Evidence-based practice: methods to evaluate individual patient improvement

The Immediate Effect of Parachute-Resisted Gallop on Heart Rate, Running Speed and Stride Frequency in Dogs

Simple Summary

Physical fitness is needed for canine athletes and working dogs to optimize their performance in various disciplines. Application of resistance on movements causes biomechanical and cardiorespiratory responses to physical exercise. However, there is still a lack of research on the effects of high-intensity resistance exercise on cardiorespiratory fitness components such as heart rate in canine athletes. In this article, we investigate the short-term effects of parachute-resisted galloping on heart rate, running speed and stride frequency. Healthy dogs of various breeds were extensively studied in five experimental single cases. The dogs ran on a straight 200 m course with and without resistive drag force applied by a parachute attached to their harness while heart rate, running speed and stride frequency were measured. Subsequently, the measurements were compared to baseline phases at rest. In the present trials we found that heart rate increases similarly with and without parachute-resistance while dogs galloped at lower speeds and with increased stride frequency with applied drag force. Our findings lead us to suggest that parachute-resisted galloping is a clinically applicable exercise in healthy dogs to achieve instant cardiorespiratory response.

Abstract

Physical fitness is required for canine athletes and working dogs to optimize performance in various disciplines. There is a lack of research on the effects of resistance exercise on cardiorespiratory variables in dogs. The aim of this study was to investigate the immediate effects of parachute-resisted (PR) gallop on heart rate, running speed and stride frequency compared to unresisted (UR) gallop in dogs. Five N-of-1 trials RCTs with alternating interventions were implemented. Dogs ran on a 200 m course with and without resistive force applied by a parachute attached to their harness while cardiac inter-beat intervals (IBI), running speed and stride frequency were measured. The results were visually displayed and interpreted in graphs and percentage of non-overlapping data estimated effect size. Both interventions showed large effects on heart rate compared to resting values. Mean IBI increased (10–17%) during PR gallop compared to UR gallop although this change was small relative to decreased running speed (19–40%) and increased stride frequency (18–63%). Minimum IBI showed no difference between interventions indicating similar maximum heartbeat per minute. In conclusion, parachute-resistance resulted in dogs galloping at lower speeds at the same cardiorespiratory level of intensity, which may be useful in canine physical rehabilitation and fitness training.

Single-Subject Research in Psychiatry: Facts and Fictions

Scientific evidence in the field of psychiatry is mainly derived from group-based ("nomothetic") studies that yield group-aggregated results, while often the need is to answer questions that apply to individuals. Particularly in the presence of great inter-individual differences and temporal complexities, information at the individual-person level may be valuable for personalized treatment decisions, individual predictions and diagnostics. The single-subject study design can be used to make inferences about individual persons. Yet, the single-subject study is not often used in the field of psychiatry. We believe that this is because of a lack of awareness of its value rather than a lack of usefulness or feasibility. In the present paper, we aimed to resolve some common misconceptions and beliefs about single-subject studies by discussing some commonly heard "facts and fictions." We also discuss some situations in which the single-subject study is more or less appropriate, and the potential of combining single-subject and group-based study designs into one study. While not intending to plea for single-subject studies at the expense of group-based studies, we hope to increase awareness of the value of single-subject research by informing the reader about several aspects of this design, resolving misunderstanding, and providing references for further reading.

Heart Rate Variability Biofeedback Stress Relief Program for Depression

Background: Depressive disorders often have a chronic course and the efficacy of evidence-based treatments may be overestimated.

Objective: To examine the effectiveness of the Heart Rate Variability Stress Reduction Program (SRP) as a supplement to standard treatment in patients with depressive disorders.

Methods: The SRP was individually administered in eight weekly sessions. Seven participants completed the full protocol and were enrolled in a single-subject ABA multiple baseline experimental design. To perform interrupted time-series analyses, daily measures were completed in a diary (depression, resilience, happiness, heart coherence and a personalized outcome measure).

Results: Five out of seven patients improved in depressed mood and/or a personalized outcome measure. The effect of treatment was reversed in four patients during the withdrawal phase. One patient reliably improved on depression, whereas two patients recovered on autonomy and one on social optimism. No consistent relationship was found between the heart rate variability-related level of coherence and self-reported mood levels.

Conclusions: The SRP is beneficial in some domains and for some patients. A prolonged treatment or continued home practice may be required for enduring effects. The intervention had more clinical impact on resilience-related outcome measures than on symptoms. The small sample size does not permit generalization of the results. We recommend future investigation of the underlying mechanisms of the SRP.

