The Evidence Based Practitioner

Applying Research to Meet Client

Needs 1st Edition, (Ebook PDF)
Visit to download the full and correct content document:
https://ebookmass.com/product/the-evidence-based-practitioner-applying-research-to
-meet-client-needs-1st-edition-ebook-pdf/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Evidence Based Counselling & Psychotherapy for the 21st

Century Practitioner Daryl Mahon

https://ebookmass.com/product/evidence-based-counselling-
psychotherapy-for-the-21st-century-practitioner-daryl-mahon/

Clinician’s Guide to Research Methods in Family

Therapy: Foundations of Evidence Based Practice 1st
Edition, (Ebook PDF)

https://ebookmass.com/product/clinicians-guide-to-research-
methods-in-family-therapy-foundations-of-evidence-based-
practice-1st-edition-ebook-pdf/

Practitioners Guide to Using Research for Evidence

Based Practice 2E 2nd Edition – Ebook PDF Version

https://ebookmass.com/product/practitioners-guide-to-using-
research-for-evidence-based-practice-2e-2nd-edition-ebook-pdf-
version/

How to Implement Evidence-Based Healthcare 1st Edition

https://ebookmass.com/product/how-to-implement-evidence-based-
healthcare-1st-edition/
Understanding Nursing Research: Building an Evidence-
Based Practice 7th Edition – Ebook PDF Version

https://ebookmass.com/product/understanding-nursing-research-
building-an-evidence-based-practice-7th-edition-ebook-pdf-
version/

Reading, Understanding, and Applying Nursing Research

5th Edition, (Ebook PDF)

https://ebookmass.com/product/reading-understanding-and-applying-
nursing-research-5th-edition-ebook-pdf/

Evidence Based Practice for Nurses: Appraisal and

Application of Research 4th Edition, (Ebook PDF)

https://ebookmass.com/product/evidence-based-practice-for-nurses-
appraisal-and-application-of-research-4th-edition-ebook-pdf/

Statistics for Nursing Research: A Workbook Evidence-

Based Practice 2nd Edition – Ebook PDF Version

https://ebookmass.com/product/statistics-for-nursing-research-a-
workbook-evidence-based-practice-2nd-edition-ebook-pdf-version/

Understanding Nursing Research E Book: Building an

Evidence Based Practice 7th Edition, (Ebook PDF)

https://ebookmass.com/product/understanding-nursing-research-e-
book-building-an-evidence-based-practice-7th-edition-ebook-pdf/
 The Evidence-Based
Practitioner: Applying Research
to Meet Client Needs

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

4366_FM_i-xxii.indd ii 27/10/16 2:13 pm
 The Evidence-Based
Practitioner: Applying
Research to Meet Client Needs
Catana Brown, PhD, OTR/L, FAOTA
Midwestern University
Department of Occupational Therapy
Glendale, Arizona

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

 F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com

Copyright © 2017 by F. A. Davis Company

Copyright © 2017 by F. A. Davis Company. All rights reserved. This product is protected by copyright. No part of it may be reproduced, stored
in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written
permission from the publisher.

Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Senior Acquisitions Editor: Christa A. Fratantoro

Director of Content Development: George W. Lang
Developmental Editor: Nancy J. Peterson
Content Project Manager: Julie Chase
Art and Design Manager: Carolyn O’Brien

As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes.
The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time
of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and
make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader
in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised
always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering
any drug. Caution is especially urged when using new or infrequently ordered drugs.

Library of Congress Cataloging-in-Publication Data

Names: Brown, Catana, author.

Title: The evidence-based practitioner : applying research to meet client
needs / Catana Brown.
Description: Philadelphia : F.A. Davis Company, [2017] | Includes
bibliographical references and index.
Identifiers: LCCN 2016046032 | ISBN 9780803643666 (pbk. : alk. paper)
Subjects: | MESH: Occupational Therapy | Evidence-Based Practice | Physical
Therapy Modalities | Speech Therapy | Language Therapy | Problems and
Exercises
Classification: LCC RM735.3 | NLM WB 18.2 | DDC 615.8/515—dc23 LC record available at https://lccn.loc.gov/2016046032

Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for
users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.25 per copy is paid directly
to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system
of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 978080364366/17 0 + $.25.

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

 For Lauren—

You’re an astonishing teacher, despite the fact that you won’t read this book.

But then I probably won’t read your opera book, either.

