hello my name is nicole clark and i am on the membership committee of the apta kansas i am also an assistant professor at the university of st mary in leavenworth kansas and it is my intention with this video to take you through critical appraisal of two interventional studies using the pedro scale but first i want to give you a little bit of information about this video so this video is intended to reacquaint physical therapists or physical therapist assistants with the pedro scale some of us may be a little bit further removed from our entry level education and maybe we haven't picked one of these up in a while and we haven't actively gone through the process of critical appraisal but it's something that you might want to do so this video is just going to take you through the steps especially if it's been a little bit of a little bit of time has passed since you have looked at a pedro also if you haven't read the articles that are attached to this video please pause the video go ahead read the articles and administer the pedro scale and then you can go ahead and resume the video because we will go through the answers item by item for each of the articles the pager scale was developed more than 20 years ago by physical therapists or as they refer to themselves as physiotherapists at the university of sydney and everything you need to complete a page row is in the methods and results section the methods and results sections are the most objective sections of the research article you're stating exactly what you did and you're stating exactly what you found there's really not a lot of room for the researcher's opinion to be interjected like it could be in the introduction and discussion now i'm not saying that bias is always present in the introduction and discussion but it's more likely that bias will be present in those sections on the pedro scale there are 11 items but the score is only out of 10 so only items 2 through 11 are used in scoring item number 1 pertains to external validity or generalizability of the study but again is not included in the scores items two through nine pertain to the internal validity of the study in establishing a cause and effect kind of relationship between the independent and dependent variable and items 10 and 11 pertain to statistical conclusion validity essentially do we have enough statistical information to draw valid conclusions about the findings so here i have some images of the pedro scale and i want you to notice that on the following page the second page of the pedro scale they have what they call notes on administration of the pager scale and so it describes what it means to meet each of the criteria all one through 11 of them and so you don't always have to know exactly what these terms mean in the items to be able to critically appraise an article so if you don't exactly remember what intention to treat analysis is from your entry level program that's okay because on the second page you can go to criteria nine and it will tell you what it means to meet that criteria so it's pretty handy i don't know that everyone knows that this is available and i think it removes a little bit of an intimidation barrier from administering a pedro scale to a research article before we proceed any further with the first article i want to just give a little bit of a disclaimer and it's that just because a study has a high pedro score and a significant treatment effect it doesn't necessarily mean that we should adopt this treatment into our clinical practice there are a lot of other things to consider that are beyond the scope of this video but things such as effect size clinical significance as opposed to just statistical significance your clinical circumstances your cost effectiveness all of these things need to be considered before adopting an intervention we shouldn't just look at a single article and make decisions based on the results as to whether or not we're going to adopt this in our clinical practice i attended a really interesting session at combined sections in 2021 and it was all about the importance of critical appraisal for research articles so you might be asking yourself at this point critical appraisal so what why is she taking the time to make this video and there are several reasons but i've put two on this slide and the first is that readers of research articles need to be aware of spin and so you've probably heard that term before with people putting their their spin on something putting their own kind of bias on it putting their own kind of personal flair and so what researchers found was that spin is present in 98 of abstracts and 83 percent of articles on intervention for back pain so most likely subconsciously and unknowingly the researchers are inserting a little bit of their personal opinion and personal bias when writing up those articles and we try to be as objective as possible but sometimes it is really challenging to remove all of your bias 100 and the second is that less than 50 percent of physical therapists can critically appraise articles and this comes up consistently in the literature with varying percentages but they tend to hover around 50 percent and what other researchers have found is that the lack of critical appraisal skills is among the top five reasons for not implementing evidence-based practice so there's all this great evidence out there and we publish journals monthly trying to disseminate information from newer studies and the lack of critical appraisal skills is creating a barrier between physical therapists implementing these newer interventions or just kind of staying what has staying with what has worked for them so far the first article we're going to discuss was published in neurology back in 2014 and it is about using mirror therapy in unilateral neglect after a stroke so again i strongly encourage you to have read this article and filled out the pager scale on your own before we go ahead and go through the answers so if you haven't done that yet and you'd like to please feel free to pause this video read the article with the pedro scale and then come back to resume to go over the answers the first item on the pedro scale is whether or not eligibility criteria were specified and recall that this is the only item on the scale that is not computed as part of the final score it has to do with the generalizability of the study not necessarily the internal validity and statistical conclusion validity so in order to meet this criterion the article must provide the source of the participants as well as the