program in physical therapy - cdn.ymaws.com · from theory to clinical practice: using clinical...

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From Theory to Clinical Practice: Using Clinical Practice Guidelines to

Implement Evidence Based Care across a Variety of Physical Therapy

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Beth Crowner PT, DPT, NCS, MPPA

Gregory Holtzman, PT, DPT, SCS

Washington University-Program in Physical Therapy

Program in Physical Therapy

Learning Objectives

• Describe what a Clinical Practice Guideline is and understand the purpose of a Clinical Practice Guideline relative to clinical care

• Describe how Clinical Practice Guidelines were/are developed and maintained

• Find specific Clinical Practice Guidelines relevant to a certain practice setting or diagnosis

• Identify all available Clinical Practice Guidelines across various practice settings.

• Illustrate how to implement aspects of the Clinical Practice Guidelines into clinical care


Clinical Practice Guidelines (CPG’s)

• Are not the same as Central Pattern Generator’s

They are:

“statements that include recommendations intended to optimize patient care that are

informed by a systematic review of evidence and an assessment of the benefits

and harms of alternative care options.”

IOM 2011


Purposes and Benefits of CPG’s

• Provides a thorough synthesis of current literature of a content area

• Indicates level of confidence in the body of literature by providing summaries or ratings of recommendations

• Provide direction for best practice based on literature

• Busy clinicians are limited in the time they have to review all the primary articles


Level of Evidence Hierarchy

State University of New York


APTA Goals and Objectives

• Support members’ knowledge translation of research into practice

• Allocates budget to support CPG development

• Training of Guideline Development Groups (CDG’s)

• Grant funding for GDG applicants

• Provide ongoing consultation; some librarian support

• PTNow – Houses many clinical summaries, recommended outcome measures, and a CPG repository

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APTA Goals and Objectives

• Designing patient registry based on CPG recommendations for measurement

• Future: Will be educating members on need to comply with CPG’s in order to get reimbursed

• MACRA legislation going into effect in 2017 has led to a push for creation of CPG’s in a number of areas (PD, CVA, spinal surgery, hip fx, knee arthroscopy)


How Does a CPG Get Created?


Section/Academy Oversight and Administrative Structure

Director of Practice/EBP Coordinator

and Advisory Committee

Vestibular Hypofunction

CPG Chair Core Outcome

Measures

CPG Chair

Locomotor Training

CPG Chair

Concussion

CPG Chair Orthotic and

Neuroprosthetic

CPG Chair

TBD in 2017


Steps for CPG Creation

Process from start to finish takes 3-4 years!!

1. Topic Identification

2. Development of CPG Team and support structure

3. Refining the scope of the CPG

4. Methods and search strategy

5. Critical appraisal process

6. Store, extract, and synthesize findings

7. Publication

8. Dissemination


Step 1: Topic Identification

• Section’s Board of Directors, Advisory Committee, and/or membership can propose a topic.

• Board and Advisory Committee prioritize topics to be transitioned into an Evidence Based Document (EBD)

• Topic should be based on clinician interest, consumer demand, prevalence of the diagnosis in physical therapy, levels of variability in practice, abundance of literature or conflicting results within the literature, the effect of the guideline in terms of cost of recommended care, or its importance for reimbursement and policy development

(Peds Manual- Pediatr Phys Ther 2013;25:257–270).


Step 2: Development of CPG Team and support structure

• Director of Practice puts out a “call” for group members for a topic

• A group can approach a Director of Practice/Board with a proposal for a topic

• Work group should have both clinical and research experts who have an understanding of evidence based practice and creation of EBD’s

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Step 2: Development of CPG Team and support structure (con’t)

• Applicants are reviewed and selected by the Advisory Committee; must have appropriate experience and limited conflict of interest;

• Group size varies with scope and type of CPG=3-6 members

• Once a group is formed, they identify other consultants or infrastructure resources


Step 2: Development of CPG Team and support structure (con’t)

After a GDG group is formed, they can attend a summer workshop at APTA for training:

• Set priorities or scope

• Identify target audience

• Identify consumer and stakeholder involvement

• Conflict of interest considerations


Topic Focused EBD Chair (methods, administrator)

