1. Evidence Based Practice: I ntervention 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 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 Type of trialTrialsQualityComments Systematic reviews 2NA Prescription of ankle foot prostheses Education for decubitus ulcers Clinical trials Ultrasound for ulcers6/10 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 45/10 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 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 ?