list of criteria to determine if someone is eligible so did the researchers in the must trial article do this and the answer is yes they did under the methods section under the participants subheading they said that they conducted the study at a stroke unit of christian medical college and hospital in india so the location or the source of the patients was provided they also went on to describe their inclusion criteria that you can see in green and their exclusion criteria that you can see in red the second criterion has to do with random assignment essentially we want to know were subjects randomly allocated to their groups and the purpose of random assignment is to for lack of better words level the playing field we want to make sure that all of the traits and prognostic indicators across all patients are evenly distributed among groups and if they are not evenly distributed even though we did random assignment we assume that it is due to chance so this criterion is satisfied if the report states that allocation was random however the method that they used does not need to be specified simply stating that allocation was random is enough to satisfy this criterion and these researchers did meet this criterion so they said in their report that all eligible participants were randomized to either the mirror therapy group or a sham mirror therapy and in this case they did say how they did it they used a random allocation sequence using using a specific software the third criterion pertains to concealed allocation and so what we want to know is if the person determining eligibility for each participant was aware or unaware we want them to be unaware to which group the participant would be assigned and so this helps prevent selection bias because a researcher could put certain participants in the intervention group if he or she thinks there's going to be a favorable outcome or put someone in the control group if they don't think there's going to be a favorable outcome so it removes the bias that is would be inserted by not having concealed allocation and this criterion is satisfied if the researchers state that allocation was using sealed opaque envelopes or that it was performed off-site these researchers did conceal allocation and you can find this in the methods section under the randomization subheading and after it names the software that they used for their random allocation they said that it was conveyed the information was conveyed to the investigators using sealed numbered envelopes the fourth criterion is were the groups similar at baseline and so what we want to know is if at least one measure of the severity of the condition and one different key outcome measure are described and judged to be equal by the reader what that means is we don't think any differences that were observed would affect the outcomes so this criterion is satisfied even if only baseline data of study completers are provided these researchers did meet this criterion you can see in table 1 they provided a lot of information and they divided their information by treatment group and control group and you might say to yourself but there are no p values how do we know if there is a significant difference and there has been a shift recently towards not including p-values in studies where there was randomization because if there's randomization we assume that the groups are equal at baseline and any observed difference is due to chance so we don't have the p-values telling us if there is a significant difference but you can look at each item in this table and look at the values for the treatment group and values for the control group and decide for yourself whether or not you think it would influence the outcomes items number five through seven have to do with blinding and so we'll tackle number five first they want to know if the participants if all participants were blinded did they know to which group they had been allocated and this one can be a little bit tricky because the researchers can sometimes claim that there was blinding on behalf of the participants however participants are only considered to be blinded if they are unable to distinguish between the treatments that are applied to the different groups so you sometimes have to ask yourself if they claim that there was blinding if i was a part of this study would i be able to distinguish between these two uh different types of interventions or the the difference between the two groups while we can't be 100 sure that the participants were not blinded we can probably assume that participants were able to tell if they were getting a mirror therapy or if they were getting a sham mirror therapy in research you have to inform your participants anytime there is a control group so if the participants were aware that there was mirror therapy and some kind of control they would probably know which group they were in so because of that we cannot give a point for this criterion next we're looking at whether or not the therapists were blinded and in physical therapy research or in journals that publish physical therapy research sometimes it's not a therapist but it's just a person delivering the intervention and so we want to know do the people delivering the interventions know to which group the participants had been allocated and this can be another tricky one like with the participants because we can claim that there was blinding however if the therapists are aware or they can tell the difference between the two interventions then how can they possibly be blinded so they're only blinded if they're unable to distinguish between the treatments that are being applied to different groups the researchers did not satisfy this criterion in this particular article so in their section under control it says that the control therapy was given by the same physiotherapist so that individual had to be aware of which intervention they were delivering in order to deliver the right one so it is impossible for that physiotherapist to be blinded so we cannot give a point for this continuing with blinding criterion 7 has to do with blinding of the raiders or the assessors we want to know if they were blinded for at least one key outcome so did they not know to which group the participants had been allocated and this can be a little bit tricky in studies using self-report measures because the assessor is essentially the participant themselves so the raters are only considered to be blinded if the participants are blinded in that same study these researchers did have blinding of the