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 Foreword

The introduction of evidence-based medicine by David the details of a particular assessment. Although it does
Sackett and other researchers in the 1990s (Sackett, require learning about research methods and design,
1997) initiated a radical shift in the approach to in- measurement, and statistics, this knowledge is mastered
struction in research methods and the application of in the context of appraising evidence in relation to a
research findings to health-care practice. Until then, particular clinical question regarding a particular clini-
practitioners learned about research through standard cal scenario. The EBP process involves a specific set of
academic research methods courses in which they were steps to formulate an answerable question, and then to
taught to read and critique journal articles using the search, select, appraise, and apply the evidence to an-
well-established criteria of reliability and validity. They swer the clinical decision at hand. Ideally, students will
were then expected to use those skills to “keep up” with have multiple opportunities to practice these steps so
the research literature relevant to their area of practice that ultimately the process can be initiated and carried
and apply the results to patient care. Unfortunately, for out smoothly and efficiently in occupational therapy
the most part, they didn’t. practice.
Sackett and his colleagues determined that the tra- One of the valuable features of this text is that it is
ditional approach to applying research to practice was designed to be used with team-based learning. This ap-
ineffective, and they proposed a radically different proach supports another important element of Sackett’s
approach—what we now recognize as evidence-based (Sackett, 1997) and others’ original recommendations for
practice. What was so different? Sackett and colleagues how to conduct EBP: that is, the importance of distrib-
recognized that research was relevant and useful to the uting the work and learning from one another’s insights.
Team-based learning models a method that can be carried
practitioner only to the extent that it addressed a clinical
forward into the “real world” to continue to implement
question of importance to practice and provided a useful
EBP in practice.
guide to clinical decision-making. From this perspec-
Here’s what this can look like: Each of the five practi-
tive, reading journal articles just to “keep current” and
tioners in a group prepares and shares an appraisal of one
without a particular question in mind was unfocused and
key study that addresses a clinical question of importance
unproductive.
to the group. In less than an hour of discussion, the group
The alternative method they proposed taught practi- synthesizes the findings and reaches a decision on the best
tioners to use research evidence as one of three integral answer (known as the “clinical bottom line” in EBP) to a
components of clinical reasoning and decision-making. clinical question at hand. One busy practitioner working
This method is reflected in the now-familiar definition of alone might find that amount of work daunting. In addi-
evidence-based practice: integration of the clinician’s exper- tion, he or she would miss the crucial insights that other
tise and the best available scientific evidence with the cli- group participants provide.
ent’s preferences and values to determine an appropriate There’s another important advantage to team-based
course of action in a clinical encounter. EBP: it’s much more fun. Group members energize one
To support the use of evidence-based practice as an another, and examining the evidence becomes an inter-
integral part of clinical reasoning, a different method of esting exploration and lively discussion of how best to
instruction was developed, which is exemplified in The balance strengths and limitations, clinical relevance and
Evidence-Based Practitioner: Applying Research to Meet feasibility, and similarities and differences in the evidence.
Client Needs. Evidence-based practice (EBP) is a pro- The outcome of that lively discussion will help ensure
cess to be learned, not a content area to be mastered that your clinical decisions are guided by the best evi-
the way we learn to identify the bones of the body or dence available to help your clients.

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 viii Foreword

In The Evidence-Based Practitioner: Applying Research to I hope that you will approach learning EBP as a great
Meet Client Needs, Catana Brown provides occupational adventure and that you and your fellow students make
therapy, physical therapy, and speech-language pathology exciting discoveries.
students with a clear and concise overview of research de-
signs, methodology, use of statistical analysis, and levels Wendy Coster, PhD, OTR/L FAOTA
of evidence, as well as the tools with which to evaluate Professor and Chair, Department of Occupational Therapy
and apply evidence. Interesting and engaging features Director, Behavior and Health Program
such as From the Evidence lead the readers through the Boston University
steps to becoming effective consumers of evidence. Exer- Boston, Massachusetts, USA
cises and Critical Thinking Questions motivate learners Sackett, D. L. (1997). Evidence-based medicine: How to
to explore how this knowledge can be applied to their practice and teach EBM. New York/Edinburgh: Churchill
clinical practice. Livingstone.

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 Preface

Evidence-based practice is no longer a new idea: it’s The text contains 11 chapters and is intended to fit
a mandate from third-party payers, accrediting bod- within a single entry-level course in a health-care pro-
ies, health-care institutions, and clients. Although the gram. It will fit ideally into programs offering a course on
majority of therapists will become practitioners and evidence-based practice, and can also be used to support a
consumers of research rather than academic research- traditional research methods text in research courses that
ers, good consumers of research must still understand cover evidence-based practice.
how a study is put together and how to analyze the re- The content of the initial chapters focuses on explain-
sults. Occupational therapists, physical therapists, and ing basic research concepts, including describing qualita-
speech-language pathologists are expected to use evi- tive and quantitative approaches. A separate chapter on
dence when discussing intervention options with clients statistics is included in this introductory material. Subse-
and their families, and when making clinical decisions. quent chapters explain the different designs used in health-
The skills required to be an effective evidence-based care research, including separate chapters for each of the
practitioner are complex; for many therapists, finding following types of research: intervention, assessment,
and reviewing research is considered a daunting or descriptive/predictive, and qualitative, as well as a chapter
tedious endeavor. In addition, evidence-based practice on systematic reviews. These chapters prepare students to
is still new enough that many working therapists were match their own evidence-based questions with the cor-
not trained in the methods, and some work settings have rect type of research. In addition, students will acquire the
not yet adopted a culture of evidence-based practice knowledge and skills necessary to understand research arti-
that provides sufficient resources. cles, including those aspects of the research article that can
be particularly befuddling: statistics, tables, and graphs.
Importantly, the chapters provide students with an under-
GUIDING PRINCIPLE: CONSUMING standing of how to evaluate the quality of research studies.
VS. CONDUCTING RESEARCH The text ends with a chapter on integrating evidence from
multiple sources, which highlights the importance of in-
The Evidence-Based Practitioner: Applying Research to Meet volving clients and families in the decision-making process
Client Needs is designed for entry-level graduate students by sharing the evidence.
in occupational therapy, physical therapy, and speech-
language pathology, particularly those in courses that
focus on evidence-based practice versus the performance
of research. Its emphasis is on providing therapists with
A TEAM-BASED LEARNING WORKTEXT
the knowledge and tools necessary to access evidence, cri- This text uses a unique team-based learning (TBL)
tique its strength and applicability, and use evidence from approach. TBL is a specific instructional strategy that
all sources (i.e., research, the client, and clinical experience) facilitates the type of learning that helps students solve
to make well-informed clinical decisions. problems. It is a method that requires active involvement
This textbook was designed with multiple features of the student in the learning process from the outset.
that allow students and practitioners not only to ac- Ideally, students work in small teams, using methods that
quire knowledge about evidence-based practice, but also enhance accountability for both individual and team work;
to begin to apply that knowledge in the real world. this can result in a deeper level of understanding that is
Numerous examples and excerpts of published journal more relevant to real-life practice. Still, this textbook is
articles from occupational therapy, physical therapy, and useful for all types of instructional strategies and is rele-
speech-language pathology are used throughout the text. vant even with approaches that do not use a TBL format.
In addition to learning about evidence-based practice, Nevertheless, TBL provides the pedagogy for applying
students are exposed to research in their own disciplines information, and therefore one strength of this text is its
and the disciplines of their future team members. emphasis on application.

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 x Preface

To facilitate application, the text is presented as a advanced skills needed for assessing the strength and
worktext that interweaves narrative with exercises, crit- applicability of evidence, and apply the material to prac-
ical thinking questions, and other means of engaging tice. The Evidence-Based Practitioner: Applying Research to
students and helping them comprehend the informa- Meet Client Needs includes several special features.
tion. When appropriate, answers to these questions are
included at the end of the chapter. An advantage of the
Key Terms
worktext approach is that it gets students engaged with
the material from the beginning. In courses that use a An alphabetical list of key terms appears at the beginning
TBL format, the worktext prepares students to be effec- of each chapter. These terms are also bolded where they
tive team members. are first described in the chapter and fully defined in the
end-of-book glossary.

