Posts Tagged EBP

[Abstract] Evidence based practice ‘on-the-go’: using ViaTherapy as a tool to enhance clinical decision making in upper limb rehabilitation after stroke – a quality improvement initiative

Abstract

Recovery of upper limb function after stroke is currently sub-optimal, despite good quality evidence showing that interventions enabling repetitive practice of task-specific activity are effective in improving function. Therapists need to access and engage with such evidence to optimise outcomes with people with stroke, but this is challenging in fast-paced stroke rehabilitation services. This quality improvement project aimed to investigate acceptability and service impact of a new, international tool for accessing evidence on upper limb rehabilitation after stroke- ‘ViaTherapy’- in a team of community rehabilitation therapists. Semi-structured interviews were undertaken at baseline to determine confidence in, and barriers to, evidence-based practice (EBP) to support clinical decision making. Reported barriers included time, lack of access to evidence, and a research-practice disconnect. The clinicians then integrated use of ‘ViaTherapy’ into their practice for four weeks. Follow-up interviews explored the accessibility of the tool in community rehabilitation practice, and its impact on clinician confidence, treatment planning and provision. Clinicians found the tool, used predominantly in mobile device app format, to be concise and simple to use, providing evidence “on-the-go.” Confidence in accessing and using EBP grew by 22% from baseline. Clinicans reported changes in intensity of delivery of interventions, as rapid access to recommended doses via the tool was available. Following this work, the participating health and social care service provider changed provision of therapists’ technology to enable use of apps. Barriers to use of EBP in stroke rehabilitation persist; the baseline situation here supported the need for more accessible means of integrating best evidence into clinical processes. This quality improvement project successfully integrated ViaTherapy into clinical practice, and found that the tool has potential to underpin positive changes in upper limb therapy service delivery after stroke, by increasing accessibility to, use of, and confidence in evidence-based practice. Definitive evaluation is now indicated.

via Evidence based practice ‘on-the-go’: using ViaTherapy as a tool to enhance clinical decision making in upper limb rehabilitation after stroke – a quality improvement initiative – UEA Digital Repository

 

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[BLOG POST] When EBP meets neurological physiotherapy …

Hello, I’m Sarah Tyson, Professor of Rehabilitation at the University of Manchester, neurological physiotherapist and enthusiast for improving outcomes for people neurological conditions using research and other evidence.

This blog has been set up in response to the discussion that was generated to an icsp (the discussion forum for the CSP) thread about the evidence-base for neuro physios and more specifically, the evidence for or against Bobath therapy (found here http://www.csp.org.uk/icsp/topics/rationale-evidence-bobath-neurological-physio  and http://www.csp.org.uk/icsp/topics/novak-review-casts-doubt-efficacy-bobath-should-we-embrace-or-ignore-it  ) Many got in touch to let me know that they would like a more open forum, so here it is. Having said that, icsp is a good resource for MCSPs – I’d encourage you to register and use it. However I’d like to expand the remit beyond the icsp thread to open a discussion (polite and respectful discussion) about evidence based neurological physiotherapy; what that means in reality, and how we could/ should/ would be delivering it.  I also doubt that I’ll be able to resist letting folk know about the rehabilitation research for people with stroke and other conditions we are doing at Manchester. So it’s only fair and reasonable that I invite others to do the same.

My original aim was to present the main topics of discussion about the evidence (or otherwise) for the Bobath concept as they appeared in the icsp discussion and to let all contributors make their points in a wider forum. However this has fallen foul of the terms and conditions of icsp and their copyright rules, so I have to summarise the contributions in my own words. I have tried to do this as openly and even-handedly as I can. You can always go back to the original icsp thread to check it out, but let me know if there is anything you object to about the way I have precise’d and I will be happy to change it.

Let’s have a lively debate.

Source: Home – When EBP meets neurological physiotherapy …

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[BLOG POST] How to do Bobath? Part 4. Motor learning and neuroplasticity – When EBP meets neurological physiotherapy …

There has been a lot of discussion in the icsp threads (found here http://www.csp.org.uk/icsp/topics/rationale-evidence-bobath-neurological-physio and http://www.csp.org.uk/icsp/topics/novak-review-casts-doubt-efficacy-bobath-should-we-embrace-or-ignore-it ) from physios who use Bobath about: what Bobath is, or isn’t, what it aims to do, how and why. Fair to say, I think, that there is considerable uncertainty, despite the earlier posts about the definition of Bobath. So I have tried to collect together the relevant discussions and to chunk them into easily digestible pieces. I hope this makes sense and represents everyone reasonably. You can always go back to the original icsp thread to check it out. If I’ve messed up, I’m happy to be shown the error of my ways. Unfortunately I can’t directly attribute the discussion to the person posting (unless they have specifically said that I can) because that would fall foul of the terms and conditions of icsp and their copyright rules, so I have to summarise the contributions in my own words. I have tried to do this as openly and even-handedly as I can.