What does the literature say about using robots on children with disabilities?

PURPOSE

The purpose of this study is to examine the extent and type of robots used for the rehabilitation and education of children and young people with CP and ASD and the associated outcomes.

METHODS

The scholarly literature was systematically searched and analyzed. Articles were included if they reported the results of robots used or intended to be used for the rehabilitation and education of children and young people with CP and ASD during play and educative and social interaction activities.

RESULTS

We found 15 robotic systems reported in 34 studies that provided a low level of evidence. The outcomes were mainly for children with ASD interaction and who had a reduction in autistic behaviour, and for CP cognitive development, learning, and play.

CONCLUSION

More research is needed in this area using designs that provide higher validity. A centred design approach is needed for developing new low-cost robots for this population. Implications for rehabilitation In spite of the potential of robots to promote development in children with ASD and CP, the limited available evidence requires researchers to conduct studies with higher validity. The low level of evidence plus the need for specialized technical support should be considered critical factors before making the decision to purchase robots for use in treatment for children with CP and ASD. A user-entered design approach would increase the chances of success for robots to improve functional, learning, and educative outcomes in children with ASD and CP. We recommend that developers use this approach. The participation of interdisciplinary teams in the design, development, and implementation of new robotic systems is of extra value. We recommend the design and development of low-cost robotic systems to make robots more affordable.

Aquatic Exercises were Associated with an Acceptable State of Symptoms in Patients with Inflammatory Rheumatic Diseases: Results from a Study with Interrupted Time-Series Design

AIM OF STUDY

The aim of this study was two-fold: to compare symptoms and daily activity in patients with inflammatory rheumatic diseases across periods with and without aquatic exercises, and to examine whether the patients reached an acceptable state of symptoms during the periods with aquatic exercises.

METHODS

Thirty-six patients reported pain, fatigue, stiffness and ability to carry out daily activities across periods with and without aquatic exercises. The study has an interrupted time-series design and variables were collected with text messages on mobile phones twice a week over a period of 35 weeks.

RESULTS

There was a significant reduction in pain, fatigue, stiffness and enhanced level of daily activity (p > 0.05) during periods of aquatic exercises compared to periods without. Further, a significantly higher proportion of patients reached an acceptable state for both pain and fatigue during periods with aquatic exercises.

CONCLUSIONS

Living with an inflammatory rheumatic disease is a lifelong challenge. Pain and fatigue are considered major obstacles for daily functioning and adequate self-management strategies are requested. Based on the high proportion of patients reporting to be in an acceptable state of both pain and fatigue during periods with aquatic exercises, the intervention should be regarded as an important self-management tool rather than a treatment option assuming long-lasting effects. Copyright © 2014 John Wiley & Sons, Ltd.

Potential treatment mechanisms of counseling for children in Burundi: a series of n=1 studies

Little is known about the impact and treatment processes of psychosocial counseling in low-income countries. This study aimed to generate hypotheses on key working mechanisms of counseling in Burundi. The authors carried out 11 empirically grounded n=1 studies with children (11-14years) screened for depression and anxiety who received counseling. The authors used quantitative (symptom scales) and qualitative instruments (treatment content and perceptions). Weekly measurements were taken preintervention (4 time points), during the intervention period (8-10 time points), and postintervention (4 time points). Five treatment mechanisms continua appeared associated with outcome trajectories: client centeredness, therapeutic alliance, active problem solving, trauma-focused exposure, and family involvement. Higher levels appeared associated with better outcomes. Contrarily, cases that demonstrated no change were characterized by a heavy focus on counselors' norms, containment and self-control, unstructured retelling and explicit avoidance, advice-oriented problem solving, and noninclusion of family members, respectively. The authors found a distinct clustering of outcome trends per therapist. The findings suggest that integrative counseling, which combines universal therapist variables with active use of specific therapeutic techniques and a systemic perspective, may be an adequate strategy to treat mental health symptoms of children in Burundi.

Using video simulated presence to reduce resistance to care and increase participation of adults with dementia

BACKGROUND

Cognitive and functional decline in dementia generally impairs performance of basic care activities. Staff assistance during these activities frequently results in confusion, anxiety, and distress, expressed through resistance to care (RTC).

METHODS

A single-system ABA withdrawal design (n = 1) evaluated the effect of video-simulated presence (VSP) for decreasing RTC and increasing participation. A family member pre-recorded videos for use during episodes of RTC, in which the family member spoke directly to the participant to encourage participation.

