We thank Dr Redfern and Dr Briffa and agree that some studies could improve their study design by using concealed group allocation and by blinding investigators to group allocation while measuring outcomes. However, the comment on the diagnosis of chronic heart failure was somewhat misleading. As we know, heart failure is a clinical syndrome characterised

by signs and symptoms of exertional dyspnoea due to structural and/or functional heart diseases with a range of left ventricular ejection fraction (LVEF) (Libby et al 2008). Some discrepancies in LVEF could be possible. “
“Systematic reviews and clinical practice guidelines are needed to inform and guide clinical practice in physiotherapy. Clinical practice guidelines should be based on systematic reviews, and both systematic reviews and clinical practice guidelines should rate the quality of evidence. However, only clinical practice guidelines should make direct recommendations about buy Ponatinib clinical practice because recommendations depend on information and judgements that go beyond systematic reviews (Guyatt et al 2008a). Many systematic reviews and clinical practice guidelines rate the strength of evidence primarily

on the basis of study design, risk RNA Synthesis inhibitor of bias, and reported p values. For example, evidence from randomised controlled trials that report statistically significant findings is rated highly. Similarly, randomised controlled trials that conceal allocation, blind assessors, and minimise drop outs are rated higher than trials that do not. This approach ignores many important aspects of evidence that need to be taken into account when rating its quality. For example, it ignores how confident we are in an estimate of the effect of a therapy and the relative importance of different types of outcomes to people who seek physiotherapy interventions. In addition, a sole focus on p values ignores imprecision which should

be used to downgrade the quality of evidence and ignores other factors that can either decrease or increase our confidence in and estimates of effect. Given the abundance of systematic reviews and the growing number of clinical practice guidelines, it is perhaps now appropriate that the international physiotherapy community focuses on improving the way we rate evidence in our reviews and guidelines. One way to improve the way we rate evidence in our systematic reviews and clinical practice guidelines is to fall in line with organisations such as BMJ Group, the Cochrane Collaboration, the American College of Physicians and the World Health Organisation, and use the GRADE system (Guyatt et al 2008a, Guyatt et al 2008b, Guyatt et al 2008c). The GRADE system (an acronym for Grading of Recommendations Assessment, Development and Evaluation) was first published in 2004. It requires authors to initially identify outcomes that are of key importance to patients and discourages authors from relying on surrogate outcomes.