Medical Librarian EBD Methodologists (2) (e.g., include Advisory Committee Member)

Stakeholder Review Committee

(e.g., MD, RN, SW, OT, SLP, Policy/payers,

Consumer/Family)

Research Content Experts (2-3)*

Clinical Content Experts (NCS) (2-3)*

Statistician

Project Manager/Admin

Support


Step 3: Refining the scope of the CPG • PICO/PECOT Question generation (Patient

group, Intervention/Exposure, Comparison, Outcomes, Time)

• Dependent upon two things: The breadth and depth of the EBD and the type of EBD

• Determine the strength of the evidence in a given content area; not all groups may end up publishing a CPG (may be a systematic review)


Step 4: Methods and search strategy • Establish inclusion/exclusion criteria for

initial CPG search

• Determine key words for search strategy

• Search Databases:

– MEDLINE

– Embase

– CINAHL

– CENTRAL Register of Controlled Trials


Step 4: Methods and search strategy

• Complete an initial search

• Identify existing evidence (CPG, SR’s, RCT’s, etc.)

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Step 5: Critical appraisal process • Critical appraisal requires the SECOND

LITERATURE SEARCH and assumes PICO question and key conceptual definitions have been clearly defined

• Conduct the search and enter abstract information into a database (Distiller or comprehensive meta-analysis software)


Step 6: Store, extract, and synthesize findings • Create a team of appraisers (it takes a village) to assist GDG members

• Train appraisers to appraise/grade articles; establish reliability of appraisers

Use a consistent tool for appraisal

1. Intervention Studies: CAT-EI

2. Outcome Measure Tools: Consensus Based Standards for the Selection of Health Measurement Instruments (COSMIN)

3. Systematic Reviews: AMSTAR

4. CPG’s: AGREE II

• Fetters and Tilson (2012) within their text, discuss and provide appraisal tools across the different types of studies: (http://www.fadavis.com/product/physical-therapy-practical-guide-evidence-based-practice-fetters-tilson)


Step 6: Store, extract, and synthesize findings

• Extract information from the articles that meet quality criteria to inform the EBD; Enter into an Evidence Table.

• Synthesize evidence across retrieved/appraised studies to come to consensus about recommendation for clinical use.


Step 6: Store, extract, and synthesize findings (Writing Recommendations)

• Make “strength of evidence” recommendations for clinical use based on the criteria/format group has previously agreed upon.

• Have a standardized scale of recommendations

• Use Bridge-WIZ to assist

• Action statements, elaboration, levels of evidence and strength of recommendation

Program in Physical Therapy Program in Physical Therapy

Step 7: Publication

• GDG drafts a manuscript that is vetted by the CPG Advisory Committee and their own stakeholder review committee

• Get’s posted for public review and comment for 30 days

• Submit to a journal for publication

http://www.fadavis.com/product/physical-therapy-practical-guide-evidence-based-practice-fetters-tilson

















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Revising CPG’s

• The goal of most Sections is to revise/update CPG’s every 5 years

• Ensures that guidelines are up to date as new evidence becomes available


Step 8: Dissemination; Where can they be found?

• Original journal (Step 1)

• Section/Academy websites

• PEDro (Physiotherapy Evidence Database)

• http://www.pedro.org.au/

• National Guidelines Clearinghouse/AHRQ

• https://www.guideline.gov/

• Guidelines International Network (G-I-N)

• http://www.g-i-n.net/

• PTNOW

• http://www.ptnow.org/Default.aspx


Step 8: Dissemination; How else can the information be delivered?-Dissemination

• Often GDG’s will have an associated taskforce created for dissemination and implementation

• Consider dissemination to providers, consumers, payers, referral sources

• Methods: Fact sheets, webinars, podcasts, apps, professional presentations, “kits” of information for providers- just to name a few


Step 8: Dissemination; How else can the information be delivered?-Implementation

• Ok, so we know about the CPG, but how do we implement the findings into practice?