CB

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

4366_FM_i-xxii.indd vi 27/10/16 2:13 pm

The introduction of evidence-based medicine by David
Sackett and other researchers in the 1990s (Sackett,
1997) initiated a radical shift in the approach to in-
struction in research methods and the application of
research findings to health-care practice. Until then,
practitioners learned about research through standard
academic research methods courses in which they were
taught to read and critique journal articles using the
well-established criteria of reliability and validity. They
were then expected to use those skills to “keep up” with
the research literature relevant to their area of practice
and apply the results to patient care. Unfortunately, for
the most part, they didn’t.
Sackett and his colleagues determined that the tra-
ditional approach to applying research to practice was
ineffective, and they proposed a radically different
approach—what we now recognize as evidence-based
practice. What was so different? Sackett and colleagues
recognized that research was relevant and useful to the
practitioner only to the extent that it addressed a clinical
question of importance to practice and provided a useful
guide to clinical decision-making. From this perspec-
tive, reading journal articles just to “keep current” and
without a particular question in mind was unfocused and
unproductive.
The alternative method they proposed taught practi-
tioners to use research evidence as one of three integral
components of clinical reasoning and decision-making.
This method is reflected in the now-familiar definition of
evidence-based practice: integration of the clinician’s exper-
tise and the best available scientific evidence with the cli-
ent’s preferences and values to determine an appropriate
course of action in a clinical encounter.
To support the use of evidence-based practice as an
integral part of clinical reasoning, a different method of
instruction was developed, which is exemplified in The
Evidence-Based Practitioner: Applying Research to Meet
Client Needs. Evidence-based practice (EBP) is a pro-
cess to be learned, not a content area to be mastered
the way we learn to identify the bones of the body or
4366_FM_i-xxii.indd vii
Foreword
the details of a particular assessment. Although it does
require learning about research methods and design,
measurement, and statistics, this knowledge is mastered
in the context of appraising evidence in relation to a
particular clinical question regarding a particular clini-
cal scenario. The EBP process involves a specific set of
steps to formulate an answerable question, and then to
search, select, appraise, and apply the evidence to an-
swer the clinical decision at hand. Ideally, students will
have multiple opportunities to practice these steps so
that ultimately the process can be initiated and carried
out smoothly and efficiently in occupational therapy
practice.
One of the valuable features of this text is that it is
designed to be used with team-based learning. This ap-
proach supports another important element of Sackett’s
(Sackett, 1997) and others’ original recommendations for
how to conduct EBP: that is, the importance of distrib-
uting the work and learning from one another’s insights.
Team-based learning models a method that can be carried
forward into the “real world” to continue to implement
EBP in practice.
Here’s what this can look like: Each of the five practi-
tioners in a group prepares and shares an appraisal of one
key study that addresses a clinical question of importance
to the group. In less than an hour of discussion, the group
synthesizes the findings and reaches a decision on the best
answer (known as the “clinical bottom line” in EBP) to a
clinical question at hand. One busy practitioner working
alone might find that amount of work daunting. In addi-
tion, he or she would miss the crucial insights that other
group participants provide.
There’s another important advantage to team-based
EBP: it’s much more fun. Group members energize one
another, and examining the evidence becomes an inter-
esting exploration and lively discussion of how best to
balance strengths and limitations, clinical relevance and
feasibility, and similarities and differences in the evidence.
The outcome of that lively discussion will help ensure
that your clinical decisions are guided by the best evi-
dence available to help your clients.
vii
27/10/16 2:13 pm
 viii Foreword
In The Evidence-Based Practitioner: Applying Research to
Meet Client Needs, Catana Brown provides occupational
therapy, physical therapy, and speech-language pathology
students with a clear and concise overview of research de-
signs, methodology, use of statistical analysis, and levels
of evidence, as well as the tools with which to evaluate
and apply evidence. Interesting and engaging features
such as From the Evidence lead the readers through the
steps to becoming effective consumers of evidence. Exer-
cises and Critical Thinking Questions motivate learners
to explore how this knowledge can be applied to their
clinical practice.
4366_FM_i-xxii.indd viii
I hope that you will approach learning EBP as a great
adventure and that you and your fellow students make
exciting discoveries.
Wendy Coster, PhD, OTR/L FAOTA
Professor and Chair, Department of Occupational Therapy
Director, Behavior and Health Program
Boston University
Boston, Massachusetts, USA
Sackett, D. L. (1997). Evidence-based medicine: How to
practice and teach EBM. New York/Edinburgh: Churchill
Livingstone.
27/10/16 2:13 pm

