level of 3 or 4 or Extrapolated evidence from studies rated as 2+

Chiropractic Philosophy and EBCMany chiropractors think of philosophy as it relates to their fundamental beliefs and underlying principles about the profession

Thus one is said to have a philosophy of chiropracticThis perception only comprises a small part of the word’s complete definition

Philosophy Definition1. The love and pursuit of wisdom by intellectual means and moral self-discipline2. Investigation of the nature, causes, or principles or reality, knowledge or values based on logical reasoning rather than

empirical methods3. The critical analysis of fundamental assumptions or beliefs4. A set of ideas or beliefs relating to a particular

Philosophy and DogmaThe chiropractic profession at large is plagued with dogmatism that affects both sides of the political fence (Seaman)Dogmatism is the principle barrier to a rational and unifying depiction of the role of chiropractors as well as the furtherance of chiropractic science (Keating)

10/6/08

Common Statistical TermsData: Measurements or observations of a variableVariable: A characteristic that is observed or manipulated…Can take on different values

*** Test Question: Know what inferential stats are and Descriptive Stats are ***

Inferential Inferential statistics or statistical induction comprises the use of statistics to make inferences concerning some unknown aspect of a population. Statistical inference is inference about a population from a random sample drawn from it or, more generally, about a random process from its observed behavior during a finite period of time. It includes:

point estimation interval estimation hypothesis testing (or statistical significance testing) prediction

There are several distinct schools of thought about the justification of statistical inference. All are based on some idea of what real world phenomena can be reasonably modeled as probability.

The topics below are usually included in the area of statistical inference.Statistical assumptions Likelihood principle Estimating parameters Statistical hypothesis testing Revising opinions in statistics planning statistical research summarizing statistical data

*** Courtesy Wikipedia ***

DescriptiveDescriptive Statistics are used to describe the basic features of the data gathered from an experimental study in various ways. They provide simple summaries about the sample and the measures. Together with simple graphics analysis, they form the basis of virtually every quantitative analysis of data.

Various techniques that are commonly used are classified as:1. Graphical displays of the data in which graphs summarize the data or facilitate comparisons. 2. Tabular description in which tables of numbers summarize the data. 3. Summary statistics (single numbers) which summarize the data.

Examples/Methods used in descriptive stats are:1. Central Tendency2. Statistical Variability: how stats differ3. Mean4. Median5. Mode6. Variance (variability of quantitative data) 7. Standard Deviation8. Square Root9. Absolute Deviation (average deviation)10. Range11. Interquartile Range12. Histograms/Curves… in which the central tendency and statistical variability can both be visualized.

*** Courtesy Wikipedia ***

HypothesesYou can only test the Null Hypothesis. The Null Hypothesis states that there is no relationship between 2 variables. Ex. Ho: Variable A = Variable B….Ex. If you take Vitamin C and don’t take Vitamin C your length of cold will be the same (so Vit C will impact the length of a cold).

Independent variable = What the researcher manipulates (ex. pill, adjustment, treatment or other intervention)Dependent Variable = Measure or outcome variable. A change of the independent variable is measured in the dependent variable. Hypothesis = what is the affect of the independent variable on the dependent variable.

*** For the exam, know the component parts of a hypothesis ***

AssumptionsSomething that may/may not be true. Mostly an assumption has not been tested.

GeneralizationClump things together based on characteristics. Hierarchal arrangement typically occurs with generalization. Generalizations are convenient, user friendly, etc. There is an inherent problem with making generalizations

ConceptSubjected to analytical process (inductive or deductive reasoning)

ConstructA concept that is upgraded by being defined with enough precision

VariableBy definition a variable is measurable. The construct is good enough to be made measurable.

ReliabilityVariables must be measured over and over to determine if they are reliable (consistent).

*** Things can be reliable but not accurate. Ex. A thermometer may be 5 degrees high, so it is reliable, but not accurate. ***

ValidityIs the test or measure that you hope to determine, what you are actually attempting to observe. IF so, this would indicate validity.