• Relates to Knowledge Translation (KT)


Monitor Knowledge

Use

Sustain Knowledge

Use

Evaluate Outcomes

Adapt Knowledge

to Local Context

Assess Barriers to

Knowledge Use

Select, Tailor, Implement

Interventions

Identify Problem ----------------------------------

Identify, Review, Select Knowledge

Products/ Tools

Knowledge Synthesis

Knowledge Inquiry

KNOWLEDGE CREATION (funnel)

Graham 2006 ACTION CYCLE (application) Program in Physical Therapy

Strategies to Sustain Compliance: Administrators

• Leadership

• Support ongoing “champions”

• Identify individual accountable for continuing to update practice

• Financial supports

• Include compliance with processes for EBP/project as component of merit increases

• Allow some “protected time” for learning new processes or procedures

• Send staff to CEU courses related to content area to enable them to feel comfortable and to act as continued resources/champions

http://www.pedro.org.au/


https://www.guideline.gov/


http://www.g-i-n.net/






http://www.ptnow.org/Default.aspx

http://www.ptnow.org/Default.aspx

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Strategies to Sustain Compliance: Clinicians

• EBP/Project should be relevant

• Education on the CPG, population to whom results are applicable

• Peer chart audits with feedback

• Journal clubs

• Report provider compliance in conferences/pt. education

• Required documentation


Published or “In Process” CPG’s-Pediatrics

Published: Congenital muscular torticollis (2013)

• http://www.ncbi.nlm.nih.gov/pubmed/24076627

• https://www.guideline.gov/

In process:

1. Physical Therapy Management of Children with Developmental Coordination Disorder (? 2017)

2. The Role of Gait Analysis in the Management of Children with Cerebral Palsy (? 2019)

3. Role of physical therapy in the prevention of contracture and deformity in Duchenne muscular dystrophy (? 2020)


Published or “In Process” CPG’s-Neurology

Published: Tx of peripheral vestibular hypofunction;

http://www.ncbi.nlm.nih.gov/pubmed/?term=peripheral+vestibular+hypofunction%2C+hall%2C+whitney


In Process:

1. Core outcome measures in neuro rehab (2017)

2. Concussion (persistent mild symptoms; multi-section sponsored; (? Late 2017 or 2018)

3. Locomotor training (CVA, SCI and TBI); (? 2018)

4. Orthotics and neuroprosthetics (? 2019)


Published or “In Process” CPG’s-Geriatrics

• Systematic Review (was to be a CPG) on outcome measures for falls; in press; associated with GeriEDGE

In Process:

• Full CPG related to falls

• Osteoporosis CPG – probably will be a guidance statement (given the many existing CPG’s)

• Hip fx CPG with Ortho section

Clinical Practice Guidelines in Orthopedics: Development and

Implementation


Clinical Practice Guidelines in Orthopedics: Development and Implementation

• 200

2001

• Body Structures/functions Impairments • Activities Limitations • Participation

Restrictions

http://www.ncbi.nlm.nih.gov/pubmed/24076627

http://www.ncbi.nlm.nih.gov/pubmed/24076627


http://www.ncbi.nlm.nih.gov/pubmed/?term=peripheral+vestibular+hypofunction,+hall,+whitney





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Clinical Practice Guidelines in Orthopedics: Development and Implementation

• Began a project to use the ICF model to develop evidence-based guidelines for a variety of orthopedic conditions

• Goal of the project was to enhance: • Diagnosis/Classification

• Prognosis

• Intervention

• Outcome Measurement

• Five Primary Tasks Identified by the Section to Complete…

2006


Orthopedic Section Project Methodology

• Identify body regions to address and specific musculoskeletal conditions that affect each body region

• For each condition, describe the following relative to the ICF • Impairments in specific body structures and functions with a focus

on structures primarily related to movement

• Limitations in an individual’s ability to perform or execute a particular action or activity

• Restrictions in an individual’s ability to participate in life situations

• Describe a system of classification for each condition to identify homogeneous subsets of individuals that will best respond to specific interventions

• Describe evidence-based interventions specific to the subsets identified for each musculoskeletal condition

• Summarize guidelines for dissemination


Body Regions Identified For CPG Development

• Foot/Ankle

• Knee

• Hip

• Lumbosacral

spine

• Cervicothoracic

spine

• Shoulder

• Elbow


Published Clinical Practice Guidelines to Date • Heel pain / Plantar fasciitis (2008)