TERMINOLOGY From the Evidence

A challenging aspect of evidence-based practice for stu-
Students often have trouble applying research concepts
dents and instructors alike is terminology. In fact, this was
to reading a research article. This key feature helps stu-
one of the greatest challenges for the author of this text.
dents make the link by providing real-world examples
In evidence-based practice, several different terms can be
from research articles in occupational therapy, physi-
used to describe the same or similar concepts. Making
cal therapy, and speech-language pathology. From the
matters more difficult, there are several issues with termi-
Evidence visually walks the student through graphic ex-
nology that can make deciphering the research literature
amples such as abstracts, tables, and figures to illustrate
perplexing. For example:
key concepts explained in the chapter. Arrows and text
• Different terms are used to describe the same or sim- boxes are used to point out and elucidate the concept
ilar concepts. of interest.
• There are disagreements among experts as to the proper From the Evidence features are included in each
use of some terms. chapter. Each has at least one corresponding question to
• Terms are used incorrectly, even in peer-reviewed ensure that the student fully understands the material.
articles. Answers to these questions are provided at the end of
• Labels and terms are sometimes omitted from research each chapter.
articles.
Because deciphering research terminology is chal- Exercises
lenging, a significant effort was directed toward using
Exercises are distributed throughout the chapters to help
the most common terms that are likely to appear in the
students learn to apply information in context. In TBL
literature. When multiple terms are routinely used, this
courses, the exercises are intended to prepare students for
is explained in the text. For example, what some call a
the in-class team assignments; similarly, in flipped class-
nonrandomized controlled trial may be described by oth-
rooms, students would complete the exercises at home
ers as a quasi-experimental study.
and arrive at class prepared for discussions and activities.
Due to the challenges with terminology, students
Each exercise is tied directly to a Learning Outcome and
need to read actual articles and excerpts of articles during
includes questions requiring students to apply the knowl-
the learning process so that these terminology issues can
edge acquired in the chapter. There is space in the text for
become transparent. When students have a more thor-
the student to complete the exercise, and the answers are
ough understanding of a concept and the terms involved,
provided at the end of the chapter.
they can better interpret the idiosyncrasies of individual
articles.
Fortunately many journals are creating standard for- Understanding Statistics
mats for reporting research, and with time some termi-
After Chapter 4, “Understanding Statistics: What They
nology issues will be resolved, although differences in
Tell You and How to Apply Them in Practice,” the
opinion and disciplines (e.g., school-based practice vs.
Understanding Statistics feature is included in chapters
medicine) will likely continue to exist.
in which specific statistical procedures are described.
Understanding Statistics boxes provide an example of a
statistic with additional explanation to reinforce informa-
SPECIAL FEATURES tion that is typically challenging. The feature also helps
The special features developed for this text will enable put the information in context for students by associating
students to better understand content, develop the the statistic with a specific research design.

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 Preface xi

Evidence in the Real World as prompts for students to evaluate their comprehension
of the chapter concepts.
The Evidence in the Real World feature uses a story-
telling or case scenario approach to demonstrate how
theoretical research concepts apply to real-life practice. CLOSING THOUGHTS
It serves as another method of demystifying research
concepts—such as how the concept of standard devia- In today’s health-care environment, occupational ther-
tions can be used to understand the autism spectrum— apists, physical therapists, and speech-language pathol-
and showing students the relevance/practical application ogists must be proficient in accessing, critiquing, and
of what they are learning. applying research in order to be effective evidence-based
practitioners. With solid foundational information and
engaging application exercises, this text provides the
Critical Thinking Questions framework for developing the evidence-based practice
Each chapter ends with Critical Thinking Questions. skills that allow practitioners to best meet their clients’
These questions require higher-level thinking and serve needs.

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4366_FM_i-xxii.indd xii 27/10/16 2:13 pm
 Acknowledgment

Although it is now widely valued, evidence-based practice rough drafts of the text and provided invaluable feedback,
is not the favorite topic of most rehabilitation therapy stu- resulting in the addition, clarification, and improvement
dents. When I began this process, I knew that I wanted a of the content. I would especially like to thank Morgan
very different sort of textbook that would require students Lloyd, who helped me with some of the content that was
to actively engage with the material; hence, the use of a the most difficult to explain.
team-based learning format. However, doing something Larry Michaelsen, who developed the team-based
different required a lot of help along the way. learning approach, inspired me to try a new way of teach-
First, I would like to acknowledge the fantastic edito- ing, which ultimately led to my insight that a new type of
rial support provided by F.A. Davis. In particular I would textbook was needed. Furthermore, I would like to thank
like to thank Christa Fratantoro, the acquisitions editor, Bill Roberson and Larry Michaelsen for contributing a
who grasped my vision for a new evidence-based textbook marvelous team-based learning primer as part of the in-
and believed in my ability to pull it off. I appreciate her structor resources.
friendship and backing. Nancy Peterson, developmental Finally, a big thanks to those who offered support, both
editor extraordinaire, was with me through every step of professional and personal, providing me with the time,
the process. All the things that are good about this text are space, and encouragement to make this text a reality. This
better because of Nancy. In addition, Nancy is my sound- includes my chair, Chris Merchant; my husband, Alan
ing board, my counselor, motivator, and guide. Berman; and my friend, Bob Gravel.
I owe a debt of gratitude to the occupational therapy
and physical therapy students at Midwestern University– Catana Brown, PhD, OTR/L, FAOTA
Glendale in Arizona, who used different variations of the

xiii

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4366_FM_i-xxii.indd xiv 27/10/16 2:13 pm
 Reviewers

Evelyn Andersson, PhD, OTR/L Sharon Gutman, PhD, OTR, FAOTA

Associate Professor Associate Professor
School of Occupational Therapy Programs in Occupational Therapy
Midwestern University Columbia University
Glendale, AZ New York, NY

Suzanne R. Brown, PhD, MPH, PT Elisabeth L. Koch, MOT, OTR/L

Educational Consultant Faculty and Clinical Coordinator
Mesa, AZ Occupational Therapy Assistant Program
Metropolitan Community College of Kansas City–Penn
April Catherine Cowan, OTR, OTD, CHT Valley, Health Science Institute
Assistant Professor Kansas City, MO
Occupational Therapy
The University of Texas Medical Branch Teresa Plummer, PhD, OTR/L, CAPS, ATP
Galveston, TX Assistant Professor
School of Occupational Therapy
Denise K. Donica, DHS, OTR/L, BCP Belmont University
Associate Professor, Graduate Program Director Nashville, TN
Occupational Therapy
East Carolina University Patricia J. Scott, PhD, MPH, OT, FAOTA
Greenville, NC Associate Professor
Occupational Therapy
Marc E. Fey, PhD, CCC-SLP Indiana University
Professor Indianapolis, IN
Department of Hearing and Speech
University of Kansas Medical Center
Kansas City, KS

Thomas F. Fisher, PhD, OTR, CCM, FAOTA

Professor and Chair
Occupational Therapy
Indiana University
Indianapolis, IN

xv

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4366_FM_i-xxii.indd xvi 27/10/16 2:13 pm
 Contents in Brief

Chapter 1 Chapter 7
Evidence-Based Practice: Why Do Using the Evidence to Evaluate
Practitioners Need to Understand Measurement Studies and Select
Research? 1 Appropriate Tests 127

Chapter 2 Chapter 8
Finding and Reading Evidence: Descriptive and Predictive Research
The First Steps in Evidence-Based Designs: Understanding Conditions
Practice 21 and Making Clinical Predictions 145

Chapter 3 Chapter 9
Research Methods and Variables: Qualitative Designs and Methods:
Creating a Foundation for Evaluating Exploring the Lived Experience 163
Research 39
Chapter 10
Chapter 4 Tools for Practitioners That Synthesize
Understanding Statistics: What They the Results of Multiple Studies:
Tell You and How to Apply Them in Systematic Reviews and Practice
Practice 59 Guidelines 183