Evidence-based practice is no longer a new idea: it’s
a mandate from third-party payers, accrediting bod-
ies, health-care institutions, and clients. Although the
majority of therapists will become practitioners and
consumers of research rather than academic research-
ers, good consumers of research must still understand
how a study is put together and how to analyze the re-
sults. Occupational therapists, physical therapists, and
speech-language pathologists are expected to use evi-
dence when discussing intervention options with clients
and their families, and when making clinical decisions.
The skills required to be an effective evidence-based
practitioner are complex; for many therapists, finding
and reviewing research is considered a daunting or
tedious endeavor. In addition, evidence-based practice
is still new enough that many working therapists were
not trained in the methods, and some work settings have
not yet adopted a culture of evidence-based practice
that provides sufficient resources.
GUIDING PRINCIPLE: CONSUMING
VS. CONDUCTING RESEARCH
The Evidence-Based Practitioner: Applying Research to Meet
Client Needs is designed for entry-level graduate students
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
the knowledge and tools necessary to access evidence, cri-
tique its strength and applicability, and use evidence from
all sources (i.e., research, the client, and clinical experience)
to make well-informed clinical decisions.
This textbook was designed with multiple features
that allow students and practitioners not only to ac-
quire knowledge about evidence-based practice, but also
to begin to apply that knowledge in the real world.
Numerous examples and excerpts of published journal
articles from occupational therapy, physical therapy, and
speech-language pathology are used throughout the text.
In addition to learning about evidence-based practice,
students are exposed to research in their own disciplines
and the disciplines of their future team members.
4366_FM_i-xxii.indd ix
Preface
The text contains 11 chapters and is intended to fit
within a single entry-level course in a health-care pro-
gram. It will fit ideally into programs offering a course on
evidence-based practice, and can also be used to support a
traditional research methods text in research courses that
cover evidence-based practice.
The content of the initial chapters focuses on explain-
ing basic research concepts, including describing qualita-
tive and quantitative approaches. A separate chapter on
statistics is included in this introductory material. Subse-
quent chapters explain the different designs used in health-
care research, including separate chapters for each of the
following types of research: intervention, assessment,
descriptive/predictive, and qualitative, as well as a chapter
on systematic reviews. These chapters prepare students to
match their own evidence-based questions with the cor-
rect type of research. In addition, students will acquire the
knowledge and skills necessary to understand research arti-
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-
standing of how to evaluate the quality of research studies.
The text ends with a chapter on integrating evidence from
multiple sources, which highlights the importance of in-
volving clients and families in the decision-making process
by sharing the evidence.
A TEAM-BASED LEARNING WORKTEXT
This text uses a unique team-based learning (TBL)
approach. TBL is a specific instructional strategy that
facilitates the type of learning that helps students solve
problems. It is a method that requires active involvement
of the student in the learning process from the outset.
Ideally, students work in small teams, using methods that
enhance accountability for both individual and team work;
this can result in a deeper level of understanding that is
more relevant to real-life practice. Still, this textbook is
useful for all types of instructional strategies and is rele-
vant even with approaches that do not use a TBL format.
Nevertheless, TBL provides the pedagogy for applying
information, and therefore one strength of this text is its
emphasis on application.
ix
27/10/16 2:13 pm
 x Preface
To facilitate application, the text is presented as a
worktext that interweaves narrative with exercises, crit-
ical thinking questions, and other means of engaging
students and helping them comprehend the informa-
tion. When appropriate, answers to these questions are
included at the end of the chapter. An advantage of the
worktext approach is that it gets students engaged with
the material from the beginning. In courses that use a
TBL format, the worktext prepares students to be effec-
tive team members.
TERMINOLOGY
A challenging aspect of evidence-based practice for stu-
dents and instructors alike is terminology. In fact, this was
one of the greatest challenges for the author of this text.
In evidence-based practice, several different terms can be
used to describe the same or similar concepts. Making
matters more difficult, there are several issues with termi-
nology that can make deciphering the research literature
perplexing. For example:
• Different terms are used to describe the same or sim-
ilar concepts.
• There are disagreements among experts as to the proper
use of some terms.
• Terms are used incorrectly, even in peer-reviewed
articles.
• Labels and terms are sometimes omitted from research
articles.
Because deciphering research terminology is chal-
lenging, a significant effort was directed toward using
the most common terms that are likely to appear in the
literature. When multiple terms are routinely used, this
is explained in the text. For example, what some call a
nonrandomized controlled trial may be described by oth-
ers as a quasi-experimental study.
Due to the challenges with terminology, students
need to read actual articles and excerpts of articles during
the learning process so that these terminology issues can
become transparent. When students have a more thor-
ough understanding of a concept and the terms involved,
they can better interpret the idiosyncrasies of individual
articles.
Fortunately many journals are creating standard for-
mats for reporting research, and with time some termi-
nology issues will be resolved, although differences in
opinion and disciplines (e.g., school-based practice vs.
medicine) will likely continue to exist.
SPECIAL FEATURES
The special features developed for this text will enable
students to better understand content, develop the
4366_FM_i-xxii.indd x
advanced skills needed for assessing the strength and
applicability of evidence, and apply the material to prac-
tice. The Evidence-Based Practitioner: Applying Research to
Meet Client Needs includes several special features.
Key Terms
An alphabetical list of key terms appears at the beginning
of each chapter. These terms are also bolded where they
are first described in the chapter and fully defined in the
end-of-book glossary.
From the Evidence
Students often have trouble applying research concepts
to reading a research article. This key feature helps stu-
dents make the link by providing real-world examples
from research articles in occupational therapy, physi-
cal therapy, and speech-language pathology. From the
Evidence visually walks the student through graphic ex-
amples such as abstracts, tables, and figures to illustrate
key concepts explained in the chapter. Arrows and text
boxes are used to point out and elucidate the concept
of interest.
From the Evidence features are included in each
chapter. Each has at least one corresponding question to
ensure that the student fully understands the material.
Answers to these questions are provided at the end of
each chapter.
Exercises
Exercises are distributed throughout the chapters to help
students learn to apply information in context. In TBL
courses, the exercises are intended to prepare students for
the in-class team assignments; similarly, in flipped class-
rooms, students would complete the exercises at home
and arrive at class prepared for discussions and activities.
Each exercise is tied directly to a Learning Outcome and
includes questions requiring students to apply the knowl-
edge acquired in the chapter. There is space in the text for
the student to complete the exercise, and the answers are
provided at the end of the chapter.
Understanding Statistics
After Chapter 4, “Understanding Statistics: What They
Tell You and How to Apply Them in Practice,” the
Understanding Statistics feature is included in chapters
in which specific statistical procedures are described.
Understanding Statistics boxes provide an example of a
statistic with additional explanation to reinforce informa-
tion that is typically challenging. The feature also helps
put the information in context for students by associating
the statistic with a specific research design.
27/10/16 2:13 pm

