1. Evidence Based Practice: Intervention for people with lower limb amputations
Karl Schurr
March 2007

2. Plan Quick review of EBP levels of evidence
What evidence is out there?
What to do with the evidence?
Implications for clinical decision making

3. Levels of evidence Possibility for concentration of poor quality data
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

4. 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

5. 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

6. 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

7. 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!

8. PEDro list Clinical trials 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
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

9. Where else? Other research areas Careful review of patient progress
Normal motor behaviour:
Learn what we practice
Task specificity: muscle actions – force, timing
Postural adjustments: sitting, standing, walking, running
Careful review of patient progress

10. 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?

11. What is this man learning?
What does he need to learn ?