Going Green: Workshop November 12th 2016 Mayston M, Forbes D & Carroll J 1 Going Green - The challenges of using evidence to influence therapy practice for children who have cerebral palsy Margaret Mayston, Dawn Forbes & Jenny Carroll APCP National Conference 2016 Brighton Neurodisability - From Birth to Transition RESEARCH BASE KNOWLEDGE & FRAMEWORKS PRACTICE GUIDELINES THERAPISTS’ EXPERTISE ICF FCS SOUND CLINICAL REASONING CLASSIFICATIONS GROWTH CURVES Why we do what we do? WHY WE DO WHAT WE DO = 2 Mayston 2016 Workshop outline: • A review of the evidence • Relevance for service delivery and interventions • Therapists’ role in EBP • Framework for evidence based practice Your role………………… • Interact using the responders • Participate in the discussion • Share experience 3 Is your responder working? A. Yes B. No C. Don’t know D. Not 100% sure Yes No Don’t know Not 100% sure 86% 3% 10% 0% 4 5 Maximise activity/participation; minimise residual impairments Happy children and families! Training functional tasks: optimal task performance; maximum participation practise and training; home activities Maintain muscle length: prevent secondary problems tone reduction/hands on/off; taping; orthotics; equipment; surgery; BoNTA Muscle activation & strengthening Facilitation, FES, repetition, loading, weight bearing, resistance Cardiovascular & general fitness exercise physiology; nutrition/diet; sport recreation Specific training: driving neuroplastic change e.g. CIMT, treadmill, robotics; Wii, VR; imagery Train postural reactions: specifically and as part of task Sensory, perceptual & cognitive function: ?sensory integration; education. neuropsychology Social/ behavioural Participation, communication: AAC; recreation, sport ‘Tools’ of therapy/intervention/management Mayston, 2007 Modify environment; Contextual factors Mobility aids; play area; family After assessment, goal setting, how do you decide which therapy/intervention tools to use? A. I consider the experimental evidence B. I do what I learnt on a course C. I do what the senior therapist suggests D. I don’t think too much, I just do it; it’s intuitive E. I have my preferred intervention e.g. Bobath, task training I consider the experiment.. I do what I learnt on a c... I do what the senior ther... I don’t think too much, I ... I have my preferred inte... 39% 0% 36% 25% 0% 6
Transcript
Going Green: Workshop November 12th 2016
Mayston M, Forbes D & Carroll J 1
Going Green - The
challenges of using
evidence to influence
therapy practice for
children who have
cerebral palsy
Margaret Mayston, Dawn Forbes & Jenny Carroll
APCP National Conference 2016 Brighton
Neurodisability - From Birth to Transition RESEARCH
BASE KNOWLEDGE &
FRAMEWORKS PRACTICE
GUIDELINES
THERAPISTS’
EXPERTISE
ICF
FCS
SOUND
CLINICAL
REASONING
CLASSIFICATIONS
GROWTH
CURVES
Why we do what we do?
WHY
WE DO
WHAT
WE DO
=
2
Mayston 2016
Workshop outline:
• A review of the evidence
• Relevance for service delivery and interventions
• Therapists’ role in EBP
• Framework for evidence based practice
Your role…………………
• Interact using the responders
• Participate in the discussion
• Share experience
3
Is your responder working?
A. Yes
B. No
C. Don’t know
D. Not 100% sure
YesNo
Don’t kn
ow
Not 100% su
re
86%
3%10%
0%
4
5
Maximise activity/participation;
minimise residual impairments
Happy children and families!
Training functional tasks:
optimal task
performance; maximum
participation
practise and training; home
activities
Maintain muscle
length: prevent
secondary problems
tone reduction/hands
on/off; taping; orthotics;
equipment; surgery;
BoNTA
Muscle activation &
strengthening
Facilitation, FES,
repetition, loading,
weight bearing,
resistance
Cardiovascular &
general fitness
exercise physiology;
nutrition/diet; sport
recreation
Specific training:
driving
neuroplastic
change
e.g. CIMT, treadmill,
robotics; Wii, VR;
imagery
Train postural
reactions:
specifically and as
part of task
Sensory, perceptual
& cognitive function:
?sensory integration;
education.
neuropsychology
Social/ behavioural
Participation,
communication: AAC;
recreation, sport
‘Tools’ of therapy/intervention/management Mayston, 2007
Modify
environment;
Contextual
factors
Mobility aids;
play area; family
After assessment, goal setting, how do you
decide which therapy/intervention tools to use?