• Revision (2014)

• Neck Pain (2008)

• Revision (2016 – in review)

• Hip Pain and Mobility Deficits / Hip Osteoarthritis (2009)

• Revision (2016 – in review)

• Knee Stability and Movement Coordination Impairments / Knee Ligament Strain (2010)

• Knee Pain and Mobility Impairments / Meniscal And Articular Cartilage Lesions (2010)

• Achilles Pain, Stiffness, and Muscle Power Deficits / Achilles Tendinitis (2010)

• Low Back Pain (2012)

• Shoulder pain and Mobility Deficits/Adhesive Capsulitis (2013)

• Ankle Stability and Movement Coordination Impairments / Ankle Ligament Sprain (2013)

• Non-arthritic Hip Joint Pain (2014)


Where can you find the Orthopedic Section CPGs

• All Orthopedic Section Clinical Practice Guidelines are published in JOSPT (Journal of Orthopedic and Sports Physical Therapy)

• All Clinical Practice Guidelines can also be found on the Orthopedic Section Website • You do not even have to be an APTA member

• But, you should be an APTA member for many

other reasons

• https://www.orthopt.org/content/home


Using CPGs to Guide Clinical Practice: Case Examples

• Shoulder pain and Mobility Deficits/Adhesive Capsulitis • Two case examples

• The purpose of this discussion is not to educate you about adhesive capsulitis, but rather to…

• Introduce you to the following: • The structure of the orthopedic clinical practice guidelines

• The use of the clinical practice guidelines to improve processes related to examination and classification

• The use of the clinical practice guidelines to direct evidence based treatment and to improve the use of specific tools to measure outcomes

• The grades of recommendation for examination and treatment that are based on evidence

• The summary statements and recommendations made by the authors

• This discussion (though specific to adhesive capsulitis) should also relate to the use of other CPGs in clinical practice

https://www.orthopt.org/content/home

https://www.orthopt.org/content/home

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Orthopedic Clinical Practice Guidelines: Structure

• Overall Recommendations • Quick read initially summarizing all of the clinical findings in the CPG

• Does not detail level of evidence of grades of recommendations

• Allows for a brief overview of recommendations as needed for practice

• Introduction • Generic explanation of purpose

• Methods • Describes search process for evidence specific to the musculoskeletal

condition addressed in the clinical practice guideline

• Defines the Levels of Evidence used to grade research articles used

• Defines the Grades of Recommendations based on the strength of the evidence

• ICF Classification


Rating Systems Used for Recommendations

Levels of Evidence

Grades of Recommendations


Orthopedic Clinical Practice Guidelines: Structure Continued • Impairment/Function Based Diagnosis

• Incidence/Prevalence

• Patho-anatomical Features

• Risk Factors

• Clinical Course

• Diagnosis/Classification

• Differential Diagnoses

• Imaging

• Examination (Structure according to ICF model) • Outcome measures

• Activity Limitations / Participation Restrictions common to musculoskeletal condition

• Physical Impairment Measures: Specific tests described


Orthopedic Clinical Practice Guidelines: Structure Continued

• Interventions • Mostly rehabilitation related

• Medical interventions addressed if appropriate for specific musculoskeletal condition

• Specific research articles discussed for each type of intervention to determine a grade of recommendation

• Examples of interventions consistently discussed across CPGs

• Patient education

• Modalities

• Manual Therapy

• Exercise (Stretching or Strengthening)

• Other

• Summary of Recommendations • Similar to initial recommendations, but includes Grades of

Recommendations based on strength of evidence


Using the Clinical Practice Guidelines: A Story of Two Patients

Patient A

• 54 year old male

• Referred to PT for left rotator cuff tendinitis

• Started as a mild/dull pain in left shoulder for several months

• Noticed difficulty reaching hand behind back

• ROM loss in several planes increased and pain worsened

Patient B

• 58 year old male

• Referred to PT for left adhesive capsulitis

• 3 months ago noticed difficulty reaching arm behind back in shower

• Pain then started to increase

• Pain with laying on left side

• Received injection 2 months after onset. • Increased ROM

• Decreased pain


History: Risk Factors Suggestive of Adhesive Capsulitis

Risk Factors Patient A Patient B Level of Evidence

Female > Male No No II

Age 40-65 Yes Yes II

Diabetes No No II/III

Thyroid disease No Yes II

Previous episode

No* No II

Grade of Recommendation: B

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History: Hallmark Activity Limitations of Adhesive Capsulitis

