Evidence Based Practice & Practice Based Evidence

Evidence Based Practice & Evidence Based Practice & Practice Based EvidencePractice Based Evidence

OTAC Conference 2008OTAC Conference 2008

Presenters: David Greene & Presenters: David Greene & Deepa ThimmaiahDeepa Thimmaiah

Today’s ObjectivesToday’s Objectives

What is evidence based practice and What is evidence based practice and practice based evidence?practice based evidence?

Why is this important?Why is this important? Where can I find information to support my Where can I find information to support my

clinical reasoning?clinical reasoning? How can I create my own evidence?How can I create my own evidence?

A bit about us…A bit about us…

A bit about you…A bit about you…

What is evidence based practice What is evidence based practice and practice based evidence?and practice based evidence? We base our practices on “evidence”, this We base our practices on “evidence”, this

“evidence” is often created from practice.“evidence” is often created from practice.

EVIDENCE

PRACTICE

““Evidence”Evidence”

Key point: evidence can be…Key point: evidence can be… Research basedResearch based Intuitive/Self-evidentIntuitive/Self-evident Book-taught/from the expertsBook-taught/from the experts

Evidence should try to stay away from gut Evidence should try to stay away from gut instinctsinstincts

Be able to verbalize your reasoningBe able to verbalize your reasoning

Clinical Clinical Reasoning!Reasoning!

Why is this important?Why is this important?


Evidence provides concrete, Evidence provides concrete, reliable justification for why we do reliable justification for why we do what we do.what we do.

Basing our interventions on Basing our interventions on evidence is an ethical matter: evidence is an ethical matter:

Consider a casual decision to use Theraband as Consider a casual decision to use Theraband as main OT intervention for 80+ year old active main OT intervention for 80+ year old active woman post unilateral total knee replacement woman post unilateral total knee replacement

What is the justification for UE strengthening for What is the justification for UE strengthening for this relatively healthy, very active individual this relatively healthy, very active individual whose muscles are up to the very temporary whose muscles are up to the very temporary task of using a walker?!? task of using a walker?!?

Is the choice of resistance and prescription of Is the choice of resistance and prescription of repetitions grounded in research establishing repetitions grounded in research establishing what really is necessary to strengthen UE what really is necessary to strengthen UE musculaturemusculature


Where do I find this evidence?Where do I find this evidence?

If research based…..If research based…..

Searching “theraband”Searching “theraband”

Searching “total knee Searching “total knee replacement”replacement”

Looking in Google Scholar: Looking in Google Scholar: “theraband”“theraband”

Best bet . . . Best bet . . . 1.1. Search literature: scan Search literature: scan

favorite journals, look in favorite journals, look in meta analyses/systematic meta analyses/systematic reviews/critical appraisals reviews/critical appraisals (OTCATs), AOTA (OTCATs), AOTA Evidence Briefs & Evidence Briefs & Structured AbstractsStructured Abstracts

2. 2. Locate a few good articles Locate a few good articles you can implement – you can implement – keeping in mind your keeping in mind your population; Stay away population; Stay away from what was done in from what was done in studies that didn’t work!studies that didn’t work!

3. Study the articles that 3. Study the articles that report success and report success and recreate the programrecreate the program

Gathering Evidence Gathering Evidence from Individual from Individual

Articles You Found in Articles You Found in a Database Searcha 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

Sports Med 2001; 31 (6): 427-438

N = 131; (n = 92)

(n = 39)

[95% CI for (Intervention) compared with (Control) 0.43, 0.84]

Out of 13 intervention studies, four reported success in preventing falls; for example:

Sports Med 2001; 31 (6): 427-438

Lehtola et al.,2000Lehtola et al.,2000Lower risk of falling in intervention Lower risk of falling in intervention

group (n=92) = an exercise class group (n=92) = an exercise class including Tai Chi once weekly plus including Tai Chi once weekly plus walking with sticks, and home walking with sticks, and home exercises each at least 3× weekly for 6 exercises each at least 3× weekly for 6 months; Control (n=39) usual activitiesmonths; Control (n=39) usual activities

Interventions in Preventing Falls in the Elderly (Cochrane Review)Gillespie, Gillespie, Robertson, Lamb, Cumming & Rowe

Go to: http://www.cochrane.org/reviews/

And search “Falls in the elderly”