A. I consider the experimental
evidence
B. I do what I learnt on a course
C. I do what the senior therapist
suggests
D. I don’t think too much, I just
do it; it’s intuitive
E. I have my preferred
intervention e.g. Bobath, task
training
I consid
er the e
xperim
ent..
I do w
hat I le
arnt o
n a c...
I do w
hat the se
nior t
her...
I don’t
thin
k too m
uch, I
...
I have m
y pre
ferr
ed inte
...
39%
0%
36%
25%
0%
6
Going Green: Workshop November 12th 2016
Mayston M, Forbes D & Carroll J 2
There is a lot of experimental evidence to
support therapy intervention. What is your
opinion?
A. Strongly Agree
B. Agree
C. Somewhat Agree
D. Neutral
E. Somewhat Disagree
F. Disagree
G. Strongly Disagree
Strongly
Agree
Agree
Somew
hat Agr
ee
Neutral
Somew
hat Disa
gree
Disagre
e
Strongly
Disagre
e
3%
0%
14%
6%
31%
44%
3%
7 8
Evidence from
systematic
Research
Patient/client
preference
Clinical expertise
Evidence based practice/therapy
Empirical evidence Experimental evidence
“analysing, synthesising, and evaluating the best available
evidence and integrating it with individual expertise and service
users needs……..” Frontline, 05.10.11; see Sackett 1997
Family/child focus
The literature review (published October 2013 [265 citations]:
Purpose:
“Overview of the current state of CP
intervention evidence” in order to:
1. Inform decision making ….. across a
wide span of disciplines.
2. Rapid comparison of similar
interventions for clinical decision
making
3. Comprehensive resource for planning
knowledge transfer priorities.
9
I read the Novak article and concluded…..
A. That it was interesting but not useful as a guide to clinical practice
B. That it could be a useful guide to intervention
C. Read all the studies cited
D. Did not have any strong thoughts about it
E. It made me very frustrated and angry
F. Did not read it
G. Have never heard about it
H. Do not know what all the fuss was/is about
That it
was i
ntere
stin
g b..
That it
could
be a
use
ful .
..
Read all th
e studie
s cite
d
Did n
ot have any s
trong .
..
It m
ade me very
frust
rat..
Did n
ot read it
Have neve
r heard
about it
Do not k
now w
hat all t
he...
24%
15%
12%
0%
6%
18%18%
9%
10
Data representation in figures:
1. Size of circles represents the
volume of published work:
calculated by number of
papers and level of evidence
calculated using Oxford levels
of evidence (5= RCT).
2. Location on y-axis
corresponds to GRADE
system rating
3. Colour correlates to the
Evidence Alert System. “The
traffic codes provide a simple
common language that can be
used by therapists,
researchers, managers, and
families to develop a shared
understanding of the
implications of best-available
evidence” Novak, 2012. 11
Results:
12
Going Green: Workshop November 12th 2016
Mayston M, Forbes D & Carroll J 3
Results:
13
Results:
14
• 166 papers; 64 interventions; 131 outcomes.
• Evidence alert system easy to ‘use’- but an
oversimplification and can lead to misuse.
• Some interventions not interventions e.g. hip
surveillance
• Some interventions ‘service ‘delivery’ e.g.
home programmes
• ‘Systems’ compared to single intervention
• Mixed type of evidence used for the review
• No reference to GMFCS levels
• No reference to age and stage of
development
• Unjustified attack on NDT?
The response - Novak et al 2014:
• A summary of evidence not a clinical ‘cook-
book
• Systematic reviews can aid, but never
replace, sound clinical reasoning
Reflections on Novak et al 2013:
15
Other reviews:
AACPDM levels
of evidence
16
• 37 studies of ‘conceptual approaches: Bobath; Conductive
Education; SI; Vojta, Functional therapy.
• Level II evidence for horse riding on posture; NDT on gross
motor functioning; goal therapy effective for attainment of
functional goals and participation
• “Robustness of evidence too weak and number of studies too
small”
• Advise a targeted approach based on ICF levels
Other reviews: Martin et al PT & OT in Paeds, 2010
17
• 34 articles: strength and functional training; NDT and
treadmill training (PBWSTT) for children aged 4-18
years
• Strength training most studied; no significant
differences for intensity of treatment.
• Oxford levels of evidence; all studies rather than RCTs
(e.g. Antilla, 2008)
Morgan et al 2016: Early intervention
• Infants birth to 2 years; 34 studies; 10 RCTs
• NDT was the most common intervention as experimental
or control
• Moderate to large treatment outcome had components of:
