Evidence based decision making in pediatric physical therapy

1. Evidence based decision makingin 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

2. EBP VS. Non-Standard treatment • Non-standard treatment • not verified through the scientific study • not published or included in peer-reviewed journals • 90% treatmentmethods 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

3. 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”

4. 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

5. 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)

6. Hierarchical Evidence Based Practice

7. Levels of Evidence

8. 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)

9. 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)

10. 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

11. 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

12. Frameworks for Decision making • Frameworks helps in clinical decision making ( diagnosis, intervention, prognosis, etc) • Nagi Model presented by SaadNagi 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.

13. 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

14. 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)

15. 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

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

17. 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??

18. 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

19. 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

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

21. 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.

22. ABA or Withdrawal Design

23. 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

24. 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)

25. 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?

26. 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

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

28. 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.

29. Questions & Comments