Evidence based decision making in pediatric physical therapy

Pediatric physical therapyo Infants ( under age2 years)o Children ( from 2-12 years) o adolescents ( from 13-16 or 18 years) Why Pediatric physical therapy is a specialized

entity ?o Physical/ psychological/emotional differenceso Family participation and Family Dynamicso Huge population (24% of 307,006,550 in USA) and 37% of

164,741,924 in PK

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

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 EBPSteps in achieving EBPo Formulating a Questiono Finding Evidenceo Appraisal of evidenceo Translation of evidence to practiceo Evaluation of evidence “ the responsibility to deliver evidence based treatment rests with all

members of profession not only with researchers”

Finding Evidence Peer-reviewed journals: Primary source of evidenceo sources; 1) Hard Copy libraries catalog2) Electronic databases ( e.g. MEDLINE, ERIC, PsycINFO, PEDro,

Cochrane, Hooked on evidence)Expert Consensus/ expert opinionso Secondary source of evidence ( e.g. practice guideline,

clinical pathway) e.g. C-Spine rule, Ottawa Ankle ruleo Appraisal of guidelines to research and evaluation (AGREE) Textbooks & personal experiences are also

secondary sources of evidence

Appraisal of evidence All available evidence is not Diamond or GoldImportant steps in appraisal ( primary source)o Find out a relevant research that you think can

answer your question ( journal article/systematic review, etc.)

o 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)

Hierarchical Evidence Based Practice

Levels of Evidence1+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+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

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)

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)

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 perspectiveso Family dynamicso Informed choices ( family voices, kid power)o Cultural differenceso Financial resources

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

Frameworks for Decision making

Frameworks helps in clinical decision making ( diagnosis, intervention, prognosis, etc)

1. Nagi Model presented by Saad Nagi in 19652.International Classification of Impairments,

disabilities, and Handicaps (ICIDH) published by WHO in 1980

3.International classification of Functioning, disability (ICF) and Health by WHO in 2001.

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

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)

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

Patient/client Management Model

(adapted from the APTA Guide to PT practice)

ExaminationPhysical 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??

Patient/client Management Model cont..

EvaluationPhysical 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

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

outcomes

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

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.

ABA or Withdrawal Design

A B A

Baseline Phase 0

Treatment Phase

Withdrawal phase 0

0 0 0 0 0 0 0 0 0 0 0 0

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

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)

Formal Program Evaluation

• Mostly evaluated by a separate evaluating body

• Summative VS Formative evaluation

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

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

Circular EBP

• Multiplicity of methods• Used in a complimentary fashion• Each research method has strengths and

weaknesses• Achieve a result – replicate with other

methods

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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