raters in this case they had one rater who was unaware of the group assignments assessed the outcome at one three and six months so their primary outcomes were not self-report measures it was the star cancellation test the line by section test and the picture identification tasks those are more task-oriented outcome measures so even though the participants themselves weren't blinded they were not self-reporting their outcomes so yes they did have a blinded rater in this study moving on to criterion number eight we want to know if there was a key outcome that was measured and greater than or equal to 85 of participants so in order to satisfy this criterion the report must state both the number of participants initially allocated and the number of participants who got the outcome measures or who did the outcome measures and so most of the time we can find this in the consort flow diagram which you'll see on the next slide so the reason it's 85 is because we want to make sure that enough people finished the study to reach valid statistical conclusions so if there was a significant difference is it because one group had 50 dropouts or is it because there really is a difference in treatment effect between whatever was being studied so it is greater than 85 percent of subjects that we're looking for i also want to state that this criterion is satisfied if 85 of people attend follow-up to at least one point in time in a case like a study like this where they have multiple follow-up episodes so they followed up at one month three months and six months and so we're really only looking for if this 85 threshold was met at least one point in time so this is the consort flow diagram that i mentioned previously most reputable journals nowadays are requiring something like this and what you get to see is how many participants potential participants were approached how many were excluded and why how many participants were randomized to each group and then we can follow that group down each line and get to how many were included in the analysis so if we look at the 27 and 21 the total of 48 that were randomized we only lost one from each group that were not included in the analysis so yes these researchers did meet this criterion criteria number nine is if all participants received treatment as allocated or did the researchers use intention to treat analysis in the case that not all participants receive treatment as allocated ethically speaking if there is a control group or actually can happen in either group participants can switch groups at any time for any reason without penalty and so this can make the analysis a little bit muddy but to minimize bias the researchers will use intention to treat analysis they can also use it when there are dropouts so this is a statistical analysis that's performed as if the participants received the treatment from the group to which they were initially allocated and this criterion is satisfied even if the report doesn't specifically mention intention to treat analysis but it states that everyone received the treatment according to the group where they were initially allocated so some people think intention to treat analysis has to do with the sham group or the control group getting the intervention at the conclusion of the study and essentially intending to treat the control group and it's not it's actually a type of statistical analysis that we use to minimize the bias that comes with the analysis when we take a look at the text and we compare it to the consort flow diagram we get some mixed messages so this one is kind of a maybe but if we're being honest if it's not clearly met it's probably going to be counted as a no so the researchers stated that they used a modified intention to treat principle and that missing values were they used the last observation carried forward method so if somebody attended the one month follow-up and received a certain value on their test but they didn't show up for the three-month follow-up they would carry the last observation forward through the conclusion of the study so when we had 27 allocated to the treatment group it says that there are only 26 in the analysis it's not really clear what they did with the one person says it was excluded from the analysis so it doesn't really fit with what they put in the text and the same thing is true with the control group they analyzed 21 for one outcome measure but for everything else it was 20 and they stated that they excluded one individual from the analysis so this is an example of where what the researchers say doesn't 100 percent match what they may have actually done so i give this one i'm going to give this one a no but uh for the for the purposes of the pedro scale it's going to be a no but i actually don't know what they did and would like a little bit more clarification in order to possibly give them a yes if i'm misunderstanding what they're writing item number 10 pertains to between group statistical comparison for at least one of the key outcomes so the bar is set kind of low if they looked at four outcomes but they only did a between group comparison for one technically it still meets this criterion so this is satisfied if you can find a p-value in the report or an estimate at its confidence interval of a between group comparison for like i had said one key outcome the researchers did meet this criterion they chose for simplicity's sake to show a lot of their information graphically so we can see a bar chart over here for the star cancellation test where they have the mean change as well as a 95 confidence interval it is stated down there in the subtext that those are what those values mean and they also included a p-value so they included a lot of information here just in this individual table but they also had supplemental materials that are available online i was unfortunately unable to access that but i'm sure it's full of a lot of information that could not possibly fit in the word count or in the page constraints of what a journal would publish so yes they did meet this criterion last but not least criterion number 11 we are looking for point measures and measures of variability for at least one key outcome so what is a point measure a point measure is usually a mean median or mode it is the best estimate of a true score measures of variability they are usually a standard deviation or confidence interval with median or i'm sorry ordinal data we might see an interquartile range you can also use the standard error or just a simple range so this can be provided graphically