Evidence Based Practice & Practice Based Evidence OTAC Conference 2008 Presenters: David Greene & DeepaThimmaiah
Today’s Objectives What is evidence based practice and practice based evidence? Why is this important? Where can I find information to support my clinical reasoning? How can I create my own evidence?
What is evidence based practice and practice based evidence? We base our practices on “evidence”, this “evidence” is often created from practice. EVIDENCE PRACTICE
“Evidence” Key point: evidence can be… Research based Intuitive/Self-evident Book-taught/from the experts Evidence should try to stay away from gut instincts Be able to verbalize your reasoning Clinical Reasoning!
Why is this important? • Evidence provides concrete, reliable justification for why we do what we do. • Basing our interventions on evidence is an ethical matter:
Why is this important? • Consider a casual decision to use Theraband as main OT intervention for 80+ year old active woman post unilateral total knee replacement • What is the justification for UE strengthening for this relatively healthy, very active individual whose muscles are up to the very temporary task of using a walker?!? • Is the choice of resistance and prescription of repetitions grounded in research establishing what really is necessary to strengthen UE musculature
Where do I find this evidence? If research based…..
Best bet . . . • Search literature: scan favorite journals, look in meta analyses/systematic reviews/critical appraisals (OTCATs), AOTA Evidence Briefs & Structured Abstracts
2. Locate a few good articles you can implement – keeping in mind your population; Stay away from what was done in studies that didn’t work!
Gathering Evidence from Individual Articles You Found in a Database Search
Lehtola et al.,2000 Intervention of exercise class including Tai Chi once weekly plus walking with sticks, and home exercises each at least 3× weekly for 6 months; Control usual activities Relative hazard for falls for the exercise group in 10mo = 0.60 Out of 13 intervention studies, four reported success in preventing falls; for example: (n = 92) N = 131; (n = 39) [95% CI for (Intervention) compared with (Control) 0.43, 0.84] Sports Med 2001; 31 (6): 427-438
Lehtola et al.,2000 Lower risk of falling in intervention group (n=92) = an exercise class including Tai Chi once weekly plus walking with sticks, and home exercises each at least 3× weekly for 6 months; Control (n=39) usual activities Sports Med 2001; 31 (6): 427-438
Go to: http://www.cochrane.org/reviews/ And search “Falls in the elderly” Interventions in Preventing Falls in the Elderly (Cochrane Review) Gillespie, Gillespie, Robertson, Lamb, Cumming & Rowe
Main results:Sixty two trials involving 21,668 people. Beneficial Interventions:Multidisciplinary, multifactorial, health/environmental risk factor screening/ intervention programmes in the community both for an unselected population of older people (4 trials, 1651 participants) and for older people with a history of falling (5 trials, 1176 participants)
Risk screening (for individuals with a history of falls) Programs in nursing home settings Strength and balance programs? Home hazard evaluation and modification (for individuals with a history of falls) Tai Chi group Interventions Supported by Evidence(meta analyses/systematic reviews)
Gathering Evidence . . . • Individual articles . . . • Systematic Analyses . . . • Meta analysis = one article summarizing years of work in a topic
A meta-analysis of fall prevention programs for the elderly: how effective are they? RESULTS: The overall mean weighted effect size for the 12 studies included in the meta-analysis was .0779 (Z = 5.03, p < .001) Exercise alone had a mean weighted effect size of .0220 (Z = .5303, p > .5) Exercise and risk modification had a mean weighted effect size of .0687 (Z = 3.41, p < .001) Comprehensive risk assessment intervention studies had an effect size of .1231 (Z = 3.97, p < .001) Mean weighted effect size for community-based studies was .0972 (Z = 5.37, p < .001) and for institution-based studies was .0237 (Z = .7822, p = .22) CONCLUSIONS: There was a 4% decrease in the rate of falls for individuals who were in the treatment groups receiving various fallprevention interventions – this conclusion based on 12 studies. Hill-Westmoreland EE; Nursing Research, 2002 Jan-Feb; 51 (1): 1-8. A look at meta analysis results:
Gathering Evidence . . . • Individual articles . . . • Systematic Analyses . . . • Meta analysis = one article summarizing years of work in a topic • Critically Analyzed Topics (CATs)
Gathering Evidence . . . • Individual articles . . . • Systematic Analyses . . . • Meta analysis = one article summarizing years of work in a topic . . . • Critically Analyzed Topics (CATs) . . . • AOTA Evidence Briefs & Structured Abstracts
S #1 AOTA Evidence Briefs: Stroke More research is needed on whether occupational therapy treatment for stroke patients after hospital discharge improves activities of daily living Corr, S., & Bayer, A. (1995). Occupational therapy for stroke patients after hospital discharge-A randomized controlled trial. Clinical Rehabilitation, 9, 291–296. Level IA2a Randomized controlled trial, 50 or more participants per condition or group, moderate internal validity, high external validity
Stroke Structured Abstract - S #1 More research is needed on whether occupational therapy treatment for stroke patients after hospital discharge improves activities of daily living CITATION: Corr, S., & Bayer, A. (1995). Occupational Therapy for stroke patients after hospital discharge: A randomized controlled trial. Clinical Rehabilitation, 9, 291-296. LEVEL OF EVIDENCE: IA2a RESEARCH QUESTIONWhat is the effectiveness of occupational therapy interventions on stroke patients after their discharge from a stroke unit?
Functional treatment may be as beneficial as sensorimotor integration Jongbloed, L., Stacey, S., & Brighton, C. (1989). Stroke rehabilitation: Sensorimotor integrative treatment versus functional treatment. American Journal of Occupational Therapy, 43, 391–397. Level IB2b Randomized controlled trial, 20 or more participants per condition or group, moderate internal validity, moderate external validity
What did the researchers find? Both groups improved significantly (see Glossary) over time on most of the outcome measures. There was no significant (see Glossary) difference between the two groups on any of the outcome measures. What do the findings mean? For therapists and other providers, the findings suggest that the sensorimotor integration approach is as beneficial as the functional approach. Thus therapists may not have to restrict themselves to a single type of treatment.
Current Briefs & Structured Abstracts • Attention Deficit Hyperactivity Disorder (ADHD) • Autism Spectrum Disorder • Chronic Pain • Cerebral Palsy • Children with Behavioral & Psychosocial Needs • Multiple Sclerosis
continued • Older Adult (Occupation and Activity-Based Interventions) • Parkinson's Disease • School-Based Interventions • Stroke • Substance Use Disorders • Traumatic Brain Injury • Young Children with Delayed Development
Exploring “Stroke” • More research is needed on whether occupational therapy treatment for stroke patients after hospital discharge improves activities of daily living. • and 22 more separate listings . . .
Where do I find this evidence? If self-evident…. Examples
Where do I find this evidence? If need to do own study…. Large Example - SCIRehab study Methods: Practice Based Evidence Method (PBE) 1500 patients with acute SCI 6 US inpatient rehab facilities All disciplines interventions documented on PDAs Info such as medications and nursing interventions taken from medical records Clinician profile information taken including clinical training, SCI expertise, and current practice patterns (full-time vs. part-time SCI services) Outcomes such as neurological, functional, social, vocational and psychological assessed through patient interviews 6 and 12 months post-injury (Model System Form I and Form II data)
Where do I find this evidence? If need to do own study…. Small Example Collect data amongst similar cases in which a protocol was used Utilize CSU for analysis More coming up in group discussion time