Chapter 5 Chapter 11
Validity: What Makes a Study Strong? 81 Integrating Evidence From Multiple
Sources: Involving Clients and
Chapter 6 Families in Decision-Making 203
Choosing Interventions for Glossary 217
Practice: Designs to Answer Efficacy
Questions 103 Index 225

xvii

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4366_FM_i-xxii.indd xviii 27/10/16 2:13 pm
 Contents

Chapter 1 Chapter 2
Evidence-Based Practice: Why Do Finding and Reading Evidence: The First
Practitioners Need to Understand Steps in Evidence-Based Practice 21
Research? 1 INTRODUCTION 22
INTRODUCTION 2 IDENTIFYING DATABASES 22
WHAT IS EVIDENCE-BASED PRACTICE? 2 PubMed 24
External Scientific Evidence 3 Cumulative Index of Nursing and Allied Health
Practitioner Experience 3 Literature 25
Client Situation and Values 5 Cochrane Database of Systematic Reviews 25
WHY EVIDENCE-BASED PRACTICE? 6 EMPLOYING SEARCH STRATEGIES 25
THE PROCESS OF EVIDENCE-BASED PRACTICE 7 Selecting Key Words and Search Terms 26
Combining Terms and Using Advanced Search 26
Formulate a Question Based on a Clinical
Using Limits and Filters 27
Problem 7
Expanding Your Search 29
Identify the Relevant Evidence 7
Evaluate the Evidence 7 ACCESSING THE EVIDENCE 29
Implement Useful Findings 8 The Research Librarian 30
Evaluate the Outcomes 8 Professional Organizations 31
WRITING AN EVIDENCE-BASED QUESTION 9 DETERMINING THE CREDIBILITY OF A SOURCE
Questions on Efficacy of an Intervention 9 OF EVIDENCE 31
Research Designs for Efficacy Questions Websites 32
and Levels of Evidence 10 The Public Press/News Media 32
Questions for Usefulness of an Assessment 13 Scholarly Publications 33
Research Designs Used in Assessment Impact Factor 33
Studies 13 The Peer-Review Process 33
Questions for Description of a Condition 14 Research Funding Bias 34
Research Designs Used in Descriptive Studies 14 Publication Bias 34
Questions for Prediction of an Outcome 14 Duplicate Publication 34
Research Designs Used in Predictive Studies 14 READING A RESEARCH ARTICLE 35
Questions About the Client’s Lived
Title 35
Experience 15
Authorship 35
Research Designs Addressing the Client’s Lived
Abstract 35
Experience 16
Introduction 35
CRITICAL THINKING QUESTIONS 16 Methods 35
ANSWERS 17 Results 36
REFERENCES 18 Discussion 37

xix

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 xx Contents

References 37 Inferential Statistics for Analyzing Relationships 72

Acknowledgments 37 Scatterplots for Graphing Relationships 72
CRITICAL THINKING QUESTIONS 37 Relationships Between Two Variables 73
Relationship Analyses With One Outcome
ANSWERS 38
and Multiple Predictors 74
REFERENCES 38 Logistic Regression and Odds Ratio 74
EFFECT SIZE AND CONFIDENCE INTERVALS 76
Chapter 3 CRITICAL THINKING QUESTIONS 78

Research Methods and Variables: ANSWERS 79

Creating a Foundation for Evaluating REFERENCES 80

Research 39
INTRODUCTION 40
Chapter 5
TYPES OF RESEARCH 40 Validity: What Makes a Study Strong? 81
Experimental Research 40 INTRODUCTION 82
Nonexperimental Research 41
VALIDITY 82
Quantitative Research 43
Qualitative Research 46 STATISTICAL CONCLUSION VALIDITY 82
Cross-Sectional and Longitudinal Research 47 Threats to Statistical Conclusion Validity 82
Basic and Applied Research 48 Fishing 83
HYPOTHESIS TESTING: TYPE I AND TYPE II Low Power 83
ERRORS 52 INTERNAL VALIDITY 85
VARIABLES 52 Threats to Internal Validity 85
Independent Variables 52 Assignment and Selection Threats 85
Dependent Variables 53 Maturation Threats 88
Control Variables 53 History Threats 89
Extraneous Variables 53 Regression to the Mean Threats 90
Testing Threats 90
CRITICAL THINKING QUESTIONS 55
Instrumental Threats 91
ANSWERS 56 Experimenter and Participant Bias Threats 91
REFERENCES 57 Attrition/Mortality Threats 93
EXTERNAL VALIDITY 95
Chapter 4 Threats to External Validity 95
Sampling Error 96
Understanding Statistics: What They Ecological Validity Threats 96
Tell You and How to Apply Them INTERNAL VERSUS EXTERNAL VALIDITY 97
in Practice 59 CRITICAL THINKING QUESTIONS 100
INTRODUCTION 60 ANSWERS 100
SYMBOLS USED WITH STATISTICS 60 REFERENCES 102
DESCRIPTIVE STATISTICS 60
Frequencies and Frequency Distributions 60 Chapter 6
Measure of Central Tendency 61
Measures of Variability 62 Choosing Interventions for
INFERENTIAL STATISTICS 65 Practice: Designs to Answer Efficacy
Statistical Significance 66 Questions 103
Inferential Statistics to Analyze Differences 66 INTRODUCTION 104
The t-test 66
RESEARCH DESIGN NOTATION 104
Analysis of Variance 66
Analysis of Covariance 69 BETWEEN- AND WITHIN-GROUP COMPARISONS 105

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 Contents xxi

RESEARCH DESIGNS FOR ANSWERING EFFICACY

QUESTIONS 107 Chapter 8
Designs Without a Control Group 108 Descriptive and Predictive Research
Randomized Controlled Trials 108
Crossover Designs 110
Designs: Understanding Conditions
Nonrandomized Controlled Trials 110 and Making Clinical Predictions 145
Factorial Designs 114 INTRODUCTION 146
Single-Subject Designs 117
DESCRIPTIVE RESEARCH FOR UNDERSTANDING
Retrospective Intervention Studies 117
CONDITIONS AND POPULATIONS 146
SAMPLE SIZE AND INTERVENTION
Incidence and Prevalence Studies 146
RESEARCH 120
Group Comparison Studies 147
USING A SCALE TO EVALUATE THE STRENGTH Survey Research 149
OF A STUDY 120
STUDY DESIGNS TO PREDICT AN OUTCOME 150
COST EFFECTIVENESS AS AN OUTCOME 122
Predictive Studies Using Correlational
CRITICAL THINKING QUESTIONS 122 Methods 150
ANSWERS 123 Simple Prediction Between Two Variables 150
REFERENCES 125 Multiple Predictors for a Single Outcome 151
Predictive Studies Using Group Comparison

Chapter 7 Methods 155

Case-Control Studies 155
Cohort Studies 155
Using the Evidence to Evaluate
EVALUATING DESCRIPTIVE AND PREDICTIVE
Measurement Studies and Select STUDIES 157
Appropriate Tests 127 LEVELS OF EVIDENCE FOR PROGNOSTIC
INTRODUCTION 128 STUDIES 158
TYPES OF SCORING AND MEASURES 128 CRITICAL THINKING QUESTIONS 159
Continuous Versus Discrete Data 128 ANSWERS 160
Norm-Referenced Versus Criterion-Referenced REFERENCES 161
Measures 129
Norm-Referenced Measures 129
Criterion-Referenced Measures 130 Chapter 9
TEST RELIABILITY 131 Qualitative Designs and Methods:
Standardized Tests 131 Exploring the Lived Experience 163
Test-Retest Reliability 132
Inter-Rater Reliability 132 INTRODUCTION 164
Internal Consistency 133 THE PHILOSOPHY AND PROCESS OF QUALITATIVE
TEST VALIDITY 134 RESEARCH 164
Construct Validity 135 Philosophy 164
Sensitivity and Specificity 136 Research Questions 165
Relationship Between Reliability Selection of Participants and Settings 165
and Validity 138 Methods of Data Collection 166
Data Analysis 167
RESPONSIVENESS 138
QUALITATIVE RESEARCH DESIGNS 168
CRITICAL THINKING QUESTIONS 141
Phenomenology 168
ANSWERS 141
Grounded Theory 170
REFERENCES 142 Ethnography 171

