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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:
child initiated, environmental modification/enrichment;
task specific training.
• Potential benefits outweigh risk of harm
• Review by Spittle et al (2012) suggests that EI for
preterm infants improves cognitive outcome but this is not
sustained into school years
• Parent-infant interaction: 18
Going Green: Workshop November 12th 2016
Mayston M, Forbes D & Carroll J 4
GMFCS I-III vs IV-V?
Bilateral vs unilateral?
Some examples of studies:
• Pin et al 2013: Systematic review of effects of
BoNTA. Poor level of studies; no conclusion
• Sewell et al 2016: Effect of spinal fusion on QOL.
• Bryant et al 2013: 6 week exercise on GMFM in
non-ambulant children (control, treadmill, bike)
• Williams & Pountney 2007: static bike training with
non-ambulant children.
• McDowell et al 2015: Efficacy of FCS in an area of
the UK. MPOC used as outcome.
• Lack of QOL studies: see Davey et al 2015 on
social participation and families of children with CP.
19 20
Evidence and current knowledge/clinical guidelines
EBP
Child and family
perspective
Therapists’
expertise
Evidence from
systematic Research
and consideration of
current knowledge,
frameworks,
guidelines…..
The ICF framework is considered to be the
universal framework for health professionals.
Which statement best reflects your view of it?
A. I know about it but am not sure how useful it is for my practice
B. The ICF is my usual clinical framework
C. I try to use it but it is difficult because not everyone else does.
D. I do not enough know about it.
E. I am not interested in using it
I know
about it b
ut am
n..
The ICF i
s my u
sual c
linica
...
I try
to u
se it
but i
t is d
iff...
I do n
ot enough
know a
...
I am
not i
ntere
sted in
usi.
.
13%
47%
0%
13%
28%
21
Clinical tool: Communication
with families
Clinical tool:
what level(s) to
work at
Clinical tool: communication
Between professionals
Clinical tool:
education
Clinical tool:
research
ICF (2001-2)/ICF-CY (2007)
Clinical reasoning tool
Clinical assessment/
outcome measure tool
Important for
environmental
considerations
Important link
to FCS
Clinical tool:
Service
planning/
delivery
Considers
personal
/cultural factors
22
Mayston 2016
I read the literature regularly and keep up to date
with new ideas and knowledge. 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
18%
24%
45%
0%0%
6%6%
23 24
EBP
Child and family
perspective
Therapists’
expertise
Evidence from
systematic Research
and consideration of
current knowledge,
frameworks,
guidelines…..
Evidence based practice……
Implications for clinical practice:
• Service delivery: how? (Dawn)
• How therapists practice & evaluate:
therapy specific activities (Jenny)
Going Green: Workshop November 12th 2016
Mayston M, Forbes D & Carroll J 5
Service delivery
25 Bobath Childrens’ Therapy Centre Wales
Do you have clear pathways for service delivery?
A. Yes
B. No
C. Not sure
D. Pathways for some areas but not all.
YesNo
Not sure
Pathways f
or som
e areas..
.
29%
46%
6%
20%
26 Bobath Childrens’ Therapy Centre Wales
Intervention? Approach?
Theory? Service delivery?
Management process?
e.g. motor control = theory e.g. hip surveillance = monitoring
27 Bobath Childrens’ Therapy Centre Wales
CIMT Fitness
OT post botox
Goal directed
Bimanual training
Context focused therapy
Home Programmes
Hip surveillance
Botulinum toxin
Pressure care
Anti-convulsants
Diazepam
SDR
Bisphosphonates
Casting Signpost
28 Bobath Childrens’ Therapy Centre Wales
Q: what’s the difference?
