1. Evidence Based Practice & Practice Based Evidence OTAC Conference 2008 Presenters: David Greene & Deepa Thimmaiah

2. Todays Objectives What is evidence based practice and practice based evidence? What is evidence based practice and practice based evidence? Why is this important? Why is this important? Where can I find information to support my clinical reasoning? Where can I find information to support my clinical reasoning? How can I create my own evidence? How can I create my own evidence?

3. A bit about us…

4. A bit about you…

5. What is evidence based practice and practice based evidence? We base our practices on evidence, this evidence is often created from practice. We base our practices on evidence, this evidence is often created from practice. EVIDENCE PRACTICE

6. Evidence Key point: evidence can be… Key point: evidence can be… Research based Research based Intuitive/Self-evident Intuitive/Self-evident Book-taught/from the experts Book-taught/from the experts Evidence should try to stay away from gut instincts Evidence should try to stay away from gut instincts Be able to verbalize your reasoning Be able to verbalize your reasoning Clinical Reasoning!

7. Why is this important?

8. Evidence provides concrete, reliable justification for why we do what we do. Evidence provides concrete, reliable justification for why we do what we do. Basing our interventions on evidence is an ethical matter: Basing our interventions on evidence is an ethical matter:

9. Consider a casual decision to use Theraband as main OT intervention for 80+ year old active woman post unilateral total knee replacement Consider a casual decision to use Theraband as main OT intervention for 80+ year old active woman post unilateral total knee replacement What is the justification for UE strengthening for this relatively healthy, very active individual whose muscles are up to the very temporary task of using a walker?!? What is the justification for UE strengthening for this relatively healthy, very active individual whose muscles are up to the very temporary task of using a walker?!? Is the choice of resistance and prescription of repetitions grounded in research establishing what really is necessary to strengthen UE musculature Is the choice of resistance and prescription of repetitions grounded in research establishing what really is necessary to strengthen UE musculature Why is this important?

10. Where do I find this evidence? If research based….. If research based…..

11. Searching theraband

12. Searching total knee replacement

13. Looking in Google Scholar: theraband

18. Best bet... 1.Search literature: scan favorite journals, look in meta analyses/systematic reviews/critical appraisals (OTCATs), AOTA Evidence Briefs & Structured Abstracts

19. 2. Locate a few good articles you can implement – keeping in mind your population; Stay away from what was done in studies that didnt work!

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

21. Gathering Evidence from Individual Articles You Found in a Database Search

23. 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:

24. Sports Med 2001; 31 (6): 427-438 Lehtola et al.,2000 Lower risk of falling in intervention group (n=92) = an exercise class including Tai Chi once weekly plus walking with sticks, and home exercises each at least 3× weekly for 6 months; Control (n=39) usual activities

25. Interventions in Preventing Falls in the Elderly (Cochrane Review) Gillespie, Gillespie, Robertson, Lamb, Cumming & Rowe Go to: http://www.cochr ane.org/reviews/ http://www.cochr ane.org/reviews/ And search Falls in the elderly

26. 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)

27. 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 Supported by Evidence (meta analyses/systematic reviews)

29. Interventions NOT! Supported Group-Delivered Exercise Group-Delivered Exercise Individual LE Strengthening Individual LE Strengthening Home Hazard Mod. w/ Medication Suggestions Home Hazard Mod. w/ Medication Suggestions Home Hazard Mod. w/ education packet on exercise and reducing falls Home Hazard Mod. w/ education packet on exercise and reducing falls Cognitive/Behavioral Approach Alone Cognitive/Behavioral Approach Alone Hm. Haz. Mod. when no Hx of falling Hm. Haz. Mod. when no Hx of falling Brisk walking in older women with UE fracture Brisk walking in older women with UE fracture

31. Individual articles... Individual articles... Systematic Analyses... Systematic Analyses... Meta analysis = one article summarizing years of work in a topic Meta analysis = one article summarizing years of work in a topic Gathering Evidence...

32. 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:

33. Individual articles... Individual articles... Systematic Analyses... Systematic Analyses... Meta analysis = one article summarizing years of work in a topic Meta analysis = one article summarizing years of work in a topic Critically Analyzed Topics (CATs) Critically Analyzed Topics (CATs) Gathering Evidence...