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 xxii Contents

Narrative 173 THE COMPLEXITIES OF APPLYING AND USING

Mixed-Method Research 175 SYSTEMATIC REVIEWS AND PRACTICE
PROPERTIES OF STRONG QUALITATIVE STUDIES 176 GUIDELINES 199
Credibility 177 CRITICAL THINKING QUESTIONS 199
Transferability 177 ANSWERS 200
Dependability 178 REFERENCES 201
Confirmability 178
CRITICAL THINKING QUESTIONS
ANSWERS 180
179
Chapter 11
REFERENCES 180 Integrating Evidence From Multiple
Sources: Involving Clients and Families
Chapter 10 in Decision-Making 203
INTRODUCTION 204
Tools for Practitioners That Synthesize
CHILD-CENTERED PRACTICE 204
the Results of Multiple Studies: Systematic
SHARED DECISION-MAKING 204
Reviews and Practice Guidelines 183
EDUCATION AND COMMUNICATION 206
INTRODUCTION 184
Components of the Process 208
SYSTEMATIC REVIEWS 184 People Involved 208
Finding Systematic Reviews 184 Engaging the Client in the Process 208
Reading Systematic Reviews 185 Consensus Building 208
Evaluating the Strength of Systematic Reviews 186 Agreement 210
Replication 186 Decision Aids 210
Publication Bias 186 Content 210
Heterogeneity 189 Resources for Shared Decision-Making 210
DATA ANALYSIS IN SYSTEMATIC REVIEWS 190 CRITICAL THINKING QUESTIONS 213
Meta-Analyses 190 ANSWERS 214
Qualitative Thematic Synthesis 193 REFERENCES 215
PRACTICE GUIDELINES 195
Finding Practice Guidelines 197 Glossary 217
Evaluating the Strength of Practice
Guidelines 198 Index 225

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 “Facts are stubborn things; and whatever may be our wishes, our inclinations,
or the dictates of our passions, they cannot alter the state of facts and evidence.”
—John Adams, second President of the United States
1
Evidence-Based Practice
Why Do Practitioners Need
to Understand Research?

CHAPTER OUTLINE

LEARNING OUTCOMES WRITING AN EVIDENCE-BASED QUESTION

KEY TERMS Questions on Efficacy of an Intervention
INTRODUCTION Research Designs for Efficacy Questions and Levels
WHAT IS EVIDENCE-BASED PRACTICE? of Evidence
External Scientific Evidence Questions for Usefulness of an Assessment
Practitioner Experience Research Designs Used in Assessment Studies
Client Situation and Values Questions for Description of a Condition
WHY EVIDENCE-BASED PRACTICE? Research Designs Used in Descriptive Studies
THE PROCESS OF EVIDENCE-BASED Questions for Prediction of an Outcome
PRACTICE Research Designs Used in Predictive Studies
Formulate a Question Based on a Clinical Questions About the Client’s Lived Experience
Problem Research Designs Addressing the Client’s Lived
Identify the Relevant Evidence Experience
Evaluate the Evidence CRITICAL THINKING QUESTIONS
Implement Useful Findings ANSWERS
Evaluate the Outcomes REFERENCES

LEARNING OUTCOMES

1. Identify the three sources of evidence, including what each source contributes to evidence-based decision-making.
2. Apply an evidence-based practice hierarchy to determine the level of evidence of a particular research study.
3. Describe the different types of research questions and the clinical information that each type of question elicits
for therapists.

4366_Ch01_001-020.indd 1 28/10/16 2:30 pm

 2 CHAPTER 1 ● Evidence-Based Practice

had obvious advantages associated with less disruption of

KEY TERMS daily life (Dahm, Brurberg, Jamtveat, & Hagen, 2010).
Without the research evidence, the recommendation
client-centered practice random assignment for bedrest may have been difficult to challenge; bedrest
did eventually ameliorate low back pain, so clinical and
control randomized controlled client experience suggested a positive outcome. Only
trial through testing of alternatives was the accepted standard
critically appraised
paper reflective practitioner challenged.
Questioning what we do every day as health-care practi-
cross-sectional research reliability tioners, and making clinical decisions grounded in science, is
evidence-based practice replication what evidence-based practice (EBP) is all about. However,
the use of scientific evidence is limited; clinical decisions are
incidence scientific method made within the context of a clinician’s experience and an in-
internal validity sensitivity dividual client’s situation. Any one profession will never have
a suitable number of relevant studies with adequate reliabil-
levels of evidence shared decision-making ity and validity to answer all practice questions. However,
longitudinal research specificity the process of science is a powerful self-correcting resource.
With the accumulation of research, clinicians can continually
PICO systematic review update their practice knowledge and make better clinical
prevalence validity decisions so that clients are more likely to achieve positive
results.
Evidence-based practitioners are reflective and able to
articulate what is being done and why. In evidence-based
practice, decisions are not based on hunches, “the way it
INTRODUCTION has always been done,” or what is easiest or most expe-
dient. Rather, in evidence-based practice, the therapist’s
“H ow much water should you drink every day?” Most
of us have heard, read, or even adhered to the rec-
ommendation that adults should drink at least eight glasses
clinical decisions and instructions can be explained, along
with their rationale; evidence-based practice is explicit by
nature.
of 8 ounces of water each day (abbreviated as “8 ⫻ 8”), with
This chapter provides an introduction to evidence-
caffeinated beverages not counting toward the total. Is this
based practice. Topics such as sources of evidence, the
widely accepted recommendation based on scientific evi-
research process, and levels of evidence are discussed
dence? Heinz Vatlin (2002) examined the research, consulted
so that the reader can understand the larger context in
with specialists in the field, and found no evidence to sup-
which evidence-based practice takes place. These topics
port the 8 ⫻ 8 advice. In fact, studies suggested that such
are then explored in greater detail in subsequent chap-
large amounts of water are not needed for healthy, sedentary
ters. This chapter focuses on the what, why, and how of
adults and revealed that caffeinated drinks are indeed useful
evidence-based practice: What is evidenced-based prac-
for hydration.
tice? Why is evidence-based practice a “best practice”? How
The 8 ⫻ 8 recommendation is an example of prac-
do practitioners integrate evidence into their practice?
tice that is not supported by research, or “evidence.”
Such practices even creep into our professions. No doubt
there are practices that rehabilitation professionals have
adopted and accepted as fact that, although they are not as
WHAT IS EVIDENCE-BASED PRACTICE?
well-known as the 8 ⫻ 8 adage, are also ingrained in Evidence-based practice in rehabilitation stems from
practice—despite the fact that they are not supported evidence-based medicine. David Sackett, a pioneer
by evidence. of evidence-based medicine, and his colleagues provided
Let’s look at an example: For decades, the recommended the following widely cited definition: “Evidence based
treatment for acute low back pain was bedrest, typically medicine is the conscientious, explicit and judicious use
for 2 days with no movement other than toileting and eat- of current best evidence in making decisions about the
ing. A Finnish study examined this recommendation in a care of individual patients” (Sackett, Rosenberg, Gray,
well-designed, randomized controlled trial that compared Haynes, & Richardson, 1996, p. 71).
2 days of bedrest with back extension exercises and ordi- Evidence-based practice requires an active exchange
nary activity (Malmiraara et al, 1995). The study found the between researchers and clinicians (Thomas, Saroyan,
best results with ordinary activity. Subsequent research & Dauphinee, 2011). Researchers produce fi ndings
confirmed this finding, or at least found that staying active with clinical relevance and disseminate those findings
was as effective as bedrest for treating low back pain, and through presentations and publications. Clinicians then