Evidence in the Real World
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.
It serves as another method of demystifying research
concepts—such as how the concept of standard devia-
tions can be used to understand the autism spectrum—
and showing students the relevance/practical application
of what they are learning.
Critical Thinking Questions
Each chapter ends with Critical Thinking Questions.
These questions require higher-level thinking and serve
4366_FM_i-xxii.indd xi
Preface xi
as prompts for students to evaluate their comprehension
of the chapter concepts.
CLOSING THOUGHTS
In today’s health-care environment, occupational ther-
apists, physical therapists, and speech-language pathol-
ogists must be proficient in accessing, critiquing, and
applying research in order to be effective evidence-based
practitioners. With solid foundational information and
engaging application exercises, this text provides the
framework for developing the evidence-based practice
skills that allow practitioners to best meet their clients’
needs.
27/10/16 2:13 pm
4366_FM_i-xxii.indd xii 27/10/16 2:13 pm

Although it is now widely valued, evidence-based practice
is not the favorite topic of most rehabilitation therapy stu-
dents. When I began this process, I knew that I wanted a
very different sort of textbook that would require students
to actively engage with the material; hence, the use of a
team-based learning format. However, doing something
different required a lot of help along the way.
First, I would like to acknowledge the fantastic edito-
rial support provided by F.A. Davis. In particular I would
like to thank Christa Fratantoro, the acquisitions editor,
who grasped my vision for a new evidence-based textbook
and believed in my ability to pull it off. I appreciate her
friendship and backing. Nancy Peterson, developmental
editor extraordinaire, was with me through every step of
the process. All the things that are good about this text are
better because of Nancy. In addition, Nancy is my sound-
ing board, my counselor, motivator, and guide.
I owe a debt of gratitude to the occupational therapy
and physical therapy students at Midwestern University–
Glendale in Arizona, who used different variations of the
4366_FM_i-xxii.indd xiii
Acknowledgment
rough drafts of the text and provided invaluable feedback,
resulting in the addition, clarification, and improvement
of the content. I would especially like to thank Morgan
Lloyd, who helped me with some of the content that was
the most difficult to explain.
Larry Michaelsen, who developed the team-based
learning approach, inspired me to try a new way of teach-
ing, which ultimately led to my insight that a new type of
textbook was needed. Furthermore, I would like to thank
Bill Roberson and Larry Michaelsen for contributing a
marvelous team-based learning primer as part of the in-
structor resources.
Finally, a big thanks to those who offered support, both
professional and personal, providing me with the time,
space, and encouragement to make this text a reality. This
includes my chair, Chris Merchant; my husband, Alan
Berman; and my friend, Bob Gravel.
Catana Brown, PhD, OTR/L, FAOTA
xiii
27/10/16 2:13 pm
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

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

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

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

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

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

 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

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

 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

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

 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

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

 “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
no related content on Scribd:
THE CORTEZ EMERALD MYSTERY, by J. A. Lath
A huge emerald—credited as part of the treasure of the
famous explorer, Cortez, in the 16th Century is stolen from
a museum at Roller University. This absorbing mystery
tells how four chums succeed in tracing the gang
responsible.
THE PHANTOM SHIP, by James (“Coach”)
Schermerhorn, Jr.
Rock Cranton in trouble, calls on his old coach in Dexter
College to come to his assistance. The Coach comes a
running, and that is the beginning of a strange mystery
yarn that no boy will want to lay down until it is completed.
These books may be purchased wherever books are sold
Send for Our Free Illustrated Catalogue

CUPPLES & LEON COMPANY, Publishers

New York
 CHAMPION SPORTS STORIES
By NOËL SAINSBURY, JR.
Every boy enjoys sport stories. Here
we present three crackerjack stories
of baseball, football, and basketball,
written in the vernacular of the boy of
to-day, full of action, suspense and
thrills, in language every boy will
understand, and which we know will
be enthusiastically endorsed by all
boys.
Large 12mo. Cloth. Illustrated. Jacket
in color. Price 50 cents per volume.
Postage 10 cents additional.