Activity Limitations

Patient A Patient B Grade of Recommendation

Pain during sleep No Yes F – Expert opinion

Pain and difficulty with grooming and dressing

Yes Yes F – Expert opinion

Pain and difficulty with reaching activities

Yes Yes F - Expert opinion

Outcome Measure: Quick Dash*

36 25 (since injection) A – Strong Evidence to support use

* Quick Dash: 0-100 where 0 is good status and 100 is poor status


Examination Patient A: Hallmark signs of Adhesive Capsulitis


Examination Patient B: Hallmark signs of Adhesive Capsulitis


The Bridge between Examination and Treatment… Tissue Irritability

Patient B prior to injection

Patient A and B at the time of evaluation


Interventions Supported by CPG: Overview


Interventions: Corticosteroid Injection

• Medical interventions not always discussed in clinical practice guidelines.

• However, there is strong support in the literature for the use of corticosteroid injections in the treatment of adhesive capsulitis to • Dampen inflammatory response

• Decrease pain

• Increase ROM

• Summary Grade of Recommendation per CPG

A

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Interventions: Patient education • Evidence suggests that clinicians should educate patients

regarding the following when treating adhesive capsulitis • The natural course of the disease (generally self-limiting process)

• Stage 1: End range pain, pain at rest, sleep disturbance lasting 1-3 months

• Stage 2: Freezing stage characterized by gradual loss of ROM in all direction due to pain. Can last for 3-9 months after symptom onset

• Stage 3: Frozen stage characterized by pain and loss of motion. Can last for 9-15 months after onset of symptoms

• Stage 4: Thawing stage characterized by decreased pain, but persistent stiffness that can last 15-24 months after onset

• Activity moderation exercise that promotes functional, pain free ROM that matches current tissue irritability


B Program in Physical Therapy

Interventions: Modalities

• Difficult to determine the effect of a singular modality on pain or ROM as modalities are often used in adjunct with other therapies

• Overall some weak evidence supports the use of diathermy, ultrasound, and electrical stimulation combined with mobility and stretching exercises to reduce pain and increase ROM

• No support provided for the use of superficial heat or cold alone so no specific recommendations in clinical practice guidelines.


C


Interventions: Joint Mobilizations • While there is some evidence that supports the benefit of

joint mobilization for the treatment of adhesive capsulitis,

• There is very little evidence to support “superior efficacy” over other interventions (such as stretching)

• Mostly Level II studies reported (no Level 1 studies)

• Authors suggest that there might be a subgroup of patients that respond better to mobilizations than others. Need for further research

• Given the frequency to which manual therapy is perceived to be provided to this patient population, the conclusion reached in this CPG is very surprising


C • Program in Physical Therapy

Interventions: Passive Stretching

• Evidence suggests that stretching does appear to decrease pain and improve ROM (Mostly Level II).

• However, stretching is not necessarily more helpful than other interventions.

• No evidence that would guide optimal frequency, repetitions, or duration.

• Future research is needed to determine what types of patients might respond best to stretching.


B


Summary of Recommendations

• At the end of every clinical practice guideline

• Summarizes the Grades of Recommendations for each aspect of diagnosis/classification and intervention

• Quick reference to guide evaluation and treatment

• Also easy to share with patient, as needed, for additional education


Cases - Summary of Treatment/Outcomes to date based on use of CPGs

• Patient A • Emphasized education regarding clinical course of adhesive capsulitis

• Patient clearly stated that he did not want a lot of exercises and would likely not be compliance with lots of exercises

• Treatment, therefore consisted of only 4-6 stretching exercises and education

• Patient was not treated with joint mobilizations

• Patient did not want to receive and injection from a physician

• Patient was seen 1-2 times per month for approximately 6 months

• Patient clearly followed typical clinical course for adhesive capsulitis into thawing phase in which he had little to no pain, improved function, and increased satisfaction

• As expected, some ROM deficits remained but function was high

• Case in which “supervised neglect” as suggested in the CPG was effective

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Cases - Summary of Treatment/Outcomes to date based on use of CPGs

• Patient B • Just stared seeing this patient about 3 weeks ago so too early to

assess progress related to the clinical course of the condition

• Good example of a patient that experienced immediate and significant improvement from a corticosteroid injection, which is well supported in the literature per the CPG

• This particularly patient had some significant concerns regarding frequency of visits and amount of co-pays that would be required

• Evidence presented in the CPG for adhesive capsulitis makes be confident that his condition can be effectively managed at a frequency of only 1x/week at most.