Outreach
block
Standard therapy
block
Single consult
e.g. 13 models of delivery
Same intervention
Intervention = treatment modality/what you will deliver Service delivery = structure of how to deliver intervention
29 Bobath Childrens’ Therapy Centre Wales
Home programmes
Not a new concept
Model of service delivery
Output
Outcome dependent on clinical reasoning
30 Bobath Childrens’ Therapy Centre Wales
Going Green: Workshop November 12th 2016
Mayston M, Forbes D & Carroll J 6
Goal directed training
Not new concept
Model of service delivery Can measure success
An element of motor control theory
31 Bobath Childrens’ Therapy Centre Wales
What is your opinion of the role of OT post botulinum toxin in management?
A. It is a model of service delivery.
B. It is a treatment modality.
C. I am not sure
D. I do not have an opinion
It is
a model o
f serv
ice d
...
It is
a treatm
ent modalit
y.
I am
not s
ure
I do n
ot have
an o
pinio
n
66%
0%
23%
11%
32 Bobath Childrens’ Therapy Centre Wales
Separate but interwoven & equally important
e.g. Family centred service 33
Bobath Childrens’ Therapy Centre Wales
Personalised therapy plan
driven by hypotheses
34 Bobath Childrens’ Therapy Centre Wales
Wisdom
Knowledge
Information
Data
35 Bobath Childrens’ Therapy Centre Wales
36 Bobath Childrens’ Therapy Centre Wales
Going Green: Workshop November 12th 2016
Mayston M, Forbes D & Carroll J 7
Cognitive ability
Time available
GMFCS level
Age
Associated difficulties
Classification
Clinical reasoning (wisdom) Research & knowledge
Right input, Right time, Right dose? 37
What is your opinion of the role of OT post botulinum toxin in management?
A. It is a model of service delivery.
B. It is a treatment modality.
C. I am not sure
D. I do not have an opinion
It is
a model o
f serv
ice d
...
It is
a treatm
ent modalit
y.
I am
not s
ure
I do n
ot have
an o
pinio
n
97%
0%0%3%
38 Bobath Childrens’ Therapy Centre Wales
Over to Jenny
39 Bobath Childrens’ Therapy Centre Wales Page 40
No clear research evidence for what
to do for a specific child.
Bobath Childrens’ Therapy Centre Wales
Page 41
Do you consider other factors than research
evidence for your clinical reasoning
A. Always
B. Never
C. Sometimes
D. Don’t know
E. Occasionally
Alway
s
Never
Sometim
es
Don’t kn
ow
Occasio
nally
100%
0% 0%0%0%
Bobath Childrens’ Therapy Centre Wales Page 42
Let’s look at the options
Bobath Childrens’ Therapy Centre Wales
Going Green: Workshop November 12th 2016
Mayston M, Forbes D & Carroll J 8
Page 43
Evidence Based Practice (Medicine) Triad
Individual Clinical
Expertise
Patient Values
and
Expectations
Best
Research
Evidence
EBP
Sackett 1996
Bobath Childrens’ Therapy Centre Wales Page 44
Best
Research
Evidence
EBP
Bobath Childrens’ Therapy Centre Wales
Page 45
Individual
Clinical
Expertise
EBP
Bobath Childrens’ Therapy Centre Wales Page 46
Individual therapists’ clinical expertise is an essential
component of successful therapy. 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
23%
46%
29%
0%0%0%3%
Bobath Childrens’ Therapy Centre Wales
Page 47
Rate the importance of individual therapy
expertise in relation to the two components of the
triad?
Very im
portant
Not im
portant
Fairl
y im
portant
As im
portant a
s oth
er ...