RESULTS

Introduction of the VSP significantly reduced RTC during the basic care tasks of feeding and talking medication. This effect was reversed when the intervention was withdrawn. Participation increased following VSP, demonstrating clear trends toward clinical significance.

CONCLUSIONS

This person-centered intervention, based on VSP of a family member, provides encouraging results for reducing RTC and increasing participation of adults with dementia in basic care tasks.

Behavioral States of children with severe disabilities in the multisensory environment

The purpose of this study was to examine the behavioral states of individual children for evidence of responsiveness within and without a multisensory environment (MSE). Three children in the age range of 3-10 years with severe multiple disabilities participated in the study. A single-system ABAB design was used. Participants' behavioral states, identified by indicators of alertness and responsiveness to context, were observed. Two participants demonstrated no change in their behavioral states with or without the MSE, suggesting that the environment did not have an effect on their responsiveness. One participant demonstrated a decrease in self-directed movement and an increase in visual attention with movement toward the MSE suggesting a more interactive shift in this participant's response to the environment. When symbolic or consistent methods of communication are absent, observation of behavioral state may provide occupational therapists an objective means of insight into the experiences of children with severe disabilities.

Development and Testing of Interventions in Occupational Therapy: Toward a New Generation of Research in Occupational Therapy

Development, refinement, and testing of occupational therapy interventions require a systematic approach. The authors explain the four phases for clinical trials used in pharmaceutical research and apply them to the development and testing of occupational therapy interventions. The challenges faced by occupational therapy researchers in designing clinical trials include difficulties in specifying the intervention, blinding subjects, therapists, and evaluators, and identifying objective but client-centered measures of primary outcomes. Examples are provided of researchers who have developed and tested occupational therapy interventions in phases.

Initial validity and reliability of the SCCAN: using tailored testing to assess adult cognition and communication

PURPOSE

The Scales of Cognitive and Communicative Ability for Neurorehabilitation (SCCAN; L. Milman & A. Holland, 2007) was developed in the hospital setting to address changes in assessment practice. The SCCAN was designed to provide an overview of impairment and activity limitations across 8 cognitive scales (Speech Comprehension, Oral Expression, Reading, Writing, Orientation, Attention, Memory, and Problem Solving). The scales were developed using item response theory so that tailored testing could be implemented to reduce test administration time. This research investigated the validity and reliability of the SCCAN.

METHOD

A battery of neuropsychological tests was administered to 40 neurologically healthy control participants and 51 participants diagnosed with left-hemisphere pathology, right-hemisphere pathology, or probable Alzheimer's disease. Analyses were performed to assess test sensitivity and specificity, construct validity, administration time, and reliability.

RESULTS

The test accurately classified 95% of the control participants and 98% of the participants diagnosed with neurological disorders. Results indicate that the test also differentiated the performance profiles of the 3 clinical populations. In addition, test scores correlated significantly with external measures of the same cognitive areas. Mean administration time was 34 min. Test-retest stability (r = .96, p < .001) and internal consistency (r = .99, p < .001) coefficients were both significant, indicating that tailored testing procedures generated reliable test scores.

Occupational therapy for patients with Parkinson's disease

BACKGROUND

Despite drug and surgical therapies for Parkinson's disease, patients develop progressive disability. It has both motor and non-motor symptomatology, and their interaction with their environment can be very complex. The role of the occupational therapist is to support the patient and help them maintain their usual level of self-care, work and leisure activities for as long as possible. When it is no longer possible to maintain their usual activities, occupational therapists support individuals in changing and adapting their relationship with their physical and social environment to develop new valued activities and roles.

OBJECTIVES

To compare the efficacy and effectiveness of occupational therapy with placebo or no interventions (control group) in patients with Parkinson's disease.