4366_Ch01_001-020.indd 2 28/10/16 2:30 pm

Another random document with
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previously resistant; and, third, a suppurative infection, as above
described.
In contradistinction to these distinct events, separated by an
appreciable, sometimes a considerable, length of time, we recognize
a mixed infection, where two or more organisms are implanted at or
about the same time. An illustration of this is seen in most cases of
gonorrhea in which there is a synchronous attack made by the
gonococcus, which is a specific microörganism, accompanied by
staphylococci or streptococci, whose effect will complicate the case
and make it assume a less particulate type of infection. Mixed
infections may often occur in other ways, as syphilis and chancroid,
chancroid and gonorrhea, etc. Most cases of mixed infection belong
rather to surgery than to general medicine, and constitute an
apparent violation of the rule to which physicians often point—that
two distinct infectious diseases are seldom communicated or
acquired at the same time. Nevertheless, the facts remain as above.
Terminal Infections.—Terminal infections constitute an apparent
paradox, perhaps oftener in medical than in
surgical cases. Few people, as Osler has shown, die of the diseases
from which they suffer. The final exitus is due to a more or less rapid
infection which terminates life. These terminal infections are mainly
due to a few well-known microbes, such as the streptococcus,
staphylococcus aureus, pneumococcus, bacillus proteus,
gonococcus, bacillus pyocyaneus, and the gas bacillus. In surgery
such infections are, perhaps, most often seen in malignant
lymphoma, diabetes, tuberculosis, syphilis, cancer, and in the so-
called surgical kidney.

BACTERIA OF PUS FORMATION.

Bacteria which act as agents in the formation of pus are
collectively known as pyogenic organisms. These are divided into
two groups:
A. The Obligate; and
B. The Facultative.
Obligate pyogenic organisms are those whose activity is
manifested in the direction of pus formation, which seem to produce
it if they produce any unpleasant action whatever. On the other hand,
the facultative organisms are those which are known occasionally to
be active in this direction, and yet which are not always nor
necessarily so. The members of group A are fairly well known and
catalogued, and are not numerous. On the other hand, there is
reason to believe that many organisms may have the occasional
effect of producing pus, as it were, by accident or at least in a way
not absolutely natural or peculiar to themselves, but still are
frequently found when there is no pus present. A suitable list of the
facultative organisms, therefore, can hardly be made, and will not be
here attempted, the effort being only to mention the more common
organisms which play this facultative role. It may be mentioned also
that even the adjectives “obligate” and “facultative” are to be
accepted with some mental reservation, since staphylococci, for
instance, may be met with even in the absence of pus, although
nearly all that we know about these organisms implies that pus
would be the result of their presence. Furthermore, there are certain
other organisms, not, strictly speaking, bacteria, which also have the
power of producing either pus or pyoid material. These also will be
mentioned in their place. Some of them belong not only to the
vegetable, but also to the animal kingdom.
Obligate Pyogenic Organisms.—One of the characteristics of
A. The Staphylococcus Pyogenes Aureus, Albus, Citreus, the
Staphylococcus Epidermidis, etc.
the staphylococci as a group is the powerful peptonizing action
which they exert. Moreover, the chemical products of their life
changes seem to be more potent in a local than a general way,
leading to greater destruction of tissue in their immediate vicinity,
with greater inhibition of the chemotactic powers of the leukocytes;
that is, with more interference with phagocytosis, by which their
progress would be interfered with. Their presence is recognized by a
peculiar odor, as of sour paste, which should lead to a prompt
change of dressings and disinfection of the wound (by irrigation,
spraying with hydrogen dioxide, etc.).
B. Streptococcus Pyogenes and Streptococcus Erysipelatis.—These two
organisms do not differ in morphology nor characteristics, and, while
for some time considered as distinct from each other, are now by
most observers regarded as identical. The streptococci grow in
chains of variable length, and individual cocci vary in size. They grow
with and without oxygen, in all media, at ordinary temperatures, do
not liquefy gelatin, stain readily, sometimes but not invariably
coagulate milk, and vary in longevity. They differ extraordinarily in
virulence according to their sources.

Fig. 4 Fig. 5

Staphylococci in pus. × 1000. (Fränkel Streptococci in pus. × 1000. (Fränkel

and Pfeiffer.) and Pfeiffer.)

There are many streptococci not included under the above head
which are indistinguishable morphologically and in other respects,
and yet which are partly or entirely free from pathogenic activity in
man. A biological study reveals remarkable and unexplainable
transformation between the different members of this species, a part
of which may be referable to conditions pertaining to the organisms
infected, but part of which apparently pertains to the bacteria. It is
held by some that scarlatina is an invasion by certain organisms of
this class; this, however, is not yet definitely established. When
found in the stools of children with summer diarrheas they are
regarded as indicating ulceration of the intestinal mucosa.
In contradistinction to the staphylococci, the streptococci manifest
a predilection for lymph vessels and lymph spaces, along which they
extend with great rapidity. They have less peptonizing power than
the staphylococci (except in the absence of oxygen); hence
streptococcus infection assumes usually the type of widespread
infiltration rather than of circumscribed and distinct edema. One sees
remarkable instances of this in cases of phlegmonous erysipelas. It
is suggested also that the peculiar manner of growth of the
streptococci, in long chains which may coil up and entangle blood
corpuscles, has much to do with the formation of fat emboli and with
pyemic disturbances.
Both these bacterial forms have the power of producing lactic
fermentation in milk; and lactic-acid formation sometimes takes place
with suppuration in the human tissues, causing acidity of discharge,
sour odor, and watery pus. It appears also that these two pyogenic
forms have less power of ptomain or toxin formation than many
others, and, consequently, that the pyrexia attending suppuration or
purulent infiltration is not always to be ascribed to this cause alone,
for fever may in some measure be due to tissue metabolism
attending their growth, the metabolic products being pyretic. This is
in a measure substantiated by the fever attending trichinosis, where
the question of ptomain poisoning has not yet been raised.
C. Micrococcus Lanceolatus.—Micrococcus lanceolatus is also known
as the diplococcus pneumoniæ or the pneumococcus of Fränkel and
Weichselbaum, and as the micrococcus of sputum septicemia of
Pasteur and of Sternberg. It is of interest to surgeons because it
causes many localized inflammations and is a frequent factor in
causing septicemia; it is often present in the mouths of healthy
individuals. It may produce the various forms of exudates as the
result of congestion set up by its presence; also otitis media,
meningitis, osteomyelitis, and suppurative disturbance in the
periosteum, the salivary glands, the thyroid, the kidney, the
endocardium, etc.
 Fig. 6

Diplococcus pneumoniæ of Fränkel. (Karg and Schmorl.)