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 Interventions SupportedSupported by Evidence by Evidence(meta analyses/systematic reviews)(meta analyses/systematic reviews)

Interventions Interventions NOT!NOT! Supported Supported

Group-Delivered ExerciseGroup-Delivered Exercise Individual LE StrengtheningIndividual LE Strengthening Home Hazard Mod. w/ Medication Home Hazard Mod. w/ Medication

SuggestionsSuggestions Home Hazard Mod. w/ education packet Home Hazard Mod. w/ education packet

on exercise and reducing fallson exercise and reducing falls Cognitive/Behavioral Approach AloneCognitive/Behavioral Approach Alone Hm. Haz. Mod. when no Hx of fallingHm. Haz. Mod. when no Hx of falling Brisk walking in older women with UE Brisk walking in older women with UE

fracturefracture

Individual articles . . .Individual articles . . . Systematic Analyses . . .Systematic Analyses . . .

Meta analysis = one Meta analysis = one article summarizing article summarizing years of work in a topicyears of work in a topic

Gathering Evidence . . .Gathering Evidence . . .

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 fall prevention 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:

Individual articles . . .Individual articles . . . Systematic Analyses . . .Systematic Analyses . . . Meta analysis = one article Meta analysis = one article

summarizing years of work in a topicsummarizing years of work in a topic

Critically Analyzed Topics Critically Analyzed Topics (CATs)(CATs)



Individual articles . . .Individual articles . . . Systematic Analyses . . .Systematic Analyses . . . Meta analysis = one article summarizing years Meta analysis = one article summarizing years

of work in a topic . . .of work in a topic . . . Critically Analyzed Topics (CATs) . . .Critically Analyzed Topics (CATs) . . .

AOTA Evidence Briefs & AOTA Evidence Briefs & Structured AbstractsStructured Abstracts

S #1 AOTA Evidence Briefs: StrokeS #1 AOTA Evidence Briefs: StrokeMore research is needed More research is needed on whether occupational on whether occupational therapy treatment for stroke patients after therapy treatment for stroke patients after hospital discharge improves activities of daily hospital discharge improves activities of daily livingliving

Corr, S., & Bayer, A. (1995). Occupational therapy for Corr, S., & Bayer, A. (1995). Occupational therapy for stroke patients after hospital discharge-A randomized stroke patients after hospital discharge-A randomized controlled trial. controlled trial. Clinical Rehabilitation, 9, 291–296.Clinical Rehabilitation, 9, 291–296.

Level IA2aLevel IA2aRandomized controlled trial, 50 or more participants Randomized controlled trial, 50 or more participants per condition or group, moderate internal validity, high per condition or group, moderate internal validity, high external validityexternal validity

Stroke Structured Abstract - S #1Stroke Structured Abstract - S #1More research is needed on whether occupational therapy More research is needed on whether occupational therapy treatment for stroke patients after hospital discharge treatment for stroke patients after hospital discharge improves activities of daily livingimproves activities of daily living

CITATION: CITATION: Corr, S., & Bayer, A. (1995). Occupational Therapy Corr, S., & Bayer, A. (1995). Occupational Therapy for stroke patients after hospital discharge: A randomized for stroke patients after hospital discharge: A randomized controlled trial. controlled trial. Clinical Rehabilitation, 9,Clinical Rehabilitation, 9, 291-296. 291-296.

LEVEL OF EVIDENCE: IA2aLEVEL OF EVIDENCE: IA2a

RESEARCH QUESTIONRESEARCH QUESTIONWhat is the effectiveness of occupational therapy interventions on What is the effectiveness of occupational therapy interventions on stroke patients after their discharge from a stroke unit?stroke patients after their discharge from a stroke unit?

Functional treatment may be as beneficial Functional treatment may be as beneficial as sensorimotor integrationas sensorimotor integration

Jongbloed, L., Stacey, S., & Brighton, C. Jongbloed, L., Stacey, S., & Brighton, C. (1989). Stroke rehabilitation: Sensorimotor (1989). Stroke rehabilitation: Sensorimotor integrative treatment versus functional integrative treatment versus functional treatment. treatment. American Journal of Occupational American Journal of Occupational Therapy, 43, 391–397.Therapy, 43, 391–397.

