Evidence based decision making in pediatric physical therapy

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Evidence based decision making in pediatric
physical therapy

• Pediatric physical therapy
• Infants ( under age2 years)
• Children ( from 2-12 years)
• adolescents ( from 13-16 or 18 years)
• Why Pediatric physical therapy is a specialized
  entity ?
• Physical/ psychological/emotional differences
• Family participation and Family Dynamics
• Huge population (24 of 307,006,550 in USA) and
  37 of 164,741,924 in PK

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EBP VS. Non-Standard treatment

• Non-standard treatment
• not verified through the scientific study
• not published or included in peer-reviewed
  journals
• 90 treatment methods in physical therapy are
  taken from professional education, continuing
  education, and experience.
• Turner and Whitfield, PTs use of EBP.
  Physiotherapy Research International, 2(1), 1997

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What is evidence based practice?Paradigm Shift
in 1992

• the conscientious, explicit and judicious use of
  current best evidence in making decisions about
  the care of individual patients
• (Sackett et al, 1996)
• Barriers for achieving EBP
• Steps in achieving EBP
• Formulating a Question
• Finding Evidence
• Appraisal of evidence
• Translation of evidence to practice
• Evaluation of evidence
• the responsibility to deliver evidence based
  treatment rests with all members of profession
  not only with researchers

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Finding Evidence

• Peer-reviewed journals Primary source of
  evidence
• sources
• Hard Copy libraries catalog
• Electronic databases ( e.g. MEDLINE, ERIC,
  PsycINFO, PEDro, Cochrane, Hooked on evidence)
• Expert Consensus/ expert opinions
• Secondary source of evidence ( e.g. practice
  guideline, clinical pathway) e.g. C-Spine rule,
  Ottawa Ankle rule
• Appraisal of guidelines to research and
  evaluation (AGREE)
• Textbooks personal experiences are also
  secondary sources of evidence

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Appraisal of evidence

• All available evidence is not Diamond or Gold
• Important steps in appraisal ( primary source)
• Find out a relevant research that you think can
  answer your question ( journal article/systematic
  review, etc.)
• Appraise Research design Quantitative Vs
  Qualitative
• Quantitative Research- Experimental Vs
  non-experimental
• Experimental research- true vs.
  quasi-experimental or experimental research with
  no control group
• Internal Vs. External validity
• Efficacy (RCT) Vs. Effectiveness
  (non-experimental)

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Hierarchical Evidence Based Practice
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Levels of Evidence
1 High quality meta-analysis (based on double blind) High quality RCT (double blind)
1 Good meta-analysis (based on single blind RCTs) Good RCT (single blind)
2 Poor quality meta-analysis (based on open studies) Poor RCT (open studies)
2 Cohort study
3 Outcomes, relationship, retrospective studies
4 Case report, expert opinion
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Five-level system of evidence

• Used for experimental design ( for single
  research)
• Level I II for randomized control trial (RCT)
• Level III IV for Quasi-experimental design (
  when there is no randomization)
• Level V for quasi-experimental design ( when
  there is no control group)

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Grades of Recommendation for systematic reviews

• A systematic review is a comprehensive survey of
  a topic in which all of the primary studies
  relevant to topic have been systematically
  identified, appraised and then summarized.
• Grade A recommendation is for at least one level
  I study
• Grade B recommendation is for at least one level
  II study
• Grade C recommendation is for level III, IV or V
  studies
• Meta-analysis(studies that used inferential
  statistics)

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Translation of evidence to practice

• Evidence alone does not make decision, people
  do
• why in health care transfer of evidence is
  practice is slow?
• Patient/client their family perspectives
• Family dynamics
• Informed choices ( family voices, kid power)
• Cultural differences
• Financial resources

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Clinical Reasoning and Decision Making

• Medical Model
• Person has a disease
• Treat the disease
• How are we going to cope with disease?
• Accepting person means we have change our
  practice, and it will cost more.
• Finally these persons are excluded

• Social model
• Person has an impairment
• What are the barriers?
• What are solutions to overcome barriers
• Diversity and cultural differences are accepted
• Finally these persons are included

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Frameworks for Decision making

• Frameworks helps in clinical decision making (
  diagnosis, intervention, prognosis, etc)
• Nagi Model presented by Saad Nagi in 1965
• International Classification of Impairments,
  disabilities, and Handicaps (ICIDH) published by
  WHO in 1980
• International classification of Functioning,
  disability (ICF) and Health by WHO in 2001.