1. CRACKER STANTON
Or The Making of a Batsman
Ralph Stanton, big, rawboned and serious, is a product of
the backwoods and a crack rifle shot. Quick thinking and
pluck bring him a scholarship to Clarkville School where
he is branded “grind” and “dub” by classmates. How his
batting brings them first place in the League and how he
secures his appointment to West Point make CRACKER
STANTON an up-to-the-minute baseball story no lover of
the game will want to put down until the last word is read.
2. GRIDIRON GRIT
Or The Making of a Fullback
A corking story of football packed full of exciting action
and good, clean competitive rivalry. Shorty Fiske is six-
foot-four and the product of too much money and
indulgence at home. How Clarkville School and football
develop Shorty’s real character and how he eventually
stars on the gridiron brings this thrilling tale of school life
and football to a grandstand finish.
3. THE FIGHTING FIVE
Or the Kidnapping of Clarkville’s Basketball Team
Clarkville School’s basketball team is kidnapped during
the game for the State Scholastic Championship. The
team’s subsequent adventures under the leadership of
Captain Charlie Minor as he brings them back to the State
College Gymnasium where the two last quarters of the
Championship game are played next evening, climaxes
twenty-four pulsating hours of adventure and basketball in
the FIGHTING FIVE....

CUPPLES & LEON COMPANY, Publishers

New York
 SORAK JUNGLE SERIES
By HARVEY D. RICHARDS
The name Sorak means War Cry in
the Malay country. He grows up
among the most primitive of the Malay
aborigines, and learns to combat all
the terrors of the jungle with safety.
The constant battle with nature’s
forces develop Sorak’s abilities to
such an extent that he is
acknowledged the chief warrior in all
his section of the jungle.
12mo. Cloth. Illustrated. Jacket in
color. Price 50 cents per volume.
Postage 10 cents additional.

1. SORAK OF THE MALAY JUNGLE

or How Two Young Americans Face Death and Win a
Friend
Two boys, Dick and Jack Preston are shipwrecked off the
Malay Peninsula and are rescued by Sorak. Their
adventures in trying to get back to civilization make an
absorbing story.
2. SORAK AND THE CLOUDED TIGER
or How the Terrible Ruler of the North Is Hunted and
Destroyed
A huge clouded tiger, almost human, leads a pack of red
dholes into Sorak’s country, and it takes all of Sorak’s
ingenuity, and the aid of his friends to exterminate the
pack.
3. SORAK AND THE SULTAN’S ANKUS
or How a Perilous Journey Leads to a Kingdom of Giants
 Sorak and his friends are trapped by a herd of elephants,
and finally run away with by the leader to an unknown
valley where a remnant of Cro-Magnon race still exists.
Their exciting adventures will hold the reader enthralled
until the last word.
4. SORAK AND THE TREE-MEN
or the Rescue of the Prisoner Queen
Captured by a band of Malay slavers, Sorak and his
friends are wrecked on an island off the coast of Burma in
the Mergui Archipelago. Their escape from the island with
the Prisoner Queen after a successful revolution brings
the fourth book of this series to an exciting and unusual
conclusion.

CUPPLES & LEON COMPANY, Publishers

New York
TOP NOTCH DETECTIVE STORIES
By WILLIAM HALL
Each story complete in itself
A new group of detective stories
carefully written, with corking plots;
modern, exciting, full of adventure,
good police and detective work.
Large 12mo. Cloth. Illustrated. Jacket
in color. Price 50 cents per volume.
Postage 10 cents additional.

1. SLOW VENGEANCE
or the Mystery of Pete Shine
A young newspaper man, whose
brother is on the police force,
becomes strangely involved in the
mysterious killing of an Italian
bootblack. Suspicion points to a well-
known politician but he proves that it
was impossible for him to have done
the deed. Then the reporter, who for a
time turns detective, gets a clue
revolving about a startling, ancient
method of combat. He follows this up,
watches a masked duelist and, with
the help of a girl, catches the
murderer who justifies his deed on the
plea of Slow Vengeance. You will be
interested in reading how the reporter
got out of a tight corner.
2. GREEN FIRE
or Mystery of the Indian Diamond
 A golf caddy who has a leaning
toward amateur detective work,
together with his younger cousin, are
accidentally mixed up in the strange
loss, or theft, of a valuable diamond,
known as Green Fire. It was once the
eye of an East Indian idol. To clear his
young cousin of suspicion, the older
boy undertakes to solve the mystery
which deepens when one man
disappears and another is found
murdered on the golf course. But, by
a series of clever moves on the part of
the young sleuth, the crime is solved
and the diamond found in a most
unusual hiding place. A rapidly
moving, exciting tale. You will like it.
3. HIDDEN DANGER
or The Secret of the Bank Vault
A young detective, who, in his private
capacity, has solved several
mysteries, decides to open an office
in another city. He meets a young
bank clerk and they become partners
just when the clerk’s bank is
mysteriously bombed and the cashier
is reported missing. It is not until next
day that it is discovered that the bank
vault has been entered in some secret
manner and a large sum stolen. The
regular detectives declared “spirits”
must have robbed the bank but the
two young detectives prove that a
clever gang did it and also kidnapped
the aged cashier. Not a dull page from
first to last. A clever story.
CUPPLES & LEON COMPANY, Publishers
New York
 NORTHWEST STORIES
By LeROY W. SNELL
A new group of stories laid in the
Canadian Northwest by Mr. Snell, a
master writer of the glories and the
thrilling adventures of the Canadian
Northwest Mounted Police. Each book
is an individual story, well written,
beautifully bound, and contains a
story that all boys will enjoy.
Large 12mo. Cloth. Illustrated. Jacket
in color. Price 50 cents per volume.
Postage 10 cents additional.