as long as it is clear if the error bars represent standard deviation or standard error and if there's categorical outcomes this criterion is considered satisfied if the number of each participants in each category is given for each or all groups the researchers did meet this criterion you can see it's the same table from the previous answer slide it's the star cancellation test and so they do have values point measures so the best estimate so that would be the top of the bar and those little things that look like eyes those are the 95 percent confidence interval so it's very clear what we're looking at based on the description below the table and so if this information is provided graphically it meets the criterion as long as it's clear as long as the researchers state what it is that we're looking at and i'm also assuming that there are more concrete kind of actual values and numbers in the supplemental material which unfortunately i was unable to access so what is the final pedro score uh what is the overall study quality so you're going to take all of your yeses for items 2 through 11 and add those up count those up and so you should get a score out of 10 and based on where that falls from 1 to 10 you can get an idea of the overall quality so the final score yes we did have random assignment we had concealed allocation we had similar groups at baseline we did not have blinding of participants or therapists we did have blinding of the raiders however we had our 85 participants get measured for one key outcome we're unclear on the intention to treat analysis so we're going to say no and we had between group statistical analysis and point measures and measures of variability so if you count that up that gives you a score of a seven out of ten so are there general categories or kind of thresholds we want to reach for what's considered a good study there's nothing hard and fast but there are some guidelines that we can use so if it's less than or equal to three we consider that to be poor quality the researchers did not do as much as they may maybe could have done to control the threats to internal validity if it's a four or five it's considered fair and if it is over a six is considered high quality so our score of 7 out of 10 is considered high quality research despite you know some of the challenges they did do a really good job of controlling threats to validity all right so one down and one to go we are going to look at this study the effects of pilates exercise on rectus abdominis thickness and balance in healthy female healthcare workers so this study was published in 2017 so a little bit more recent than the previous study that we just went through and like i had said previously if you haven't taken the time to read the article and go through the pager scale on your own i strongly encourage you to pause the video and go ahead and do that so we could go through the answers together okay item number one is whether or not the eligibility criteria were specified and i'm going to spend a little bit less time introducing each criterion since we talked about it in the first part of the video and i want to be efficient and respectful of your time so remember that they must list the source of the participants as well as the criteria to determine if someone is eligible and that usually comes in the form of inclusion and exclusion criteria whether it's listed in the text or a part of a table the researchers did provide enough information to meet this criterion they said that 40 healthy female health workers were included in the study so just a couple of inclusion criteria their exclusion criteria were various comorbid conditions being under age 18 because of consent and the issues of being an adult versus not being an adult with consent previous surgeries etc and they did provide the location although it's not highlighted on my slide here this study took place in istanbul physical therapy and rehabilitation training and research hospitals uh back in 2010 so they did provide enough information to meet this criterion item number two is random assignment were the participants randomly allocated to groups and recall that random assignment helps make sure that the groups are equal in all prognostic indicators at baseline so they're all starting in the same place and this is satisfied if the report states that allocation was random but they do not need to specify exactly what they did the researchers did not meet this criterion you can see in the consort flow diagram that they use the terminology convenient randomization and that is not really a true form of randomization but if you look over into the text it says these individuals were separated into groups according to their availability from working time and it resulted in equal sized populations in each group so the groups did end up being equivalent with this method of assignment that they used and they indicate in the text that it was not randomization true randomization however they did call it randomization in their consort flow diagram so this is another instance where you need to look multiple places to get a good idea of what the researchers actually did the next criterion is concealed allocation recall from earlier that this prevents selection bias meaning we're not going to assign people to groups based on whether or not there's going to be a favorable outcome or we're not going to accept or reject certain participants because we don't think they will meet the goals that we have in mind for our intervention so the person determining eligibility should not be aware to which group this person will be assigned in this study the researchers did not meet this criterion they had a polyclinic secretary do the allocation to groups and they stated that she was blinded to the study however she was not blinded or she was aware of to which group these participants were going so based on the information that was provided in the study there was not concealed allocation criterion number four is were the groups similar at baseline so remember with randomization we can assume that the groups are equal at baseline and any differences we observe are due to chance because there was not randomization in this study we cannot assume that all traits would be evenly distributed so we probably need to take a closer look and so we're looking at one measure of severity and one different key outcome measure are they judged to be equal by the reader meaning they won't affect the outcomes the researchers did provide enough information to meet this criterion