evidence based practice: i ntervention for people with lower limb amputations
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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 ?
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