D. The Micrococcus Tetragenus.—Suppurations produced by these

organisms are prolonged, mild in character, not painful, but
accompanied by much brawny induration of tissues.
E. The Micrococcus Gonorrhœæ.—The micrococcus gonorrhœæ, or
gonococcus, is found constantly in the pus of true gonorrhea, in
many cases the pus being a pure culture of this organism. These
cocci are generally seen in pairs (biscuit-shaped), while their
inclusion within the leukocytes or their attachment in or to epithelial
cells is characteristic. Unlike other pyogenic cocci, they do not stain
by Gram’s method, being decolorized by iodine, by which fact they
may be distinguished. They are cultivated with difficulty, and are
known rather by their clinical effects than by their laboratory
characteristics; are human parasites, other animals, so far as known,
being practically immune. The gonococcus may also produce
abscesses, and may be carried to distant parts of the body, where its
effects are commonly noted as pyarthrosis, although endocarditis,
pericarditis, pleurisy, etc., are known to be due to it, and fatal pyemia
has been produced in consequence. In some way it is probably the
explanation of the post gonorrheal arthritis, wrongly spoken of as
gonorrheal rheumatism.
F. The Bacillus Coli Communis or Colon Bacillus.—This is an inhabitant
of the intestinal canal; varies extremely in virulence and somewhat in
morphological appearances; coagulates milk; is often associated
with other organisms; migrates easily both along the alimentary
canal and from it into the surrounding tissues or channels. It is a
disturbing element in the production of kidney and hepatic disease,
also in the production of appendicitis and peritonitis. Ordinarily its
pyogenic properties are not virulent; occasionally, however, it
becomes extremely virulent.
G. The Bacillus Pyocyaneus.—The bacillus pyocyaneus, a widely
distributed organism, often observed in the skin and outside of the
body; a motile, liquefying bacillus, growing at ordinary temperatures,
seldom seen alone, but occasionally producing pus without
association with other organisms; it stains the discharges and
dressings a bluish-green and imparts sometimes an offensive odor.
Suppuration caused by this bacillus is usually prolonged, but
characterized by little constitutional disturbance.
Facultative Pyogenic Organisms—i. e., those which have the
power of provoking
suppuration, but which have other and more distinct pathogenic
activities as well.
A. Bacillus Typhi Abdominalis.—This is found in many pus foci,
developing during or after typhoid fever. It is occasionally met with
alone, though most of these abscesses are really mixed infections. It
is generally found in the bone or beneath the periosteum. Such
abscesses are frequently seen in the ribs, and may not be noticed
until months after convalescence from the fever. The pus contained
within them is not always typical in appearance, but may be unduly
thin or unduly thick.
B. Bacillus Proteus.—Under this name are included three distinct
forms, which were originally described by Hauser as distinct species,
but which are now regarded as pleomorphic forms of the same
organism. It is a motile bacillus, met with in decomposing animal and
vegetable material, and occasionally found in the alimentary canal. It
has been known to produce pus, especially in the peritoneal cavity
and about the appendix. It may even cause general infection and
peritonitis.
C. Bacillus Diphtheriæ.—A non-motile bacillus, varying considerably
in size and shape, changing the reaction in sweet bouillon from acid
to alkaline; produces a dangerous infective inflammation of exposed
surfaces, with tenacious exudate amounting to a distinct membrane.
As a part of its life history it also produces a toxalbumin, which is one
of the most powerful cell poisons known, the disintegration of the cell
constituents due to its action being rapid and pronounced. This
accounts for the heart failures which are often reported in connection
with the disease.
D. Bacillus Tetani.—More will be said about this organism when
considering tetanus, and to that subject the reader is referred. The
tetanus bacillus is occasionally found in pus which comes from the
area through which the original infection was produced. But these
bacilli do not travel to any distance in the human body, and are
seldom found away from the area involved. Under most
circumstances the pus is the product of a mixed infection.
E. Bacillus Œdematis Maligni.—This organism will be more fully
considered under a different heading. (See Malignant Edema.) It is a
long, anaërobic bacillus, widely distributed in the soil and the feces
of animals. It is believed that this, like the tetanus bacillus, may
occasionally lead to formation of pus.
F. Bacillus Tuberculosis.—This organism likewise will receive fuller
description in an ensuing chapter. (See Tuberculosis.) The pus of old
cold abscesses in which the more obligate pyogenic organisms have
long since died usually contains this organism in mildly virulent form.
On the other hand, fresh suppurations occurring in connection with
tuberculous disease are mixed infections. There is reason to believe,
however, that this organism is capable of producing pus even when
none of these are present; for example, in that form of acute miliary
tuberculosis which is occasionally met with as bone abscess it may
be found.
G. Bacillus Anthracis.—This is one of the most malignant and
resistant organisms known, being in the highest degree poisonous
for the smaller animals, man being less susceptible. One of its
characteristic lesions in the human body is a form of pustule
commonly known as malignant pustule, the pus in which is usually a
pure culture of this organism. (See Anthrax.)
H. Bacillus Mallei.—This is the organism which produces glanders in
the lower animals and in man. That form of the disease known as
farcy, in which the infected nodules rapidly break down, is likely to
contain pus which will be more or less a pure culture of this
organism.
I. Bacillus Lepræ.—This is the microörganism which produces
leprosy, closely resembling the tubercle bacillus. It is constantly and
exclusively present in the lesions of leprosy, which are often of the
suppurative type, the bacilli being enclosed within pus cells; it is also
found in the fluid surrounding them. Although suppuration in these
cases may be in a large measure due to secondary infection, it is
positive that the leprous bacilli deserve to be grouped in this place.
J. The Bacillus Pneumoniæ of Friedlander.—The bacillus pneumoniæ
of Friedländer was at one time regarded as the cause of croupous
pneumonia, which is now known to be due to the micrococcus
lanceolatus. The Friedländer bacillus, however, is capable of
producing bronchopneumonia, and is occasionally met with in
empyema, suppurative meningitis, and inflammations about the
nasopharyngeal cavity, of which it is known to be an occasional
inhabitant.
K. The Bacillus of Rhinoscleroma.—A distinctive organism has been
described for this disease and given this name. It has such wide
morphological differences, however, that it is possible that it is only
the bacillus of Friedländer above mentioned. At all events, an
organism of this general character is constantly found in this disease
in the thickened tissues from the nose (Fig. 8).
L. The Bacillus of Bubonic Plague.—This was recently discovered by
Kitasato, and, in view of the recent ravages of the disease in the
Orient, has assumed considerable importance. It grows upon most
media, and is found in the blood, in buboes, and in all internal organs
of patients suffering from this disease. The smaller animals are
susceptible upon inoculation. Animals fed with inoculated foods die
also, showing the possibility of infection through the intestine. When
exposed to direct sunlight for a few hours the bacillus dies. The
general symptoms of the disease are those of hemorrhagic
septicemia and its consequences.
M. The Bacillus of Rauschbrand.—This is seldom, if ever, seen in this
country. It is known in England as “the black-leg” or “quarter-evil.” It
is an anaërobic organism, frequently met with in cattle, which causes
a peculiar emphysema of subcutaneous tissue, spreads deeply, and
is followed by a copious exudate of dark serum with gas formation.
The smaller animals are not ordinarily inoculable; but if to the culture
material there is added 20 per cent. of lactic acid, their
insusceptibility is overcome and they succumb to the disease. So,
also, as in the case of the tetanus bacillus, by addition of the bacillus
prodigiosus or of proteus vulgaris the disease may be produced in
otherwise insusceptible animals.
N. The Bacillus Aerogenes Capsulatus.—The bacillus aërogenes
capsulatus seems capable sometimes of causing pyogenic and even
fatal infection. Its presence is associated with gas formation. It grows
as an anaërobe.
O. The Bacillus of Chancroid.—The bacillus of chancroid identified by
Ducrey, and briefly described in the chapter on that subject.
 Fig. 7 Fig. 8

Rhinoscleroma: infiltration of tissues Bacilli of rhinoscleroma. × 1000.

about the nose. (Case reported by Dr. (Fränkel and Pfeiffer.)
Wende, Buffalo.)

YEASTS.
Busse was the first to call attention of clinicians and pathologists to
the role played by yeasts in certain infections. Since the original
observations of Busse in a case in which the organism produced a
general infection, the lesions of which were a combination of tumor
and abscess formation, various observers have noted the presence
of pathogenic yeasts, usually in skin lesions. Gilchrist and Stokes
were the first in this country to determine the nature of these
organisms, and their observations have been followed by the
detection of a large number of similar cases. In the skin lesions the
organisms are found in minute abscesses; in the subcutaneous
tissue and in the infections similar to those of Busse large abscesses
surrounded by extensive masses of granulation tissue characterize
the infection. The organisms can be detected in the pus by means of
an examination of the fresh unstained fluid (Fig. 9).
 FUNGI.
Besides the micro-organisms everywhere grouped as bacteria,
there are other minute organisms which have also the power of
engendering pus. One of these is the ray fungus, known as the
actinomycis, which causes the disease known as lumpy jaw or
actinomycosis. Suppuration is always a concomitant of the advanced
lesions of this disease, and, while it may be in many instances a
mixed infection, it is not necessarily so. Moreover, the pus produced
under these circumstances contains minute calcareous particles
which are pathognomonic, by which a diagnosis can sometimes be
made off-hand.
Besides these fungi, others, belonging rather to the class of
vegetable molds, which are yet pathogenic for human beings, may
be occasionally met with under these circumstances—e. g., the
fungus of Madura foot, the leptothrix, and other molds from the
mouth, while the different varieties of aspergillus may be found in
pus about the ear or even in that from the brain.