In this chunk some of the theoretical beliefs about how Bobath works are considered in the light of evidence. I’ve taken the Vaughan-Graham 2009 paper (Top Stroke Rehabil 2009;16(1):57–68) as a starting point. In the paper there are several statements specifying aspects of the Bobath Concept. I published that list before in the icsp thread a while ago. At the time it didn’t raise a lot of discussion. So I’ve grouped the statements into several sections and will consider how they compare with the evidence. Ive also added some relevant queries, stated beliefs and discussion from the icsp threads and drawn on the Bobath Concept book (pub 2009 – a most illuminating read). There is a sprinkling of references to back up my claims or I have recommended other reading (would hate to be accused of not justifying my claims!) These are by no means a comprehensive indication of the evidence, they are some examples.

 

Part 4. Neuroplasticity and motor learning

The Bobath tutors say: the Bobath concept utilizes present-day knowledge of motor control, the nature of movement dysfunction, neuromuscular plasticity, biomechanics, and motor learning….. The Bobath Concept is part of an active learning process. It assists the patient in problem solving and enables him or her to experience the patterns of movement and success in achieving the task. …… Treatment is focused toward remediation, exploring the individual’s potential to regain abilities through neuromuscular plastic adaptation.

 Neuroplasticity and motor learning are considered two of the main mechanisms by which BB has its effect (ie how it works). It is the mechanisms for all other types of neuro physio too, but we’ll leave that aside for now. In their book, the Bobath tutors have sections on motor learning and on neuroplasticity. They outline the principles of both and highlight some of the conditions needed to promote both, and carry-over into every-day life. These include:

  • Working on meaningful goals/ tasks
  • training in different real-life situations as appropriate and not only in the therapy department.
  • enabling active participation which involves engaging the patient in a problem-solving process [ie the patient has to work out how to perform and to correct the activity themselves]
  • using repetition effectively – varied tasks; varied environments; varied repetitions (random more than blocked practice); whole tasks (more than part task or practicing components);
  • training intensively (the more the better)
  • giving feedback occasional on the outcome (knowledge of results with wide ‘band-width, to use the jargon) more than continuous/ frequent feedback about the way the person is moving (narrow band-width knowledge of performance).

The BB book also includes mental practice, modelling (or demonstration) and guidance [AKA facilitation] as techniques that promote motor learning and neuroplasticity, which is extrapolating some early stage research a bit too far IMHO. However they do note that “excessive guidance [NB: guidance AKA facilitation] or physical devices offering continuous restraint and direct movement reduces the need for problem-solving and does not improve learning.”

All of which is sensible stuff and I agree with !! I can see the headlines now #TysonagreeswithBobathShock, they will be saying that I endorse BB next, Oh wait, they already do!  BUT but, but, but, there is nothing in the book, the courses or the papers they have published to actually connect BB with these principles.  No evidence that Bobath generates motor learning or neuroplasticity, although there is plenty of evidence that other interventions do: The EB ones like CIMT, exercise, electro-mechanical gait-training and treadmill training. It is just stated that they do, presumably we are accepted to take this at face value.  Although that may have been on in the past (for lack of an alternative), it is an insufficient basis for credibility now-a-days. Show us data to demonstrate that BB produces neuroplasticity and motor learning.

Although there is no evidence that BB involves the conditions that promote motor learning and neuroplasticity. There is evidence that it does not involve the right conditions to achieve it. Granted it is very low level but it does come from the horse’s mouth. Think of the Bobath courses you have been on; look at the examples of BB in action in the case studies (presumably the good ones) on the BBTA website (http://www.bbta.org.uk/poster-presentations-bobath-concept); look at the examples of BB in action in their book. How many examples involve meaningful goals/ tasks; training in different real-life situations; an actively engaged patient (them actually doing a meaningful/ functional task for themselves); varied practice conditions; high repetitions; varied practice conditions; knowledge of results; low frequency feedback?

Exactly! None or next to none. How often have you seen the conditions which prevent motor learning – excessive guidance, continuous restraint and directing of movement, abstract rather than functional movements, the patient being passive rather than active, low number of repetitions? Nearly all of them.