ScienceScience starts with a variable. If it not measurable, it is not science.

LawUltimately, the best way of learning something is a law.

TheoryDescribes or predicts a phenomenon. It doesn’t need to have a shred of proof beyond it. (Ex. Garden Hose Theory)Theory should generate hypothesis that are testable and measurable

Chiropractic TheoriesBOOP, Fixation Theory, Innate Intelligence

*** Hypothesis vs. Theory…Hypotheses are testable vs. Theory which may/may not be testable and can have no evidence behind it***

DATA TYPES1. Normal DataA numeric system used to describe something. The data falls around a mean (average) with the data presenting as a bell shaped curve. A majority of the data is within a couple standard deviations of the mean.

2. Ordinal DataYou assign an order (ex. 1st, 2nd, 3rd). The problem is you don’t know the size of intervals or distance between the two.

*** Wikipedia: In this classification, the numbers assigned to objects represent the rank order (1st, 2nd, 3rd etc.) of the entities measured. The numbers are called ordinals . The variables are called ordinal variables or rank variables. Comparisons of greater and less can be made, in addition to equality and inequality. However, operations such as conventional addition and subtraction are still meaningless. The corresponding variable can be called an ordered categorical variable ***

3. Interval DataArbitrary zero occurs. O degrees Fahrenheit is a numerical place. The location of 0 limits what you can do with numbers mathematically.

*** Wikipedia: The numbers assigned to objects have all the features of ordinal measurements, and in addition equal differences between measurements represent equivalent intervals. That is, differences between arbitrary pairs of measurements can be meaningfully compared. Operations such as averaging and subtraction are therefore meaningful, but addition is not, and a zero point on the scale is arbitrary; negative values can be used. The formal mathematical term is an affine space (in this case an affine line). Variables measured at the interval level are called interval variables, or sometimes scaled variables, as they have a notion of units of measurement, though the latter usage is not obvious and is not recommended.

Ratios between numbers on the scale are not meaningful, so operations such as multiplication and division cannot be carried out directly. But ratios of differences can be expressed; for example, one difference can be twice another.

Examples of interval measures are the year date in many calendars , and temperature in Celsius scale or Fahrenheit scale ; temperature in the Kelvin scale is a ratio measurement.

Statistical measures: The central tendency of a variable measured at the interval level can be represented by its mode , its median , or its arithmetic mean . Statistical dispersion can be measured in most of the usual ways, which just involved differences or averaging, such as range, interquartile range, and standard deviation.

Since one cannot divide, one cannot define measures that require a ratio, such as studentized range or coefficient of variation.More subtly, while one can define moments about the origin, only central moments are useful, since the choice of origin is arbitrary and not meaningful. One can define standardized moments, since ratios of differences are meaningful, but one cannot define coefficient of variation, since the mean is a moment about the origin, unlike the standard deviation, which is (the square root of) a central moment.

4. RatioThe highest form of numbers. A true zero exists with equal intervals. Ratio, interval data are called parametric data. Nominal and ordinal data is non-parametric data.

*** Wikipedia: A ratio measurement scale is one in which the ratio between any two measurements is meaningful. To achieve this ratio scale has to have a non-arbitrary zero value. Then operations such as multiplication and division become meaningful as well. For a ratio scale one can thus say "This value is double this other value".

"If it's twice as cold today as it was yesterday," runs a popular joke, "and it was zero degrees yesterday, how cold is it today?" This illustrates the limitation of interval measurements such as Celsius and Fahrenheit temperature: by setting zero at an arbitrary point, they make it impossible to multiply and divide meaningfully.

Examples: Most physical quantities, such as mass, length or energy are measured on ratio scales; so is temperature measured in Kelvin’s, that is, relative to absolute zero…Social variables of ratio measure include age, length of residence in a given place, number of organizations belonged to or number of church attendances in a particular time.