• Focus of intervention (in addition to injection)

• Patient education

• Home exercise program to stretch shoulder

• Passive stretching when he does come in to the clinic


Knowledge Translation Process

• Identify Problem and Select the Knowledge Tool

• Adhesive Capsulitis and Clinical Practice Guideline

• Adapt Knowledge to Local Context

• Access to actual clinical practice guidelines

• What does your clinical setting afford with regards to evaluation and treatment

• Access to physician resource for injections

• Modality Equipment

• Educational Resources

• Mobilization/manual therapy training

• Patient care model (frequency/duration of treatments)

• Assess Barriers to Knowledge Use

• Patient access to care (i.e. rehabilitation services or medical services/injection)

• Patient insurance limitations

• Patient population concerns

• Clinical practice limitations/equipment

• Based on these factors you can best tailor your interventions

• Evaluate outcomes to sustain knowledge use or change practice behavior


Implementation of CPG using Technology • Clinical Pattern Recognition Application

• Distributed by Michael Wong

• Applications available for Apple

• Web App available for Desktop or Android devices

• Disclosures: None

• Includes comprehensive summaries of many of the clinical practice guidelines that can be used to guide evidence based clinical practice

• Includes information/videos regarding • Clinical reasoning

• Movement impairment tests

• Tests for source of symptoms

• Specific interventions including manual therapy techniques and relevant exercise prescription

• Current demonstration relates to adhesive capsulitis but other apps cover a variety of joints/body regions


Clinical Pattern Recognition Tools


Brief Application Demonstration

• Clinical Practice Guidelines versus Clinical Pattern Recognition

• Shoulder Pain with Mobility Deficits • Prevalence

• Clinical Findings to include nature course of the condition

• Include video

• Physical Exam

• Key findings

• Clinical reasoning – power point

• Exam techniques – video

• Differential Exam Finding

• Interventions

• Clinical reasoning – power point

• Manual therapy

• Exercise and functional activity

• Patient education – Script

• Modalities

• Outcome Measures – Links to measures


Forthcoming Clinical Practice Guidelines in Orthopedics • Under Development

• Patellofemoral pain syndrome

• Carpal Tunnel Syndrome (in collaboration with Hand Rehab Section)

• Elbow Epicondylitis (in collaboration with Hand Rehab Section)

• Distal Radius Fractures (in collaboration with Hand Rehab Section)

• Shoulder Instability (in collaboration with Sports Section)

• Hip Fracture (in collaboration with Academy on Geriatrics)

• Post Concussion Syndrome (in collaboration with Neuro and Sports Sections)

• Medical Screening in Management of Common Musculoskeletal Conditions ( in collaboration with Federal PT Section)

• Prevention of ACL injuries ( in collaboration with Sports Section)

• Planned CPGs • Shoulder Rotator Cuff Syndrome

• Others • Antepartum Pelvic Pain

• Work Rehabilitation

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Take Home Messages

• Orthopedic Clinical Practice Guidelines (and others) serve as a concise summary of best practice (evaluation, diagnosis, interventions, and outcome measures) for specific body regions based on the best available evidence at the time of publication

• Today, we have shown you how these tools can guide clinical practice

• Keep in mind that someday, these guidelines may likely guide payment/reimbursement

• Take the time to read the clinical practice guidelines related to your individual practice/patient population

• Utilize technology if needed/available to reduce barriers to access for the clinical practice guidelines

• Attend the additional talks today regarding additional clinical practice guidelines relative to your practice


program in physical therapy - cdn.ymaws.com · from theory to clinical practice: using clinical...

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