In the icsp discussions, contributors wondered whether low repetition/ intensity of practice was a factor in BB’s lack of evidence. She said “I would question the notion of “person centred approach” being used in the same sentence as the Bobaths’ approach.  All the Bobath courses I’ve attended were very much geared towards what the therapist was doing to or for the client, rather than what they [the patient] were generating for themselves within or beyond the treatment”….. The link between repetitive practice and neuroplasticity is well established in Neurophysiology research, and we know a significant amount of repetition is required.  Perhaps 1 reason why NDT/Bobath is not achieving proof of effectiveness or significant change in research trials is insufficient repetition?”

Another contributor agreed, adding that “If you want to learn to walk you need to practice walking; this is how infants learn to walk and how we all acquire new skills. However, in Sheila Lennon’s study ([D& R 2006:28;873-881] where the major aim was to enhance mobility by advanced Bobath techniques;  the patients actually walked for only 7-12% of their therapy time. This concurs with my own experience that Bobath trained therapists can be more interested in applying their complex handling techniques to patients than helping the patient do something useful themselves. The emphasis needs to be more on the patient practicing functional tasks than on ourselves exhibiting high level handling techniques; especially when the best evidence indicates they are are better alternatives”. 

The observation of a gap between what BB says and what they do is further illustrate din some work I did a while ago now, about the how neuro physio therapy is delivered in ‘real life’. Tyson, Connell, Lennon, Busse Clin Rehab 2009; 23;11;1051-1055  D&R 2009: 31:18;1494-150 D&R 2009;31:6;448-457. These showed that Bobath practitioners spent most of their time in therapy sessions ‘preparing’ patients using passive techniques such as mobilisations and facilitating selective movements. There were precious few repetitions, the patient was passive most of the time and the activities were abstract rather than functional.  None of which promote motor learning or neuroplasticity

Source: How to do Bobath? Part 4. Motor learning and neuroplasticity – When EBP meets neurological physiotherapy …

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[ARTICLE] Moving Research From the Bedside Into Practice | Physical Therapy Journal – Full Text

Evidence-based practice (EBP) is firmly entrenched in the lexicon of physical therapist practice,1,2 but beliefs about how best to translate scientific evidence into clinical practice are far from settled. There are major gaps in our scientific knowledge; however, even more disturbing is the fact that an enormous amount of existing scientific knowledge remains unused in practice. As noted in the Institute of Medicine (IOM) report titled Crossing the Quality Chasm, “Between the health care we have and the care we could have lies not just a gap, but a chasm.”3

Thankfully, the infamous 264-year period between the discovery of citrus’s benefit in preventing scurvy and the widespread use of citrus on British ships is no longer the norm.4 But the frequently quoted statement about the lag time between publication and adoption of research—only 14% of original research is applied for the benefit of patient care, and that takes 17 years5,6—is alarming enough. There is consensus that the transfer of evidence from proven health care discoveries to patient care is unpredictable and highly variable and needs to be accelerated.4,7,8

For those of us who want to speed the adoption of EBP in physical therapy and across health care more broadly, Naylor9 described 4 distinct phases or strategies that are instructive:

Phase 1, the “Era of Optimism,” is characterized by a belief in passive diffusion of scientific evidence into practice. In this (still-dominant) phase, students and clinicians are trained to critically appraise the scientific literature to identify valid new information that could be applied to practice.

Phase 2, the “Era of Innocence Lost and Regained,” acknowledges that much of clinical practice is not evidence based and that it is virtually impossible for clinicians to keep up with the explosion of medical literature. This understanding has led to the emergence of evidence-based clinical practice guidelines, in which the literature is systematically reviewed and summary recommendations are graded according to the strength of the supporting evidence. Guidelines are widely disseminated on the assumption that providers will read them and that practice will change accordingly.

Phase 3, the “Era of Industrialization,” is on the rise, as evidence mounts that the passive efforts of phases 1 and 2 fail to actually change practice. In this phase, aggressive strategies are implemented by regulatory entities or professions to improve care. These efforts frequently involve performance measurement and reporting,10 which are intended to encourage providers to become more accountable and more focused on quality improvement. Many professions have risen to this challenge and have developed their own approaches to change patient management as described by Naylor.9APTA’s Physical Therapy Outcomes Registry,11 an organized system for collecting data to evaluate patient function and other clinically relevant measures, is a phase 3 effort, with improving practice and fulfilling quality reporting requirements as 2 of its major goals.

Phase 4, the final phase, is the “Era of Information Technology and Systems Engineering,” which is driven by the belief that it is not sufficient to focus on individual practitioners, but rather the redesign of service delivery systems to address barriers and incentives is required to bridge the wide gap between best evidence and common practice. For this phase, a different type of evidence base—one describing the most effective ways to change provider behavior9,12—is needed. Hence the emergence of the relatively new field of implementation research.

Continue —> Moving Research From the Bedside Into Practice | Physical Therapy Journal

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