Statistical measures: All statistical measures can be used for a variable measured at the ratio level, as all necessary mathematical operations are defined. The central tendency of a variable measured at the ratio level can be represented by, in addition to its mode , its median , or its arithmetic mean , also its geometric mean . In addition to the measures of statistical dispersion defined for interval variables, such as range and standard deviation , for ratio variables one can also define measures that require a ratio, such as studentized range or coefficient of variation .

In a ratio variable, unlike in an interval variable, the moments about the origin are meaningful, since the origin is not arbitrary.

"True measurement": The interval and ratio measurement levels are sometimes collectively called "true measurement", although it has been argued that this usage reflects a lack of understanding of the uses of ordinal measurement. Only ratio or interval scales can correctly be said to have units of measurement .

Overview of Numbers

Level Can define… Relation or Operation Mathematical structure

nominal mode equality (=) standard set structure (unordered)

ordinal median order (<) totally ordered set

interval mean, standard deviation subtraction (−) and weighted   average affine line

ratio geometric mean, coefficient of variation

addition (+) and multiplication (×) field

VASWhere 0 pain is different for each person. The uncertainty of zero places the scale in the ordinal. The scales measure best in the middle (ex. 4-5 or 5.-6)

Reliability, Validity, Accuracy, ErrorEx. Intra-examiner and inter-examiner reliability of static and motion palpation may not be better than a coin flip.

Nuisance Variable/Confounding Variables/Intervening VariableA variable that is not under control in the study that affects the outcome measure.

10/13/08

Statistical PowerAffected by sample size. The ability of your experiment to find an affective difference if one exists in the data. Is there a difference between both groups based on the data. Is your experiment good enough to find this difference. How well your intervention and outcome measures are refer back to statistical power*** Test question on statistical power. The answer may be all of the above ***

*** Wikipedia: The power of a statistical test is the probability that the test will reject a false null hypothesis (that it will not make a Type II error). As power increases, the chances of a Type II error decrease. The probability of a Type II error is referred to as the false negative rate (β). Therefore power is equal to 1 − β.

Power analysis can either be done before (a priori) or after (post hoc) data is collected. A priori power analysis is conducted prior to the research study, and is typically used to determine an appropriate sample size to achieve adequate power. Post-hoc power analysis is conducted after a study has been completed, and uses the obtained sample size and effect size to determine what the power was in the study, assuming the effect size in the sample. Statistical power depends on:

the statistical significance criterion used in the test the size of the difference or the strength of the similarity (that is, the effect size) in the population the sensitivity of the data.

A significance criterion is a statement of how unlikely a result must be, if the null hypothesis is true, to be considered significant. The most commonly used criteria are probabilities of 0.05 (5%, 1 in 20), 0.01 (1%, 1 in 100), and 0.001 (0.1%, 1 in 1000). If the criterion is 0.05, the probability of the difference must be less than 0.05, and so on. One way to increase the power of a test is to increase (that is, weaken) the significance level. This increases the chance of obtaining a statistically significant result (rejecting the null hypothesis) when the null hypothesis is false, that is, reduces the risk of a Type II error. But it also increases the risk of obtaining a statistically significant result when the null hypothesis is in fact true; that is, it increases the risk of a Type I error.

Calculating the power requires first specifying the effect size you want to detect. The greater the effect size, the greater the power.

Sensitivity can be increased by using statistical controls, by increasing the reliability of measures (as in psychometric reliability), and by increasing the size of the sample. Increasing sample size is the most commonly used method for increasing statistical power.

Although there are no formal standards for power, most researchers who assess the power of their tests use 0.80 as a standard for adequacy

Hypothesis Testing InvolvesIV, DV, NV

Purpose of SampleIs to be able to draw a generality back to the population. Sample selection is important when making generalizations. Making generalizations outside the sample should be made with caution if a particular segment of the population is specifically in the sample (ex. college students).

P ValueProbability…Statistics are probability based. What are the chances of flipping heads in a coin flip? How bout 5 straight times? How bout 10 straight times? Etc.