37. Individual articles... Individual articles... Systematic Analyses... Systematic Analyses... Meta analysis = one article summarizing years of work in a topic... Meta analysis = one article summarizing years of work in a topic... Critically Analyzed Topics (CATs)... Critically Analyzed Topics (CATs)... AOTA Evidence Briefs & Structured Abstracts AOTA Evidence Briefs & Structured Abstracts

40. S #1 AOTA Evidence Briefs: Stroke More research is needed on whether occupational therapy treatment for stroke patients after hospital discharge improves activities of daily living Corr, S., & Bayer, A. (1995). Occupational therapy for stroke patients after hospital discharge-A randomized controlled trial. Clinical Rehabilitation, 9, 291–296. Level IA2a Randomized controlled trial, 50 or more participants per condition or group, moderate internal validity, high external validity

41. Stroke Structured Abstract - S #1 More research is needed on whether occupational therapy treatment for stroke patients after hospital discharge improves activities of daily living CITATION: Corr, S., & Bayer, A. (1995). Occupational Therapy for stroke patients after hospital discharge: A randomized controlled trial. Clinical Rehabilitation, 9, 291-296. LEVEL OF EVIDENCE: IA2a RESEARCH QUESTION What is the effectiveness of occupational therapy interventions on stroke patients after their discharge from a stroke unit?

43. Functional treatment may be as beneficial as sensorimotor integration Jongbloed, L., Stacey, S., & Brighton, C. (1989). Stroke rehabilitation: Sensorimotor integrative treatment versus functional treatment. American Journal of Occupational Therapy, 43, 391–397. Level IB2b Randomized controlled trial, 20 or more participants per condition or group, moderate internal validity, moderate external validity

44. What did the researchers find? Both groups improved significantly (see Glossary) over time on most of the outcome measures. There was no significant (see Glossary) difference between the two groups on any of the outcome measures. Both groups improved significantly (see Glossary) over time on most of the outcome measures. There was no significant (see Glossary) difference between the two groups on any of the outcome measures. What do the findings mean? For therapists and other providers, the findings suggest that the sensorimotor integration approach is as beneficial as the functional approach. Thus therapists may not have to restrict themselves to a single type of treatment. For therapists and other providers, the findings suggest that the sensorimotor integration approach is as beneficial as the functional approach. Thus therapists may not have to restrict themselves to a single type of treatment.

45. Current Briefs & Structured Abstracts Attention Deficit Hyperactivity Disorder (ADHD) Attention Deficit Hyperactivity Disorder (ADHD) Autism Spectrum Disorder Autism Spectrum Disorder Chronic Pain Chronic Pain Cerebral Palsy Cerebral Palsy Children with Behavioral & Psychosocial Needs Children with Behavioral & Psychosocial Needs Multiple Sclerosis Multiple Sclerosis

46. continued Older Adult (Occupation and Activity- Based Interventions) Older Adult (Occupation and Activity- Based Interventions) Parkinson's Disease Parkinson's Disease School-Based Interventions School-Based Interventions Stroke Stroke Substance Use Disorders Substance Use Disorders Traumatic Brain Injury Traumatic Brain Injury Young Children with Delayed Development Young Children with Delayed Development

47. Exploring Stroke More research is needed on whether occupational therapy treatment for stroke patients after hospital discharge improves activities of daily living. More research is needed on whether occupational therapy treatment for stroke patients after hospital discharge improves activities of daily living. and 22 more separate listings... and 22 more separate listings...

48. Where do I find this evidence? If self-evident…. If self-evident…. Examples Examples

49. Where do I find this evidence? If need to do own study…. If need to do own study…. Large Example - SCIRehab study Large Example - SCIRehab study Methods: Methods: Practice Based Evidence Method (PBE) Practice Based Evidence Method (PBE) 1500 patients with acute SCI 1500 patients with acute SCI 6 US inpatient rehab facilities 6 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 medical records Info such as medications and nursing interventions taken from medical records Clinician profile information taken including clinical training, SCI expertise, and current practice patterns (full-time vs. part-time SCI services) Clinician profile information taken including clinical training, SCI expertise, and current practice patterns (full-time vs. part-time SCI services) Outcomes such as neurological, functional, social, vocational and psychological assessed through patient interviews 6 and 12 months post-injury (Model System Form I and Form II data) Outcomes such as neurological, functional, social, vocational and psychological assessed through patient interviews 6 and 12 months post-injury (Model System Form I and Form II data)

50. Where do I find this evidence? If need to do own study…. If need to do own study…. Small Example Small Example Collect data amongst similar cases in which a protocol was used Collect data amongst similar cases in which a protocol was used Utilize CSU for analysis Utilize CSU for analysis More coming up in group discussion time More coming up in group discussion time

51. Small Group Time

52. 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 program 5.Multidisciplinary

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

54. Thank You! For presentation Slides and Small-Group Discussion Outcomes go to: http://www.mycahs.colostate.edu/david.greene/ http://www.mycahs.colostate.edu/david.greene/