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Nagi Model

• Active Pathology Interruption or interference
  of normal processes and efforts of the organism
  to regain normal state.
• Impairment Anatomical, physiological, mental,
  or emotional abnormalities or loss.
• Functional limitation Limitation in performance
  at the level of the whole organism or person
• Disability Limitation in performance of
  socially defined roles and tasks within a
  sociocultural physical environment

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ICIDH

• Disease Intrinsic pathology or disorder
• Impairment Loss or abnormality of
  psychological, physiological, or anatomical
  structure or function at organ level
• Disability Restriction or lack of ability to
  perform an activity in a normal manner
• Handicap Disadvantage resulting from impairment
  or disability that limits or prevents
  fulfillments of a normal role in community (
  Depending age, sex, cultural factors)

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ICF

• Body Functions and Structures Changes in body
  functions (physiological) or structures
  (anatomical). Change may be positive or negative(
  impairment)
• Activities Functioning at an individual level
• Participation Functioning at a societal level
• Activities and participation can be viewed in
  terms of capacity and performance
• Disability occurs when activities are limited or
  participation in societal roles is restricted.
• Example child with Hemiplegia

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Patient/client Management Model
(adapted from the APTA Guide to PT practice)
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Examination

• Physical therapists are educated and clinically
  trained to perform a number of tests and measures
  that can assess an impairment/problem
• History ( General information core interview)
• General Information Age, Gender,
  Race/ethnicity, Past medical/surgical history,
  clinical tests
• Core Interview History of present illness, pain
  symptom assessment, medical treatment, current
  level of fitness, review of systems
• How to incorporate evidence in examination??

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Patient/client Management Model cont..

• Evaluation
• Physical therapists can utilize data collected
  during examination procedures to assess
  impairment that may reflect current pathology,
  and functional limitation, as well as the
  propensity for future injury which may impact
  quality of life, and mortality

• Diagnosis
• Physical therapists can utilize data collected
  during examination procedures to provide a
  physical therapy diagnosis including
  impairments, and functional limitations
• Examples of PT diagnosis
• Muscle weakness, muscle Imbalance, lack of
  coordination

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Patient/client Management Model cont..

• Prognosis
• Based on the outcomes measured during the
  examination process, the PT can make statements
  regarding potential benefits to be derived from
  interventions that target impaired measurements,
  as well as resultant or potential pathology, and
  functional limitation.

• Interventions
• Physical therapists may provide
• coordination, communication, and documentation
• patient/client education
• direct intervention

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outcomes

• What will be final outcomes?
• Minimize functional limitations
• Health promotion and wellness
• Optimization of patient/client satisfaction
• Prevention of disability

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Evaluation of intervention/outcomes

• Case report ( non-experimental)
• Single subject design (experimental)
• ABA or withdrawal design
• A number of observations with no treatment (the A
  or baseline sessions) are followed by a number of
  observations with treatment (B).
• If the treatment is successful, there should be
  improvement on the Dependent variable in the B
  sessions.
• To show that the improvement is the effect of the
  Independent variable and not maturation or
  history, another no-treatment or A session is
  given.

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ABA or Withdrawal Design
A A A A B B B B A A A A
Baseline Phase 0 Baseline Phase 0 Baseline Phase 0 Baseline Phase 0 Treatment Phase Treatment Phase Treatment Phase Treatment Phase Withdrawal phase 0 Withdrawal phase 0 Withdrawal phase 0 Withdrawal phase 0
0 0 0 0 0 0 0 0 0 0 0 0
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Physiotherapy program evaluation

• Overall monitoring of program effectiveness
• Evaluation of record keeping
• Monitoring of therapist adherence to program
  policies
• Monitoring of therapist interaction with client,
  other health care provider, and third party
  payers
• Evaluation of client satisfaction and long-term
  outcomes

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Monitoring services within a database

• Multiple users
• Proper organization and storage of data
• Can easily be retrieved, updated and reorganized
• Requirement of Joint Commission on Accreditation
  of Healthcare Organizations (JCAHO) Commission
  on Accreditation of Rehabilitation Facilities (
  CARF)

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Formal Program Evaluation

• Mostly evaluated by a separate evaluating body
• Summative VS Formative evaluation

• Framework for program evaluation
• Does the method of service delivery represents
  the best educational practices?
• Is the intervention being implemented accurately
  and consistently?
• Is an attempt being made to verify the
  effectiveness of intervention objectively?
• Does the program carefully monitor patient
  progress and demonstrate a sensitivity to points
  in which changes in services need to be made?
• Does a system exist for determining the adequacy
  of patient progress and service delivery?
• Is the program accomplishing its goals and
  objectives?
• Does the service delivery system meet the needs
  and values of the community and clients it serves?

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Circular versus Hierarchical EBP

• Hierarchical model based on pharmacology model of
  therapy
• Applied to other complex interventions
• Surgery
• Physiotherapy
• Occupational Therapy
• Complementary or Alternative Medicin

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Circular EBP

• Multiplicity of methods
• Used in a complimentary fashion
• Each research method has strengths and weaknesses
• Achieve a result replicate with other methods

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Circle of Methods

• Experimental methods that test specifically for
  efficacy (upper half of the circle) have to be
  complemented by observational, non-experimental
  methods (lower half of the circle) that are more
  descriptive in nature and describe real-life
  effects and applicability.

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• Questions
• Comments