Central Limit TheoremA measure to try to find what would happen if you took repeated measures of the same subject group over and over again. The people are chosen to represent a wide demographic. Sampling is a big deal and how you do it affects statistical power.

Convenience SampleAnyone can walk through the door and be a subject…You do not discriminate between subjects, as you seek a specific number of people( ex. 40 subjects needed) not a type of subject (ex. 20 year old males).

P Value.05 and .01…..05 = 5/100 you could get the results by random chance about 5% of the time and not a systematic relationship between independent and dependent variables. .01 = 1/100 is less than 1% of time you’ll get the result by random. .001 = 1/1000 that you would expect to get the results by random chance. Replicated studies over and over again with very good P values (very low numbers) bring efficacy to the treatment. The more the study and result are replicated with success, the greater the reliability that the treatment and effect have.*** Test question ***

OperationalizationOperationalization = A protocol that you do in detail, so that if another investigator wants to replicate your study, they can do it the exact same way. *** Test Question ***

Gaussian Distribution/Normal DistributionThe curve is symmetrical on both sides of the mean. Most of statistics are based on theoretical characteristics of a frequency distribution. Whatever you measure, should fit on the curve/frequency distribution. The key is area under the curve.

Mean = Arithmetic averageMedian = The middle # in a setMode = Most frequent # in a set

You want to know how the numbers are spread around the mean. The spread is called standard deviation. Sample size, range (highest, lower and middle number), median, and standard deviation all together give a good overview of the data. In a standard curve:

+/- 1 Standard Deviation give 68% of all the data. (so 34% is +1, 34% is -1 SD)+/- 2 SD’s is about 95% of all data+/- 3 SD’s gives 99% of all information.

The middle is the 50 th percentile. Within 1 SD of the mean, 84% of the numbers fit . 16% is the cutoff (1 SD below)…Typically, those below 1 SD don’t pass an exam. *** This will be on the midterm ***

Journal Article Statistical analysisMean, Standard Deviation and Confidence Interval = These are usually reported in journal/research articles

Confidence IntervalConfidence interval ties back to standard deviation, 95% confidence ties into 2 standard deviations. Ex. Salary of a group…100,000 +/- 10,000 has a confidence of 95% if it includes 2 standard deviations. That means 95% of the people have income between 90,000 and 110,000.

Bimodal Distribution2 humps in a data set…2 large distributions of data (so the data may not be normally distributed).

10/15/08

HIERARCY OF RESEARCH1. Systematic Review2. RCT3. Cohort Studies (a good cohort study may be better than a bad RCT)4. Case-control studies5. Case Series 6. Case Reports7. Editorials and Opinions8. Animal Studies

Information LiteracyInformation literacy is common to all disciplines to all learning environments and to all levels of education. It enables learners to engage critically with content and extend their investigations, become more self directed, and assume grater control over their own learning.

The information literate person..1. Recognizes the need for information and determines the nature and extent of the information needed. 2. Finds needed information effectively and efficiently 3. Critically evaluates information and the information seeking process 4. Manages information collected or generated 5. Applies prior and new information to construct new concepts or create new understandings 6. Uses information with understanding and acknowledges cultural, ethical, economic, legal, and social issues

surrounding the sue of information

Information literacy intersects with a range of other graduate attributes such has critical thinking and writing, group work communication and problem solving skills.*** There will be test questions on information literacy ***

NE Journal of Medicine has an impact factor 38 vs. JMPT which has an impact factor of about .8.

