Evidence Based

Practice:

Intervention for people with

lower limb amputations

Karl SchurrMarch 2007

Plan

Quick review of EBP levels of evidence

What evidence is out there?

What to do with the evidence?

Implications for clinical decision making

Levels of evidence Level 1: Systematic reviews – preferably high

quality RCT’s

Publication bias: positive outcomes more likely to be published

Possibility for concentration of poor quality data

Level 2: RCT: high quality – specific criteria to

minimise bias: (eg PEDro scale)

Level 3: Pseudorandomised controlled trial

(eg alternate allocation)

Level 4: Case series

Level 5: Expert opinion, position statements

Why is expert opinion the lowest level of evidence? Potential for charismatic “experts” to exert undue influence Ignore evidence when it already exists Concentration of one person’s biases/opinions:

American paediatrician Dr Spock : “Baby and Child Care”

“one of the most influential books of the 20th century”

Sold > 22 million copies in 26 languages.

Recommended babies to sleep on their stomachs

1970: clear evidence that this was lethally bad advice

Estimates of:

10,000 unnecessary cot deaths in UK

50,000 unnecessary cot deaths in US, Australia and Europe

Expert Opinion

Conclusions: Expert opinion not always correct

Need to maintain a healthy skepticism

Essential to measure the effectiveness of

our own intervention decisions

Carefully consider options for each patient

Features of high quality Randomised controlled trials

We are all biased! Concealed random allocation Assessors blind to allocation Minimal drop outs Intention to treat analysis Standardised reliable measurement

All aim to minimise potential for bias

Minimising personal bias

Movement scientists: Measure effectiveness of intervention Each patient becomes a research question Ongoing review of each patient’s progress Continue to seek evidence Uncertainty is a fact of clinical life

Learn to enjoy it!

PEDro list

Type of trial Trials Quality Comments

Systematic

reviews 2 NA

Prescription of ankle foot prostheses

Education for decubitus ulcers

Clinical trials

Ultrasound for ulcers 6/10

No specific investigation of rehabilitation training strategies.

Rigid dressings: (to be discussed in later session)

ES for circulation for residual leg

6/10

Wound healing X 4 5/10

Prosthesis comparison: Gait

Weight acceptance

Oxygen/Energy consumption 2-5/10 Exercise vs angioplasty

TENS

Prevention of amputation

Videotape feedback

Where else? Other research areas

Normal motor behaviour: Learn what we practice Task specificity: muscle

actions – force, timing Postural adjustments: sitting,

standing, walking, running Careful review of patient

progress

What are the person’s goals?

How to push their limits? Falls risk

What specific skills do they need to learn?

What are the essential requirements of that skill?

What is this man learning?

What does he need to learn ?