PROTOZOA.
The protozoa have the power of producing, if not absolute ideal
pus, something so nearly resembling it that we may include them
among the facultative pyogenic organisms. The best known of these
protozoa are the amebæ, which are met with in the intestinal canal in
some countries, occasionally in the United States, especially as the
exciting causes of a peculiar type of dysentery often accompanied by
abscess of the liver. In these abscesses the amebæ are found, and
no other organisms. Another group of the protozoa, known to
biologists as the coccidia, are also capable of causing pus formation,
more particularly in some of the lower animals. Numerous other
parasites, belonging higher in the animal kingdom, are undoubted
exciters of pus formation, though it is not necessary to lengthen the
list beyond those already mentioned.
 Fig. 9

Blastomycetic pus (fresh). × 1000. (Gaylord.)

Protozoa have recently been established as the active agents in

the production of smallpox and probably also of scarlatina. They
have been seen so generally in and around cancer cells as to make
it extremely probable that cancer is a protozoan infection. In syphilis
also they are found as the spirochetæ, now regarded as its cause.
 Protozoa are as ubiquitous as bacteria, but their recognition is as
yet more difficult, as but little is known of them. The numerous
stages through which they pass in completing their life cycles only
complicate the subject, while the difficulties encountered in
cultivating them are still to be overcome. As we become more
familiar with them we shall more frequently find them to be
pathogenic organisms.

CLINICAL CHARACTERISTICS OF PUS FROM DIFFERENT

AGENCIES.
Staphylococcus.—Dirty white, moderately thick, with sour-paste
odor.
Streptococcus.—Thin, white, often with shreds of tissue.
Colon Bacillus.—Thick, brownish, with fetid odor, or thin, dirty
white, with thicker masses.
Micrococcus Lanceolatus.—Thin, watery, greenish, often copious.
Bacillus Pyocyaneus.—Distinctly green or blue in tint.
Bacillus Tuberculosis.—Thick, curdy, white paste, or thin, greenish,
with small, cheesy lumps or even with bone spicules.
Actinomycis.—Thick, brownish white, with small, firm, gritty or
chalky nodules of yellow color.
Ameba Coli.—Thick, brownish red.

BACTERIAL DETERMINATION AS AN INDICATION IN

TREATMENT.
There is a practical side of great importance pertaining to the
recognition of the nature of the infectious organism in many cases of
suppuration and abscess. For instance, pus which is due to
streptococcus invasion indicates a collection which should be freely
evacuated and carefully drained. This is also true in essential
respects of staphylococcus pus, particularly that due to the
streptococcus aureus. Putrid pus from any source requires
disinfection and free drainage, the former preferably perhaps by
hydrogen dioxide. Pus which is due to the colon bacillus is not often
extremely virulent, which accounts for so many cases of appendicitis
recovering with or without operation. A collection of this pus needs
little more than mere drainage and opportunity for escape. Pus from
a recognizable tuberculous source may still contain living tubercle
bacilli. This means either that the cavity whence it came should be
completely destroyed and eradicated, or else that the margins of the
incision or opening through which it has escaped should be so
cauterized that infection of a fresh surface is impossible. The same
is true of abscesses due to glanders bacilli and to certain cases of
suppurating bubo following chancroid, where the whole course of
events shows the virulent character of the organisms at fault.

