[ evidence in practice ]

STEVEN J. KAMPER, PhD1

Confidence Intervals:
Linking Evidence to Practice
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J Orthop Sports Phys Ther 2019;49(10):763-764. doi:10.2519/jospt.2019.0706

T
wo previous Evidence in Practice articles described the shift confident that the interval contained the
in clinical research toward using between-group differences as true population estimate.
the measure of treatment effectiveness.2,3 One key advantage to Confidence intervals are commonly
misinterpreted. A confidence interval is
reporting the between-group difference (the effect estimate),
not the range of effects that 95% of pa-
as opposed to only providing a P value from a hypothesis test, is that it tients in the population will fall into. It is
tells the reader about the size of the effect. also not strictly true to say that there is a
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

The effect in a study is called an “es-
timate” because the data are collected
from a sample of people, not from every-
one in the population. But what readers
need is a measure of the treatment effect
in the whole population—the concept of
generalizability will be covered in the
next Evidence in Practice article. The
estimate of treatment effect provided by
Journal of Orthopaedic & Sports Physical Therapy®
enced by the size of the sample and the
variability in the treatment effect. A small
study will generally have a wider confi-
dence interval compared to a large study.
If the treatment is very effective for some
people and the control is more effective
for others, then the confidence interval
will be wide.
A 95% confidence interval tells the
95% chance that the confidence interval
includes the true population effect.
The confidence interval is the range
of effects that will most likely contain the
true mean effect of treatment, compared
to the control. The reader can be confi-
dent about the size of the mean effect of
treatment when the confidence interval
is narrow, but unsure when the confi-

a study is associated with some error, so
it is important to know something about
how precise the estimate is. An effect es-
timate and its confidence interval give the
reader important information about the
size, spread, and direction of the popula-
tion treatment effect.
Confidence intervals can be applied
to estimates from many different types
of research questions, for example, about
treatment effectiveness, prevalence, risk
or prognostic factors, or diagnostic test
accuracy. The same principles apply to
confidence intervals in any study, but for
simplicity, this article focuses on treat-
ment effectiveness studies.
What Are Confidence Intervals?
Confidence intervals span a range of val-
ues above and below an effect estimate.
The mathematics behind calculating a
confidence interval are strongly influ-
reader the following: if the same treat-
ments were compared in 100 randomized
controlled trials in the same population,
and the researchers generated 100 confi-
dence intervals, the true between-group
difference would fall within 95 of those
confidence intervals. Five of the 100 con-
fidence intervals would not contain the
true between-group difference.
Because researchers typically only
conduct a study on the same population
once, the reader cannot be completely
sure that the confidence interval contains
the true effect—hence, 95% confidence.
Researchers usually report the 95% con-
fidence interval, but other intervals can
be calculated. A 90% confidence interval
would be narrower (more precise), but
the reader would have less confidence
that it contained the true effect. A 99%
confidence interval would be wider (less
precise), but the reader would be more
dence interval is wide. The true popula-
tion mean treatment effect is more likely
to be close to the effect estimate (in the
middle of the confidence interval) rather
than near either end of the range.
Using Confidence Intervals in Practice
The confidence interval gives the range
of plausible effects clinicians and patients
can expect from a treatment. This infor-
mation should form an important part
of the conversation when coming to a
shared treatment decision.
The concept of clinically meaningful
effects, described in 2 previous Evidence
in Practice articles,2,3 is also relevant
when interpreting confidence intervals.
If the lower end of the confidence inter-
val is lower than the clinically meaning-
ful effect, it is possible that the treatment
does not have a worthwhile benefit, re-
gardless of the size of the effect estimate.

School of Public Health, University of Sydney, Camperdown, Australia; Centre for Pain, Health and Lifestyle, Australia. t Copyright ©2019 Journal of Orthopaedic & Sports Physical
1

Therapy®

journal of orthopaedic & sports physical therapy | volume 49 | number 10 | october 2019 | 763
 [ evidence in practice
When a confidence interval crosses the are not very helpful when making deci-
line of no effect (ie, contains the value sions about treatment, and why well-
of zero when assessing between-group conducted meta-analyses are valuable.
differences), it is possible that the treat- Appropriately combining results from
ment is not more effective than the con- several studies in a single analysis (ie,
trol (FIGURE). meta-analysis) narrows the confidence
A study with a wide confidence inter- interval and provides a more precise es-
val does not provide useful information timate of treatment effect. Researchers
Downloaded from www.jospt.org at University of Sydney on October 1, 2019. For personal use only. No other uses without permission.
about the effectiveness of a treatment in the physical therapy field are report-
(FIGURE). This is partly why small studies ing effect estimates with confidence in-
Treatment is effective and the effect is large
enough to be meaningful
Treatment is effective, but the effect may or
may not be meaningful
Treatment is effective, but the effect is too
small to be meaningful
Treatment has no effect, is trivially effective,
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
or is trivially harmful
Treatment is harmful
Treatment is very harmful
Treatment may be trivially harmful, have no
effect, or have a trivial or large benefit
Treatment may be moderately or trivially
harmful, have no effect, or have a trivial or
Journal of Orthopaedic & Sports Physical Therapy®
moderate benefit
Treatment may be strongly or trivially
harmful, have no effect, or have a
trivial benefit
 No Meaningful 
Increasing Increasing
effect effect
harm benefit
FIGURE. Interpreting confidence intervals. Adapted with permission from Kamper.4
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764 | october 2019 | volume 49 | number 10 | journal of orthopaedic & sports physical therapy
]
tervals more regularly,1 helping readers to
accurately interpret the evidence.
Conclusion
Reporting confidence intervals is part of
a shift from judging treatment effective-
ness solely by P values to estimating the
size of an effect. Confidence intervals give
the reader critical information about the
precision of an effect estimate reported
in a trial. Integrating information about
the likely effect and its precision, along
with understanding the concept of clini-
cal meaningfulness, helps the clinician
engage patients in an informed, shared
decision-making process. t
REFERENCES
1. F reire APCF, Elkins MR, Ramos EMC, Moseley AM.
Use of 95% confidence intervals in the reporting
of between-group differences in randomized
controlled trials: analysis of a representative
sample of 200 physical therapy trials. Braz J Phys
Ther. 2019;23:302-310. https://doi.org/10.1016/
j.bjpt.2018.10.004
2. Kamper SJ. Interpreting outcomes 2—statistical
significance and clinical meaningfulness: linking
evidence to practice. J Orthop Sports Phys
Ther. 2019;49:559-560. https://doi.org/10.2519/
jospt.2019.0704
3. Kamper SJ. Interpreting outcomes 3—clinical
meaningfulness: linking evidence to practice.
J Orthop Sports Phys Ther. 2019;49:677-678.
https://doi.org/10.2519/jospt.2019.0705
4. Kamper SJ. Showing confidence (intervals).
Braz J Phys Ther. 2019;23:277-278. https://doi.
org/10.1016/j.bjpt.2019.01.003