Level IB2bLevel IB2b

Randomized controlled trial, 20 or more Randomized controlled trial, 20 or more participants per condition or group, moderate participants per condition or group, moderate internal validity, moderate external validityinternal validity, moderate external validity

What did the researchers find?What did the researchers find? Both groups improved Both groups improved significantly (significantly (see see

Glossary) over time on most of the outcome Glossary) over time on most of the outcome measures. There was no significant measures. There was no significant (see (see Glossary) difference between the two groups on Glossary) difference between the two groups on any of the outcome measures.any of the outcome measures.

What do the findings mean?What do the findings mean? For therapists and other providers, the findings For therapists and other providers, the findings

suggest that the sensorimotor integration suggest that the sensorimotor integration approach is as beneficial as the functional approach is as beneficial as the functional approach. Thus therapists may not have to approach. Thus therapists may not have to restrict themselves to a single type of treatment.restrict themselves to a single type of treatment.

Current Briefs & Structured Current Briefs & Structured Abstracts Abstracts

Attention Deficit Hyperactivity Disorder Attention Deficit Hyperactivity Disorder (ADHD)(ADHD)

Autism Spectrum DisorderAutism Spectrum Disorder Chronic PainChronic Pain Cerebral PalsyCerebral Palsy Children with Behavioral & Psychosocial Children with Behavioral & Psychosocial

NeedsNeeds Multiple SclerosisMultiple Sclerosis

continuedcontinued Older Adult (Occupation and Activity-Older Adult (Occupation and Activity-

Based Interventions)Based Interventions) Parkinson's DiseaseParkinson's Disease School-Based InterventionsSchool-Based Interventions StrokeStroke Substance Use DisordersSubstance Use Disorders Traumatic Brain InjuryTraumatic Brain Injury Young Children with Delayed Young Children with Delayed

DevelopmentDevelopment

Exploring “Stroke”Exploring “Stroke” More research is needed on whether More research is needed on whether

occupational therapy treatment for stroke occupational therapy treatment for stroke patients after hospital discharge improves patients after hospital discharge improves activities of daily living.activities of daily living.

and 22 more separate listings . . . and 22 more separate listings . . .


If self-evident….If self-evident…. ExamplesExamples


If need to do own study….If need to do own study…. Large Example - Large Example - SCISCIRehab studyRehab study

Methods:Methods: Practice Based Evidence Method (PBE)Practice Based Evidence Method (PBE) 1500 patients with acute SCI1500 patients with acute SCI 6 US inpatient rehab facilities6 US inpatient rehab facilities All disciplines interventions documented on PDAs All disciplines interventions documented on PDAs Info such as medications and nursing interventions taken from Info such as medications and nursing interventions taken from

medical records medical records Clinician profile information taken including clinical training, SCI Clinician profile information taken including clinical training, SCI

expertise, and current practice patterns (full-time vs. part-time expertise, and current practice patterns (full-time vs. part-time SCI services) SCI services)

Outcomes such as neurological, functional, social, vocational Outcomes such as neurological, functional, social, vocational and psychological assessed through patient interviews 6 and and psychological assessed through patient interviews 6 and 12 months post-injury (Model System Form I and Form II data)12 months post-injury (Model System Form I and Form II data)


If need to do own study….If need to do own study…. Small Example Small Example

Collect data amongst similar cases in which a Collect data amongst similar cases in which a protocol was usedprotocol was used

Utilize CSU for analysisUtilize CSU for analysis More coming up in group discussion timeMore coming up in group discussion time

Small Group TimeSmall Group Time

Discussion Outcomes:1.Gain general info about what is important to the client to learn about motivation, determine goals. Is there evidence this is beneficial (worth charging for?)2.Intuitive practice – like energy conservation; what are the indicators this is beneficial? Necessary?3.Family-based approach to treatment – how prove this is effective?4.Survey research – school District; beginning and end of the school year: parents’ understanding of students’ OT program5.Multidisciplinary

1. Survey research – school District; beginning and end of the school year: parents’ understanding of students’ OT program

Thank You!Thank You!

For presentation Slides and Small-Group For presentation Slides and Small-Group Discussion Outcomes go to:Discussion Outcomes go to:

http://www.mycahs.colostate.edu/david.greene/

Documents

Evidence Based Practice & Practice Based Evidence