SEARCH STRATEGY

Relevant trials were identified by electronic searches of MEDLINE (1966-April 2007), EMBASE (1974-2000), CINAHL (1982-April 2007), Psycinfo (1806-April 2007), Ovid OLDMEDLINE (1950-1965), ISI Web of Knowledge (1981-April 2007), National Library for Health (NLH) (April 2007), Nursing, Midwifery and Allied Health (NMAP) (April 2007), Intute: Medicine (December 2005), Proquest Nursing Journals (PNJ, 1986 - April 2007); rehabilitation databases: AMED (1985-April 2007), MANTIS (1880-2000), REHABDATA (1956-2000), REHADAT (2000), GEROLIT (1979-2000); English language databases of foreign language research and third world publications: Pascal (1984-2000), LILACS (1982- April 2007), MedCarib (17th Century-April 2007), JICST-EPlus (1985-2000), AIM (1993-April 2007), IMEMR (1984-April 2007), grey literature databases: SIGLE (1980-2000), ISI-ISTP (1982-April 2007), DISSABS (1999-2000), Conference Papers Index (CPI, 1982-2000) and Aslib Index to Theses (AIT, 1716- April 2006), The Cochrane Controlled Trials Register (Issue 2, 2007), the CenterWatch Clinical Trials listing service (April 2007), the metaRegister of Controlled Trials (mRCT, April 2007), Current controlled trials (CCT) (April 2007), ClinicalTrials.gov (April 2007), CRISP (1972-April 2007), PEDro (April 2007), NIDRR (April 2007) and NRR (April 2007) and the reference lists of identified studies and other reviews were examined.

SELECTION CRITERIA

Only randomised controlled trials (RCT) were included, however those trials that allowed quasi-random methods of allocation were allowed.

DATA COLLECTION AND ANALYSIS

Data was abstracted independently by two authors and differences were settled by discussion.

MAIN RESULTS

Two trials were identified with 84 patients in total. Although both trials reported a positive effect from occupational therapy, all of the improvements were small. The trials did not have adequate placebo treatments, used small numbers of patients and the method of randomisation and concealment of allocation was not specified in one trial. These methodological problems could potentially lead to bias from a number of sources reducing the strength of the studies further.

AUTHORS' CONCLUSIONS

Considering the significant methodological flaws in the studies, the small number of patients examined, and the possibility of publication bias, there is insufficient evidence to support or refute the efficacy of occupational therapy in Parkinson's disease. There is now a consensus as to UK current and best practice in occupational therapy when treating people with Parkinson's disease. We now require large well designed placebo-controlled RCTs to demonstrate occupational therapy's effectiveness in Parkinson's disease. Outcome measures with particular relevance to patients, carers, occupational therapists and physicians should be chosen and the patients monitored for at least six months to determine the duration of benefit. The trials should be reported using CONSORT guidelines.

Applying evidence standards to rehabilitation research

OBJECTIVE

To describe evidence grading methods employed in the systematic reviews in this special series of articles. To provide an overview of results of these reviews to critique the quality of rehabilitation research. To identify issues in the application of evidence grading methods to rehabilitation.

DESIGN

Conceptual review of evidence-based practice and evidence grading methods. English-language research studies on rehabilitation of persons with spinal cord injury, traumatic brain injury, and burn for the 5-yr period of 1999-2004 were reviewed using methods of the American Academy of Neurology supplemented by Cochrane criteria and summarized.

RESULTS

Rehabilitation has a shortage of high-level studies. The number of level 1 treatment studies was quite limited (five in spinal cord injury, 15 in traumatic brain injury, 12 in burn rehabilitation), as was the number of level 2 studies (26, 4, and 2, respectively). Despite the large number of correlational studies published, the number of high-level (1 or 2) diagnostic and prognostic studies was surprisingly limited (34, 11, and 5, respectively). The rate of production of high-level studies is rapidly increasing. Problems were encountered in applying standard evidence criteria to complex issues encountered in some studies, suggesting limitations and issues in evidence grading methodology.

CONCLUSIONS

Rehabilitation needs more high-level studies. Some improvements in research methodology are relatively affordable (e.g., improved blinding), whereas others are expensive (e.g., large randomized controlled trials). Lower-level investigations reporting promising results need to be followed by more definitive, higher-level trials.

Rehabilitation of traumatic injuries: use of the delphi method to identify topics for evidence-based review

Evidence-based reviews of research literature are useful in determining the efficacy of specific clinical practices, but the review process is frequently time-consuming and costly. The purpose of this study was to identify important research questions in rehabilitation that are appropriate for evidence-based reviews. The focus of this study was rehabilitation after traumatic injuries. Topics were identified using the Delphi method, which utilized a panel of 24 researchers and clinicians with expertise in rehabilitation of traumatic injuries. The experts identified 71 topics, predominantly in the areas of spinal cord injury and traumatic brain injury rehabilitation. The most commonly suggested intervention topics involved assessment of pharmacologic agents, the timing or intensity of interventions, or specific nonpharmacologic therapies and exercises. Topics were ranked by mean importance score. Ten of 24 questions in the top tertile were considered to have some or a substantial amount of available research and thus may be appropriate for structured evidence-based reviews. Similar methods could be used to identify appropriate topics in other areas of rehabilitation.