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Evidence Based Practice: Intervention for people with lower limb amputations

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Evidence Based Practice: Intervention for people with lower limb amputations Karl Schurr March 2007 Plan Quick review of EBP levels of evidence What evidence is out ... – PowerPoint PPT presentation

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Title: Evidence Based Practice: Intervention for people with lower limb amputations


1
Evidence Based Practice Intervention for people
with lower limb amputations
  • Karl Schurr
  • March 2007

2
Plan
  • Quick review of EBP levels of evidence
  • What evidence is out there?
  • What to do with the evidence?
  • Implications for clinical decision making

3
Levels of evidence
  • Level 1 Systematic reviews preferably
    high quality RCTs
  • Publication bias positive outcomes more likely
    to be published
  • Possibility for concentration of poor quality
    data
  • Level 2 RCT high quality specific criteria
    to minimise bias (eg PEDro scale)
  • Level 3 Pseudorandomised controlled trial (eg
    alternate allocation)
  • Level 4 Case series
  • Level 5 Expert opinion, position statements

4
Why is expert opinion the lowest level of
evidence?
  • Potential for charismatic experts to exert
    undue influence
  • Ignore evidence when it already exists
  • Concentration of one persons biases/opinions
  • American paediatrician Dr Spock Baby and Child
    Care
  • one of the most influential books of the 20th
    century
  • Sold gt 22 million copies in 26 languages.
  • Recommended babies to sleep on their stomachs
  • 1970 clear evidence that this was lethally bad
    advice
  • Estimates of
  • 10,000 unnecessary cot deaths in UK
  • 50,000 unnecessary cot deaths in US, Australia
    and Europe

5
Expert Opinion
  • Conclusions
  • Expert opinion not always correct
  • Need to maintain a healthy skepticism
  • Essential to measure the effectiveness of our
    own intervention decisions
  • Carefully consider options for each patient

6
Features of high quality Randomised controlled
trials
  • We are all biased!
  • Concealed random allocation
  • Assessors blind to allocation
  • Minimal drop outs
  • Intention to treat analysis
  • Standardised reliable measurement
  • All aim to minimise potential for bias

7
Minimising personal bias
  • Movement scientists
  • Measure effectiveness of intervention
  • Each patient becomes a research question
  • Ongoing review of each patients progress
  • Continue to seek evidence
  • Uncertainty is a fact of clinical life
  • Learn to enjoy it!

8
PEDro list
Type of trial Trials Quality Comments
Systematic reviews 2 NA Prescription of ankle foot prostheses Education for decubitus ulcers
Clinical trials Ultrasound for ulcers 6/10 No specific investigation of rehabilitation training strategies. Rigid dressings (to be discussed in later session)
Clinical trials ES for circulation for residual leg 6/10 No specific investigation of rehabilitation training strategies. Rigid dressings (to be discussed in later session)
Clinical trials Wound healing X 4 5/10 No specific investigation of rehabilitation training strategies. Rigid dressings (to be discussed in later session)
Clinical trials Prosthesis comparison Gait Weight acceptance Oxygen/Energy consumption 2-5/10 No specific investigation of rehabilitation training strategies. Rigid dressings (to be discussed in later session)
Clinical trials Exercise vs angioplasty 2-5/10 No specific investigation of rehabilitation training strategies. Rigid dressings (to be discussed in later session)
Clinical trials TENS 2-5/10 No specific investigation of rehabilitation training strategies. Rigid dressings (to be discussed in later session)
Clinical trials Prevention of amputation Videotape feedback 2-5/10 No specific investigation of rehabilitation training strategies. Rigid dressings (to be discussed in later session)
9
Where else?
  • Other research areas
  • Normal motor behaviour
  • Learn what we practice
  • Task specificity muscle actions force, timing
  • Postural adjustments sitting, standing,
    walking, running
  • Careful review of patient progress

10
What are the persons goals?
How to push their limits? Falls risk What
specific skills do they need to learn? What are
the essential requirements of that skill?
11
What is this man learning?
What does he need to learn ?
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