and this criterion is satisfied only even if only baseline data of study completers are present so they did do this in table four and table five those are the data for the study completers and you can see that there are no p values because the researchers did not do a between group comparison at baseline so we can look at the data ourselves and say okay is there a difference between the pilates group and the control group that we think might justify a difference in outcome did they start at the same place or did they start at different places and that might skew our interpretation of the outcome so they did provide enough information for this criterion even though they did not provide p values criterions five through seven have to do with blinding so we start off by looking at the blinding of all participants did they know to which group they had been allocated are they going to be able to distinguish between being a part of the control group or being a part of the treatment group so in this case were the participants blinded they did not meet this criterion because they had a control group that was a wait and see versus a treatment group that was a plot was doing pilates for eight weeks so it would be evident to the participants whether or not they were on the wait and see list or they were doing pilates the next item is blinding of the therapists or in this case in this study it was a pilates instructor so did the pilates instructor know to which group the participants had been allocated because the control group was a wait-and-see group the pilates instructor was only delivering an active intervention wasn't delivering a control intervention so this person was aware of whether or not they were delivering an intervention which was exercise so they did not satisfy the this criterion because the instructors were aware of who was doing pilates and who wasn't last in the blinding category is blinding of the raiders or the assessors were they blinded for at least one key outcome did they know to which group the participants had been allocated and recall that when studies use self-report measures which in this case some of them were self-report measures the assessor is only considered to be blinded if the participants are considered to be blinded the researchers did meet this criterion they did have a an assessor who was blinded to at least one key outcome so in this case it was the ultrasound measurements of rectus abdominis thickness this physiatrist who did these measurements was blinded to group allocation however it goes on to say that the falling index was evaluated by a trained researcher it doesn't necessarily say whether that person was blinded or not and there was a self-report questionnaire at least one one of them being the beck depression scale and so because the participants weren't blinded in this study they were not blinded for that outcome but remember it's only one key outcome that will meet this criterion so because they had the ultrasound measurements by the physiatrist who was blinded this does meet the criterion of blinding of raiders next we're looking to see if a key outcome was measured in at least 85 percent of participants so in the report in the research article must state that both must state both the number of participants who are initially allocated to groups as well as the number of participants for whom key outcome measures were obtained and most of the time we will find this in the consort flow diagram so that would be the first place that i would look so was a key outcome measured in more than 85 percent of participants and the answer is yes this is the consort flow diagram where it talks about how many participants were assessed for eligibility why people were excluded and how they progressed through the study after randomization or in this case not randomization all the way down to analysis so we can see that we start with 40 participants with 20 going to each group and in the pilates group we have analysis for 18 of them and it says that they excluded none from the analysis even though they started with 20 you kind of wonder what happened to the other two in the control group they started with 20 and they analyzed 19 and it said that 0 were excluded from the analysis so it's a little confusing because the numbers don't match however they did provide enough information here to know that 85 percent of participants are accounted for so yes they did meet this criterion criteria number nine has to do with participants receiving the treatment as allocated or in the case that they did not did the researchers use intention to treat analysis so remember the intention to treat analysis is there are varying ways to do this but it's part of the statistical analysis that allows you to analyze data as if the participants received the treatment to which they were initially allocated so did the researchers do this and the answer is no they did not use an intention to treat analysis it says at the bottom of the consort flow diagram that even though they started with 20 participants they analyzed data from 18. so we have to wonder what happened to those two data points that are missing for each measurement and then in the control group we had 19 out of 20 complete and it says none were excluded from the analysis but we don't really know what they did with the data from that one person it probably was not included in the analysis so what the researchers did here was called a per protocol analysis so they analyzed the data of people who completed the study protocol and just excluded the data from the people who did not complete so this does introduce a little bit of bias depending on why people dropped out but with so few dropouts hopefully it wouldn't interject too much bias in the analysis item number 10 has to do with the between group statistical comparison for at least one key outcome so remember that this is satisfied if the researchers provide a p-value or an estimate in its confidence interval for a between group comparison only for one key outcome despite the p-values in the charts here we have to look at what they actually analyze so the presence of a p-value doesn't necessarily mean that they did a between group comparison in fact these researchers only did a within group comparison so the p-values that they provided we're looking at we'll look at the top line for the pilates group rectus abdominis thickness so they gave the before value and the after value and they provided information that says that there was a significant difference between those two measurements