Article Posted in Class25 classes for CLBP and interventions were analyzed. The article states, “the articles pose more questions than they answer. Taken together these reviews demonstrate the serious deficiencies in available research for many of the treatment approaches that are commonly used for CLBP because of either unavailable, insufficient, or conflicting research results. These articles do not present convincing evidence that is current possibly to select one treatment approach over another for patients with CLBP and give very little guidance on when any specific treatment approach is indicated…When viewed optimistically, the articles in this special focus issue do suggest that a reasonable approach to CLBP would include education strategies, exercise, simple analgesics, a brief course of manual therapy in the form of spinal manipulation, mobilization or massage, and possibly acupuncture. IN patients with longstanding or severe symptoms and psychological comorbidities there is some evidence that a comprehensive multidisciplinary approach with cognitive, behavioral treatment, fear avoidance training or functional restoration is at least as beneficial as surgery…It is somewhat disappointing to note that 14 years after dozens of highly promoted new interventions, thousands of studies, millions of lost work days, and billion of dollars spent on its care, so little has changed in the evidence available to guide stakeholders and support for treatments for CLBP….In this supermarket of over 200 available treatment options for CLBP, we are still in the era of caveat emptor buyer beware.”

Summary of the Above ArticleThere is almost no way to tell or separate which patient belongs in which category of care/treatment group. There is not enough research to make the distinguishment if your care for a patient is any more or less effective.

A Clinical Prediction Rule to Identify Patients with Low Back Pain Most Likely to Benefit from Spinal Manipulation: A Validation StudyIntervention: Patients were randomly assigned to receive manipulation plus exercise or exercise alone by a physical therapist for 4 weeks.

Limitations: The response rate for the 6 month follow-up resulted in inadequate power to detect statistically significant differences for some comparisons.

Conclusion: The spinal manipulation clinical prediction rule can be used to improve decision making for patients with low back pain.

Critical Analysis: The study does not take into context the fact that this is a multi site study with multiple clinicians of different training. The study does not take into context what type of back pain they have (acute, chronic or sub-acute). The study has huge holes in it.

10/22/08*** Going over the study guide handed out in class ***

Evidence Informed Vs. Evidence BasedEvidence Based:

Informed: Allows more room for clinical judgment

Descriptive vs. InferentialInferential stats test hypotheses.

NOIR = Nominal Ordinal Interval. Ratio

Generalized – Law: Theory does not include investigation. Theories can occur without evidence

Prospective Study: Look at something now and project into the futureRetrospective Study: Looking at cancer patients and go backwards to see if they smoked (looking at something present and tracing the behavior backwards).

Confidence Interval of a Non-Normal DistributionTall, skinny curve has smaller confidence interval, than a normal curve.

Population: The group that you study (the sample). The sample can be random or can be convenient (students looking for EC).

Random Sample: Getting people from your study at random from across many demographics. There are few truly, randomized selection studies as they are too difficult.

Random Assignment: People in the study are randomly placed into groups.

Matching: Matching helps gives better comparison groups (examples = matched for age, grade point average, or educational background)

Case study: 1 reportCase Series: 2 or more reports

Case Control Study: People picked with and without condition and studied

Cohort Study: People studied prospectively with and without condition

Cross Sectional Study: Look at a point in time of people with and without condition

Operationalization: Detailed overview of how you perform the measurement or study, so the experiment can be replicated

Generalization – Law:

Confidence Interval: 2 SD’s above and below the mean…Refers to how the observations are distributed around the mean (middle)...Ex. 95% confidence would indicate within 2 SD’s around the mean. We look at variability around the middle. Effect Size: How much difference does your intervention make. Ex. Acupuncture Studies…Show a decline in 3 mm of BP (small effect)…Effect size is related to statistical power (Better effect size, better statistical power)

Reliability: Can you get the same measure over and over…

Validity: Are you measuring what you think you are measuring

Journal Article Oder of Info: Abstract, intro, methods, results, discussion, conclusion, references). Author compares results with similar studies in the discussion section.

Controlled and Uncontrolled: Experimental study is like an RCT where an investigator controls intervention. True Experimental Studies have control of the intervention or not

Observational Study: People are chosen based on characteristics (ex. we don’t choose if a person smokes or not)…We don’t control the subject’s smoking.

Quasi-Experimental/Observational: The two terms are synonymous…

Control Group: Does not get interventionExperimental Group: Gets the intervention

Having a good placebo results in better generalization.