SUPPURATION.
Although it may be possible to produce in certain laboratory
experiments metamorphosed material which very closely simulates
pus, or, in fact, by injection of chemical irritants, to sometimes imitate
the suppurative processes, nevertheless, the student should be
brought face to face with the statement, to which for surgical
purposes there is no practical exception, that suppuration, i. e.,
formation of pus, is due to the presence in the tissues of the specific
irritants already catalogued and described, and of the peculiar
peptonizing or other biochemical changes which bacteria exert upon
living animal cells.
Coagulation Necrosis.—Coagulation necrosis is the term applied
to the characteristic changes occurring in
the tissue cells when thus attacked, which may be summarized as a
fading away of cell outlines, diminution in reaction to reagents, and a
merging of cells and intercellular substance. Coagulation necrosis is
not the only result of bacterial activity, but may be produced by other
causes. Nevertheless, pyogenic bacteria do not exert their
deleterious action upon the tissues without occasioning changes
included under this term. In an area thus infected, as already
described, leukocytes, i. e., phagocytes, are present in increased
number for purposes already mentioned. As we approach the centre
of activity phagocytes are more numerous than cells, and
intercellular barriers completely break down. When bacteria are
found in greatest number, there also occurs the greatest phagocytic
activity, and there also will be found the evidence of suppuration,
i. e., pus. As already indicated, the polynuclear leukocytes are most
active in the process of defence. Where coagulation necrosis is most
marked there has been the greatest activity of conflict with the
greatest death of cells. Around these areas bacteria and cells are
found in indiscriminate arrangement. Tissue vitality is impaired by
intoxication of the cells by the excretory products of the bacteria,
i. e., the so-called ptomains, toxins, etc., and their power of
resistance is thus weakened. From the mechanical results of
pressure tension around the centre of activity is increased, by which
tension vitality is still more impaired and more rapid tissue death
occurs. Thus there occurs migration or burrowing of pus; or, to state
it more clearly, the tissues break down in front of the advancing
destruction, and in the direction of least resistance. This is known as
the pointing of pus, which brings it many times to the surface, and
often in other and less desirable directions.
Abscess.—An abscess is a circumscribed collection of pus. The
term is used in contradistinction to purulent infiltration, in
which the collection is not circumscribed, but is exceedingly diffuse
and extends itself in various directions, the amount at any spot being
almost inappreciable. Purulent infiltration is regarded as the more
serious of the two conditions, as it is more difficult for pus to escape
under these circumstances than when it can be evacuated through a
single opening. The term phlegmon is one now generally used to
indicate a suppurative process, usually of the general character of
purulent infiltration rather than of abrupt abscess, but generally
employed to include both conditions. The adjective phlegmonous is
coupled with the names of other surgical infectious diseases to
indicate that it is complicated by suppuration, e. g., phlegmonous
erysipelas. Pus is a product of bacterial activity usually formed
rapidly rather than otherwise, and abscess formation or
phlegmonous activity of any kind is a question of but a few days.
Empyema means a collection of pus in a preëxisting cavity.
The significance of this condition is well described in the story of
inflammation and suppuration, to paraphrase Sutton, read
zoölogically, as though it were the story of a battle: The leukocytes
(phagocytes) are the defending army, the vessels its lines of
communication, the leukocytes being, in effect, the standing army
maintained by every composite organism. When this body is invaded
by bacteria or other irritants, information of the invasion is
telegraphed by means of the vasomotor nerves, and leukocytes are
pushed to the front, reinforcements being rapidly furnished, so that
the standing army of white corpuscles may be increased to thirty or
forty times the normal standard. In this conflict cells die, and often
are eaten by their companions. Frequently the slaughter is so great
that the tissues become burdened by the dead bodies of the soldiers
in the form of pus, the activity of the cells being proved by the fact
that their protoplasm often contains bacilli in various stages of
destruction. These dead cells, like the corpses of soldiers who fall in
battle, later become hurtful to the organism which, during their lives,
it was their duty to protect, for they are fertile sources of septicemia
and pyemia. This illustration may seem romantic, but is warranted by
the facts.
Around the margin of the site of an acute abscess a barrier is
formed by condensation and cell infiltration of the surrounding
tissues. This is not a distinct wall nor membrane, yet, nevertheless,
serves as a sanitary cordon to confine the mimic conflict within
reasonable bounds. This is the zone of real inflammation; within it
there are tissue destruction and coagulation necrosis. By virtue of
the peptonizing power of the pyogenic organisms the parts involved
in this necrosis gradually liquefy the intercellular substance
dissolving first. It is this which in the main forms the fluid portion of
the pus. Various tissues show widely differing resistance to this
softening process. In true glands the interlobular septa seem to
break down first, and in this way suppuration extends around the
acini or gland lobules, and thus pus may contain masses of easily
recognizable size. These masses are ordinarily known as sloughs.
It is by virtue of the so-called lymphoid cells, which are those
principally involved in producing the barrier or boundary of the acute
abscess as above described, that granulation tissue is formed, which
takes up the effort of repair as soon as pus is evacuated. This
boundary has no sharp limit, but shades off into healthy surrounding
tissues.
 Under the term “abscess” is meant that which is described as
acute abscess. Under certain circumstances, especially when they
are produced by the facultative pyogenic organisms rather than the
obligate, abscesses form more slowly, and may be spoken of as
subacute. These are terms used in contradistinction to the so-called
cold abscesses, which, although clinically bearing a certain
resemblance to the acute, are in almost every pathological respect
different from it. Cold abscesses will be considered under the head
of Tuberculosis. It is possible to have an acute pyogenic infection of
a cold abscess; in such case we have acute manifestations.
Gravitation abscesses are those where pus forming in one part tends
to migrate, usually in the direction in which gravity would take it,
extending into portions deeper or lower. Perhaps the best illustration
of this is the pointing of a psoas abscess below Poupart’s ligament.
Metastatic abscesses are those which are formed as the result of
embolic processes, each one being in miniature a repetition of a
lesion which has occurred at some other part of the body. The
underlying fact concerning metastatic abscesses is that the primary
process has occurred in some other portion of the body, whence it
has been distributed as above. These will be considered in the
chapter treating of Pyemia.
The product of all acute suppurative lesions is pus. This is an
opaque fluid of creamy consistence and whitish or grayish
appearance, varying in density, met with in amounts from a minute
drop to half a gallon or more. Under ordinary circumstances it is
odorless, and its reaction, either acid or alkaline, is very faint. It is,
like the blood, composed of a fluid and a solid portion. The solid
portion consists of so-called pus corpuscles and other debris of
tissue, which vary with the site of the disease and the parts involved.
The source of the pus corpuscles has been cited and the statement
made that they are in effect the bodies of phagocytes which have
perished in the biochemical fight for existence of the parent
organism. Cocci or bacilli are found in pus corpuscles and also in the
surrounding fluid.
Pus should be without odor, but under certain circumstances it
possesses an odor which will vary in character according to the
source of the pus or the nature of its principal bacterial excitant. Pus
from the upper end of the alimentary canal frequently has the sour
smell of gastric contents; that from the neighborhood of the lower
end, the fetid odor which is for the most part due to the action of the
colon bacillus. Inasmuch as colon bacilli are found in widely distant
parts of the body, they may also give an unpleasant odor to pus even
from a brain abscess. When the pus has become contaminated with
the ordinary saprophytic organisms, it may smell like any other
decomposing material. The older writers called it ichorous pus, while
sanious pus was supposed to be that more or less mixed with blood,
undergoing ammoniacal decomposition or else strongly acid. Pus
sometimes has a well-marked blue or bluish-green tint. This is due to
the presence of the bacillus pyocyaneus, already described. An
orange tint is sometimes given by the presence of hematoidin
crystals, due to the original hemorrhagic character of the infected
exudate. The former appearance indicates usually a slow course to
the suppurative lesion, while the latter has been regarded by some
as affording an unfavorable prognosis. Distinctly red pus, whose tint
is due to the presence of a bacillus giving bright-red cultures on
blood serum, has been noted in other instances. This can readily be
distinguished from blood, because upon dressings it does not
change color.
Pus may form superficially, when it is called subcutaneous
suppuration, in which case there is a minimum of pain, because
tension is not great and the distance to the surface is short.
Collections which form beneath the fasciæ, especially the deeper
fasciæ of the limbs and trunk, give rise to much more extensive
disturbance, both locally and generally, and frequently do not point
for many days; or, instead of pointing, burrow deeply and find their
outlet at some undesirable point. These are known as subfascial
collections. Subperiosteal abscesses give rise to still more pain,
because of the unyielding character of their limiting structures, and
the symptoms caused by them are acute and distressing.
An illustration of the pain which may follow deep suppuration may
also be seen in the ordinary panaritium, or bone felon, where the
path of infection is from without, but the destructive lesion is confined
within absolutely unyielding tissues, at least at first. Along certain
tissues infection spreads with rapidity. This is particularly true of the
delicate areolar tissue seen between tendons and tendon sheaths,
and the infectious process may follow this tissue wherever it shall
lead, even along complex courses.
The question often arises, Can pus be resorbed? There is no
question but that small amounts of pus are disposed of by
phagocytic activity, and the disappearance of purulent infiltration,
under the influence of favoring remedies, or even when let alone, is
not infrequently noted. True pus resorption is a question of
phagocytic possibilities, and can occur only in very limited degree, as
a result upon which it is not safe to count, and which is capable of
encouragement only up to a certain point.
One inevitable law seems to govern collections of pus, that when
they advance or migrate in any direction it is in that of least
resistance. This causes them to take peculiar and sometimes
disastrous courses, but it is a law which is never violated. It leads to
the bursting of abscesses into the brain, into the pleural cavity, into
the peritoneal cavity, the bowel, and elsewhere; it leads to a
condition where pus may travel along a path even a foot or more in
length, rather than come to the surface, a distance of perhaps an
inch, and affords one of the best reasons for early operative
interference so that the disastrous effects of burrowing may be
obviated. When the pus is limited to a drop or fraction thereof the
abscess is called a furuncle, especially when in the skin. The
average “boil” of the layman is a subcutaneous or subfascial
abscess. When the infiltration is pronounced, and when there has
been more or less extensive destruction of tissue, with perhaps
formation of numerous outlets for the escape of pus and detritus, it is
known as a carbuncle. (See Chapter XXVI.) In certain conditions
small superficial furuncles or boils form, sometimes in great number
and almost synchronously, or, as it were, in crops. This condition is
known as general furunculosis.
Signs and Symptoms of Abscesses.—The appearances by which pus
may be suspected or detected are those of congestion and
hyperemia, more or less abruptly circumscribed and markedly
accentuated. Along with these there is more or less edema or
edematous infiltration of the skin and overlying tissue, which permits
of that peculiar appearance known as “pitting on pressure.” Often,
too, there is a distinctly edematous swelling of the parts, especially
around the margin, with brawny infiltration of the centre of the
infected area. Numerous vesicles occasionally are noted upon the
skin, which may be filled with reddish serum. When softening and
pus formation occur, there is a condition which to the palpating
fingers gives the characteristic sensation known as fluctuation.
Fluctuation simply points out the presence of fluid beneath; but when
in an area marked as thus described fluctuation is noted, it means
the presence of pus. It is detected by manipulating in a direction
parallel to and concentric with the axis of the limb or part. The pain is
also in most instances significant; patients speak of it as having an
intense and throbbing character. With these local signs occur
symptoms indicating some degree of septic intoxication, i. e.,
pyrexia, chills, malaise, sweats, etc., which are corroborative
indications, their intensity being a reasonably correct index of the
severity and gravity of the local infection.
When a deep-seated abscess is suspected a careful blood count
will often permit a diagnosis to be made. This is conspicuously true
of cases of appendicitis. If leukocytosis is established there should
be immediate operation. (See Chapter II.)
It is seldom that a superficial collection of pus can be mistaken for
anything else. In small and superficial abscesses (boils, furuncles)
as pus approaches the superficial layer (epidermis) of the skin it may
be discovered through its thin covering. In deep lesions there is often
a doubt, even on the part of the most experienced. The measure
now usually resorted to for purposes of diagnosis and exact
recognition is the exploring or aspirating needle. The old exploring
needle was one of good size, having a groove along which, after
introduction, pus might pass. Since the almost universal use of the
hypodermic syringe, a small aspirating needle attached to the
ordinary syringe is the measure commonly adopted. Such a needle
may be introduced into the brain, into the liver, or into almost any
and every soft tissue without danger, and if properly manipulated is
almost sure to facilitate detection of pus. Exploration done with either
of these means and for this purpose should always be conducted as
an aseptic, even if a minor operation, in order that no extra infection