1. THE LEAD DISK

Tom Baley, leaving college goes north into Canada,
hoping to join the Northwest Mounted Police. His
application is turned down by his own uncle, an officer on
the force, but after many thrilling adventures and
encounters with the Disk Gang he is able to win the
coveted uniform.
2. SHADOW PATROL
Luke Myers is sent into the Caribou Mountains to solve
the mystery of The Shadow, about whom many conflicting
stories are told. There are struggles with the outlaws, and
finally a great running battle down the fog-obscured
mountain trails ... at the end of which the outlaws are
captured and the mystery of The Shadow is solved.
3. THE WOLF CRY
Donald Pierce is sent to solve the mystery of his father’s
disappearance, into the unmapped barrens where King
Stively weaves his web of wickedness, and rules a
territory the size of a small empire with a ruthlessness and
cunning that baffles the best of the Mounted Police.
Behind all is the dread Wolf Cry which causes brave men
to shudder....
4. THE SPELL OF THE NORTH
Sergeant David Stanlaw, stationed at Spirit River, is
puzzled by a local killing, the disappearance of the body,
the finding of a code message, and by the mystery of the
“Listening Forest,” which casts a shadow of dread over the
little town of Wiggin’s Creek. With the help of Jerry Bartlett
they capture the leaders of the gang and solve the
mystery of the “Listening Forest.”
5. THE CHALLENGE OF THE YUKON
Robert Wade whose patrol runs from Skagway on
Chattam Strait north into the Yukon country follows in the
wake of a stampede to a new gold strike. With the aid of
his friend, Jim MacPhail, Wade frustrates the outlaws, who
try to trap the whole town behind the “Pass of the Closing
Door,” and then races them to and across the breaking ice
floes of the Yukon. A strong adventure story all boys will
enjoy.

CUPPLES & LEON COMPANY, Publishers

New York
 TRANSCRIBER’S NOTES:
Obvious typographical errors have been corrected.
Inconsistencies in hyphenation have been
standardized.
Archaic or variant spelling has been retained.
*** END OF THE PROJECT GUTENBERG EBOOK BOMBA THE
JUNGLE BOY AT THE GIANT CATARACT ***

Updated editions will replace the previous one—the old editions

will be renamed.

Creating the works from print editions not protected by U.S.

copyright law means that no one owns a United States copyright
in these works, so the Foundation (and you!) can copy and
distribute it in the United States without permission and without
paying copyright royalties. Special rules, set forth in the General
Terms of Use part of this license, apply to copying and
distributing Project Gutenberg™ electronic works to protect the
PROJECT GUTENBERG™ concept and trademark. Project
Gutenberg is a registered trademark, and may not be used if
you charge for an eBook, except by following the terms of the
trademark license, including paying royalties for use of the
Project Gutenberg trademark. If you do not charge anything for
copies of this eBook, complying with the trademark license is
very easy. You may use this eBook for nearly any purpose such
as creation of derivative works, reports, performances and
research. Project Gutenberg eBooks may be modified and
printed and given away—you may do practically ANYTHING in
the United States with eBooks not protected by U.S. copyright
law. Redistribution is subject to the trademark license, especially
commercial redistribution.

START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE
 PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg™ mission of promoting the

free distribution of electronic works, by using or distributing this
work (or any other work associated in any way with the phrase
“Project Gutenberg”), you agree to comply with all the terms of
the Full Project Gutenberg™ License available with this file or
online at www.gutenberg.org/license.

Section 1. General Terms of Use and

Redistributing Project Gutenberg™
electronic works
1.A. By reading or using any part of this Project Gutenberg™
electronic work, you indicate that you have read, understand,
agree to and accept all the terms of this license and intellectual
property (trademark/copyright) agreement. If you do not agree to
abide by all the terms of this agreement, you must cease using
and return or destroy all copies of Project Gutenberg™
electronic works in your possession. If you paid a fee for
obtaining a copy of or access to a Project Gutenberg™
electronic work and you do not agree to be bound by the terms
of this agreement, you may obtain a refund from the person or
entity to whom you paid the fee as set forth in paragraph 1.E.8.