within that one group same thing is true for the so that was the rectus abdominis thickness at rest same thing for contracted rectus abdominis thickness that was statistically significant at the 0.05 level so with the information provided in the study we don't actually know if the pilates group outperformed the control group i mean looking at the data we can probably infer that they did and we as physical therapists often believe that exercise is going to outperform no treatment but we can't really be sure unless we run the analysis which is missing from this article all right last criterion for this article as well as the presentation criterion 11 is a point measure and measure of variability present for at least one key outcome so remember that point measures are your mean median and mode and they can be described as the difference between groups or the outcomes of each individual group so your measures of variability the most common ones that you're going to see are standard deviation your 95 confidence interval and your interquartile range the researchers can provide this graphically as long as it's clear what is being represented and usually they'll describe that in some subtext at the bottom of the table despite the lack of between group statistical analysis the authors did provide enough information to meet this criterion so remember that it's met if the outcomes in each group or for all groups are presented so they do have the final eight week week eight measurements for each group therefore they did provide enough information to satisfy this criterion so what is the final pager score you're going to take all of your yeses from items 2 through 11 and add those up and you should get a number out of 10 for your final score and you can get an idea of the overall quality of the research article so these researchers did not meet the criteria for random assignment and concealed allocation nor for the blinding of both participants and therapists or in their case instructors they did not use an intention to treat analysis nor did they provide a between group statistical analysis they did however have similar groups at baseline they were able to blind the rater for at least one key outcome they did measure outcomes and more than 85 percent of the participants and they provided point measures and measures of variability for all groups in the study so this will give them a final pedro score of 4 out of 10 and if you can think back to a previous slide where i gave guidelines for what's considered poor fair and good you can get an idea where this falls a pager score of 4 out of 10 would put this article in the fair range so less than 3 less than or equal to 3 is poor greater than six or equal to six is high quality so this is considered a fair quality article and it doesn't mean that because it's not high we have to discount all of the findings in the study we just have to interpret the results with caution because there were some threats to study validity and i have yet to see a study that has a pedro score of 10 out of 10. usually it's one of the blinding aspects where they will get hit on the one of the points so no study is perfect even after the fact after you do a study you realize all of these things that you could have done differently to tighten up the validity so these are not hard and fast rules it's not oh this is a six i must implement this intervention into my practice because we also have to consider yes it was statistically significant but was it clinically significant what was the treatment effect that we observed so there's a lot that can go into this but the pedro score can give you an overall kind of general feel for whether or not the researchers took steps to control the threats to validity so i want to conclude with a couple comments and and takeaways at the end of this presentation on study validity using the pedro scale the first thing i want to point out is that evidence-based practice there's multiple tiers to evidence-based practice but it's using the best available evidence and so if there's a new intervention that's just starting to be studied or new treatment parameter parameters for an existing treatment that we we've already been using if the only study that's been done is a pedro score of four or five that is the best available evidence so we can read that study we can interpret the information with caution knowing that there were some threats to validity and decide for ourselves whether or not we want to implement that intervention i also want to remind everyone that all information that you need to complete the pedro scale can be found in the methods and results section so while it can be beneficial to read the entire article the introduction you can gain some new information discussion it's really interesting to see how they interpret their findings everything you need the most objective information is in the methods and results section so it can make reading a research article a little less intimidating from a time perspective where you might read only three pages instead of the full you know nine or ten or 11 pages that the research article might be so it can cut down on some time by improving your efficiency the next thing that i want to point out is that apta kansas does have a research committee and we're currently trying to bridge the gap between clinicians who are interested in research and getting them to become more familiar with what it takes for publication and so you can reach out to that committee if you feel like that is something that you would like to explore and we're happy to help you with that and then finally if you like this type of presentation and you would like more of it please let us know via the qualtric survey we are committed to trying to meet the needs of our members and so if this is something that you found beneficial we are happy to try to provide more of it here are my references if you would like additional information or to dive a little bit deeper in some of the articles that i used to substantiate this presentation i wanted to thank you for taking the time to go through these articles and go through this presentation with me we have a growing body of literature in physical therapy and so sometimes it's hard to know what to do with it all so the pedro scale is a tool for interventional studies that you can use to hopefully decide for yourself whether or not you want to implement certain interventions into your clinical practice so again thank you very much for taking the time and i hope you have a wonderful day