Don’t kn
ow
20% 20% 20%20%20%• More important
• Equally important
• Less important
• Not important at all
• Don’t know
Bobath Childrens’ Therapy Centre Wales Page 48
Individual Expertise
• Gain as much expertise as possible
• Up to date science
• Child development
• Different approaches
Bobath Childrens’ Therapy Centre Wales
Going Green: Workshop November 12th 2016
Mayston M, Forbes D & Carroll J 9
Page 49
Individual Expertise
• Train your critical thinking and analysis
• Constantly challenge your clinical
reasoning
• Develop your observational skills
• Find a framework for doing this that helps
you
Bobath Childrens’ Therapy Centre Wales Page 50
1. How do typical children function in the considered area?
2. Why do they do so?
3. How do the atypical children function in this area?
4. Why don’t they do as the typical children?
5. Why do they do as they do?
6. What would be better for them in the long term?
7. How can they be helped to achieve this? Dan 2010
Bobath Childrens’ Therapy Centre Wales
Page 51
Patient
Values
and
Expectations
EBP
Bobath Childrens’ Therapy Centre Wales Page 52
Body Functions
and Structure
(Impairment)
Activity
(Limitations) Participation
(Restrictions)
Environmental
Factors
Personal
Factors
Health
Condition
International Classification of Functioning Disability and Health
(WHO 2001)
Page 53
What we can do to consider child
and families values and
preferences
Bobath Childrens’ Therapy Centre Wales
Carroll
Forbes and
Parkinson
2014
Going Green: Workshop November 12th 2016
Mayston M, Forbes D & Carroll J 10
Page 55
Do you measure the outcome of each
intervention?
A. Not sure
B. Never measure an outcome
C. Sometimes measure an outcome
D. Usually measure an outcome
E. Always measure an outcome
F. Measure several outcomes
Not sure
Never m
easure
an o
utcom
e
Sometim
es measu
re a
n ...
Usually
measu
re an
ou...
Alway
s measu
re an o
ut...
Measu
re se
vera
l outc
omes
0% 0%
12%
3%
50%
35%
Bobath Childrens’ Therapy Centre Wales Page 56
Measure results for the individual
• PREMS
• PROMS
• Outcomes
Bobath Childrens’ Therapy Centre Wales
Page 57
Patient Report Experience Measures
(PREMS)
• Measure of Process of Care (MPOC)
• Patient stories
Bobath Childrens’ Therapy Centre Wales Page 58
Patient Reported Outcome Measures
(PROMS)
• EQ-5D
• PedsQL
• Patient stories
Bobath Childrens’ Therapy Centre Wales
Page 59
Domains of quality
PREMs
Experience of care - What do patients think
of the process of care eg dignity,
information, trust in staff, cleanliness,
timeliness?
PROMs
Effectiveness of care - Does it reduce
symptoms, improve function, improve
quality of life?
Safety - Does it cause harm eg mortality,
complications?
Bobath Childrens’ Therapy Centre Wales Page 60
Outcome Measures
• Goals
– SMART
– Goal Attainment Scaling (GAS)
Bobath Childrens’ Therapy Centre Wales
Going Green: Workshop November 12th 2016
Mayston M, Forbes D & Carroll J 11
Page 61
Measure goals
• For individual
• For service
Bobath Childrens’ Therapy Centre Wales Page 62
Using goals for service audit
Bobath Childrens’ Therapy Centre Wales
Page 63
Evidence Based Practice Triad
Individual Clinical
Expertise
Patient Values
and
Expectations
Best
Research
Evidence
EBP
Sackett 1996
Bobath Childrens’ Therapy Centre Wales Page 64
Summary……………
Page 65
This workshop has broadened my view of
evidence based practice. 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
46%
37%
17%
0%0%0%0%
Page 66
What one thing will you take away from the
workshop?
A. Some ideas on how to understand research evidence
B. It has broadened my thinking on evidence based practice
C. I will think more about service delivery vs intervention
D. I will go in to more depth in my clinical reasoning
E. I will routinely use outcome measurement in my practice
F. All of the above
G. Some of the above
Some id
eas on h
ow to
u...
It has b
roadened m
y thin
...
I will
thin
k more
about se...
I will
go in to
more
depth
..
I will
routin
ely u
se o
utc...
All of t
he above
Some o
f the a
bove
0%
26%
12%
6%
32%
9%
15%