1.B. “Project Gutenberg” is a registered trademark. It may only

be used on or associated in any way with an electronic work by
people who agree to be bound by the terms of this agreement.
There are a few things that you can do with most Project
Gutenberg™ electronic works even without complying with the
full terms of this agreement. See paragraph 1.C below. There
are a lot of things you can do with Project Gutenberg™
electronic works if you follow the terms of this agreement and
help preserve free future access to Project Gutenberg™
electronic works. See paragraph 1.E below.
1.C. The Project Gutenberg Literary Archive Foundation (“the
Foundation” or PGLAF), owns a compilation copyright in the
collection of Project Gutenberg™ electronic works. Nearly all the
individual works in the collection are in the public domain in the
United States. If an individual work is unprotected by copyright
law in the United States and you are located in the United
States, we do not claim a right to prevent you from copying,
distributing, performing, displaying or creating derivative works
based on the work as long as all references to Project
Gutenberg are removed. Of course, we hope that you will
support the Project Gutenberg™ mission of promoting free
access to electronic works by freely sharing Project
Gutenberg™ works in compliance with the terms of this
agreement for keeping the Project Gutenberg™ name
associated with the work. You can easily comply with the terms
of this agreement by keeping this work in the same format with
its attached full Project Gutenberg™ License when you share it
without charge with others.

1.D. The copyright laws of the place where you are located also
govern what you can do with this work. Copyright laws in most
countries are in a constant state of change. If you are outside
the United States, check the laws of your country in addition to
the terms of this agreement before downloading, copying,
displaying, performing, distributing or creating derivative works
based on this work or any other Project Gutenberg™ work. The
Foundation makes no representations concerning the copyright
status of any work in any country other than the United States.

1.E. Unless you have removed all references to Project

Gutenberg:

1.E.1. The following sentence, with active links to, or other

immediate access to, the full Project Gutenberg™ License must
appear prominently whenever any copy of a Project
Gutenberg™ work (any work on which the phrase “Project
Gutenberg” appears, or with which the phrase “Project
Gutenberg” is associated) is accessed, displayed, performed,
viewed, copied or distributed:

This eBook is for the use of anyone anywhere in the United

States and most other parts of the world at no cost and with
almost no restrictions whatsoever. You may copy it, give it
away or re-use it under the terms of the Project Gutenberg
License included with this eBook or online at
www.gutenberg.org. If you are not located in the United
States, you will have to check the laws of the country where
you are located before using this eBook.

1.E.2. If an individual Project Gutenberg™ electronic work is

derived from texts not protected by U.S. copyright law (does not
contain a notice indicating that it is posted with permission of the
copyright holder), the work can be copied and distributed to
anyone in the United States without paying any fees or charges.
If you are redistributing or providing access to a work with the
phrase “Project Gutenberg” associated with or appearing on the
work, you must comply either with the requirements of
paragraphs 1.E.1 through 1.E.7 or obtain permission for the use
of the work and the Project Gutenberg™ trademark as set forth
in paragraphs 1.E.8 or 1.E.9.

1.E.3. If an individual Project Gutenberg™ electronic work is

posted with the permission of the copyright holder, your use and
distribution must comply with both paragraphs 1.E.1 through
1.E.7 and any additional terms imposed by the copyright holder.
Additional terms will be linked to the Project Gutenberg™
License for all works posted with the permission of the copyright
holder found at the beginning of this work.

1.E.4. Do not unlink or detach or remove the full Project

Gutenberg™ License terms from this work, or any files
containing a part of this work or any other work associated with
Project Gutenberg™.
 1.E.5. Do not copy, display, perform, distribute or redistribute
this electronic work, or any part of this electronic work, without
prominently displaying the sentence set forth in paragraph 1.E.1
with active links or immediate access to the full terms of the
Project Gutenberg™ License.

1.E.6. You may convert to and distribute this work in any binary,
compressed, marked up, nonproprietary or proprietary form,
including any word processing or hypertext form. However, if
you provide access to or distribute copies of a Project
Gutenberg™ work in a format other than “Plain Vanilla ASCII” or
other format used in the official version posted on the official
Project Gutenberg™ website (www.gutenberg.org), you must, at
no additional cost, fee or expense to the user, provide a copy, a
means of exporting a copy, or a means of obtaining a copy upon
request, of the work in its original “Plain Vanilla ASCII” or other
form. Any alternate format must include the full Project
Gutenberg™ License as specified in paragraph 1.E.1.

1.E.7. Do not charge a fee for access to, viewing, displaying,

performing, copying or distributing any Project Gutenberg™
works unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8. You may charge a reasonable fee for copies of or

providing access to or distributing Project Gutenberg™
electronic works provided that:

• You pay a royalty fee of 20% of the gross profits you derive from
the use of Project Gutenberg™ works calculated using the
method you already use to calculate your applicable taxes. The
fee is owed to the owner of the Project Gutenberg™ trademark,
but he has agreed to donate royalties under this paragraph to
the Project Gutenberg Literary Archive Foundation. Royalty
payments must be paid within 60 days following each date on
which you prepare (or are legally required to prepare) your
periodic tax returns. Royalty payments should be clearly marked
as such and sent to the Project Gutenberg Literary Archive
Foundation at the address specified in Section 4, “Information
 about donations to the Project Gutenberg Literary Archive
Foundation.”

• You provide a full refund of any money paid by a user who

notifies you in writing (or by e-mail) within 30 days of receipt that
s/he does not agree to the terms of the full Project Gutenberg™
License. You must require such a user to return or destroy all
copies of the works possessed in a physical medium and
discontinue all use of and all access to other copies of Project
Gutenberg™ works.

• You provide, in accordance with paragraph 1.F.3, a full refund of

any money paid for a work or a replacement copy, if a defect in
the electronic work is discovered and reported to you within 90
days of receipt of the work.

• You comply with all other terms of this agreement for free
distribution of Project Gutenberg™ works.

1.E.9. If you wish to charge a fee or distribute a Project

Gutenberg™ electronic work or group of works on different
terms than are set forth in this agreement, you must obtain
permission in writing from the Project Gutenberg Literary
Archive Foundation, the manager of the Project Gutenberg™
trademark. Contact the Foundation as set forth in Section 3
below.

1.F.

1.F.1. Project Gutenberg volunteers and employees expend

considerable effort to identify, do copyright research on,
transcribe and proofread works not protected by U.S. copyright
law in creating the Project Gutenberg™ collection. Despite
these efforts, Project Gutenberg™ electronic works, and the
medium on which they may be stored, may contain “Defects,”
such as, but not limited to, incomplete, inaccurate or corrupt
data, transcription errors, a copyright or other intellectual
property infringement, a defective or damaged disk or other
medium, a computer virus, or computer codes that damage or
cannot be read by your equipment.

1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES -

Except for the “Right of Replacement or Refund” described in
paragraph 1.F.3, the Project Gutenberg Literary Archive
Foundation, the owner of the Project Gutenberg™ trademark,
and any other party distributing a Project Gutenberg™ electronic
work under this agreement, disclaim all liability to you for
damages, costs and expenses, including legal fees. YOU
AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE,
STRICT LIABILITY, BREACH OF WARRANTY OR BREACH
OF CONTRACT EXCEPT THOSE PROVIDED IN PARAGRAPH
1.F.3. YOU AGREE THAT THE FOUNDATION, THE
TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER
THIS AGREEMENT WILL NOT BE LIABLE TO YOU FOR
ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE
OR INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF
THE POSSIBILITY OF SUCH DAMAGE.

1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If

you discover a defect in this electronic work within 90 days of
receiving it, you can receive a refund of the money (if any) you
paid for it by sending a written explanation to the person you
received the work from. If you received the work on a physical
medium, you must return the medium with your written
explanation. The person or entity that provided you with the
defective work may elect to provide a replacement copy in lieu
of a refund. If you received the work electronically, the person or
entity providing it to you may choose to give you a second
opportunity to receive the work electronically in lieu of a refund.
If the second copy is also defective, you may demand a refund
in writing without further opportunities to fix the problem.

1.F.4. Except for the limited right of replacement or refund set

forth in paragraph 1.F.3, this work is provided to you ‘AS-IS’,
WITH NO OTHER WARRANTIES OF ANY KIND, EXPRESS
OR IMPLIED, INCLUDING BUT NOT LIMITED TO
WARRANTIES OF MERCHANTABILITY OR FITNESS FOR
ANY PURPOSE.

1.F.5. Some states do not allow disclaimers of certain implied

warranties or the exclusion or limitation of certain types of
damages. If any disclaimer or limitation set forth in this
agreement violates the law of the state applicable to this
agreement, the agreement shall be interpreted to make the
maximum disclaimer or limitation permitted by the applicable
state law. The invalidity or unenforceability of any provision of
this agreement shall not void the remaining provisions.

1.F.6. INDEMNITY - You agree to indemnify and hold the

Foundation, the trademark owner, any agent or employee of the
Foundation, anyone providing copies of Project Gutenberg™
electronic works in accordance with this agreement, and any
volunteers associated with the production, promotion and
distribution of Project Gutenberg™ electronic works, harmless
from all liability, costs and expenses, including legal fees, that
arise directly or indirectly from any of the following which you do
or cause to occur: (a) distribution of this or any Project
Gutenberg™ work, (b) alteration, modification, or additions or
deletions to any Project Gutenberg™ work, and (c) any Defect
you cause.

Section 2. Information about the Mission of

Project Gutenberg™
Project Gutenberg™ is synonymous with the free distribution of
electronic works in formats readable by the widest variety of
computers including obsolete, old, middle-aged and new
computers. It exists because of the efforts of hundreds of
volunteers and donations from people in all walks of life.

Volunteers and financial support to provide volunteers with the

assistance they need are critical to reaching Project