Distinguishing theories of dysfunction, treatment and care. Reflections on ‘Describing rehabilitation interventions’

Synthesising knowledge for physiotherapy practice. Key steps towards review methodology

Background:

One of the consequences of rethinking evidence-based practice in physiotherapy is acknowledging the complexity and the different kinds of knowledge used in the decision-making of physiotherapists. This has profound consequences for the kinds of knowledge that should be researched and synthesised in order to inform practice.

Methods:

A critical review of review methodology was carried out and results were interpreted using narrative synthesis.

Findings:

This article focuses on how to generalise (synthesise) different kinds of knowledge with the available review methodology in order to adequately inform physiotherapy practice. It does so by suggesting a set of key steps and offering a brief overview of review methodology.

Conclusions:

More awareness and use of the diversity in review methodology in physiotherapy can improve theory building and inform practice better. Reviewers could increase the impact of their studies by focusing more on the external validity of methods and results. The article finishes with recommendations for improving the critical use of different review methodologies for physiotherapy practice.

Reconsidering evidence-based practice in prosthetic rehabilitation: a shared enterprise

BACKGROUND

A divide is experienced between producers and users of evidence in prosthetic rehabilitation.

OBJECTIVE

To discuss the complexity inherent in establishing evidence-based practice in a prosthetic rehabilitation team illustrated by the case of prosthetic prescription for elderly dysvascular transfemoral amputee patients.

STUDY DESIGN

A qualitative research design was used, in which data from multiple sources was triangulated to extract themes for discussion.

METHODS

This discussion paper draws on empirical material gathered by individual and focus-group interviews with members of a prosthetic rehabilitation team, information on technological advancements presented on websites of orthopaedic industry, guidelines and literature study.

RESULTS

A prosthetic rehabilitation team needs to deal with lack of evidence, contradictory results, various classification systems, diverging interests of different stakeholders and many modifying factors, and all of this in a continuous technological changing environment. Integrating research designs with different strengths but not sharing the same biases may help researchers to deal with the multimorbidity and multifaceted disability of the target group. Articulating clinical knowledge, patients' needs and values in a systematic way provides depth, detail, nuance and context for evidence-based practice issues in prosthetic rehabilitation.

CONCLUSIONS

Reconsidering the relationship between evidence, technology and rehabilitation practice is an imperative shared enterprise for clinicians and researchers. Scientific, clinical and patient-related knowledge are seen as important knowledge practices that should inform and strengthen each other.

CLINICAL RELEVANCE

This discussion paper puts the academic clinical debate on evidence-based practice in prosthetics and orthotics in another light. By demonstrating the complexities surrounding evidence-based practice, it is argued and illustrated how both researchers and clinicians can contribute to optimal patient care in which evidence, technology and rehabilitation practice are integrated.

Clinical effectiveness of knee rehabilitation techniques and implications for a self-care treatment model

BACKGROUND

Physiotherapy is a complex intervention frequently recommended for knee conditions. The International Classification of Functioning and Disability (ICF) can be used as a framework to evaluate evidence to develop care models and clinical guidelines.

OBJECTIVE

To evaluate the clinical effectiveness of knee rehabilitation modalities categorised according to the ICF domains.

DATA SOURCES

A keyword search of Medline, Cinahl, Amed, Embase and Cochrane databases from 1996 to 2010 using terms related to the knee joint and physiotherapeutic interventions.

STUDY SELECTION

Reviewer assessment using inclusion/exclusion criteria and a quality assessment tool compiled from the Critical Appraisal Skills Programme Tool, Consort and Cochrane Bone Joint and Muscle Trauma Groups.

DATA EXTRACTION

Information about the research design, intervention and subjects was extracted. Outcome measures and findings were categorised according to ICF domains.

DATA SYNTHESIS

The majority of studies evaluated exercise. Findings were supportive but specific recommendations were limited due to variations in content and application. There was limited quality research to support the theory that manual therapy, electrotherapy or taping in isolation contributes to recovery. Multimodality physiotherapy programmes were found to be beneficial and to reflect clinical practice, but the effectiveness of each component is unknown. Outcome measures from the participation domain of the ICF were used least frequently and were not generally true measures of participation.

CONCLUSION

Development of participation outcome measures is required to evaluate the long-term benefits of interventions. Rehabilitation should be based around delivery of effective exercise programmes incorporating participation outcomes to provide feedback and complement self-care for knee conditions.

Improving rehabilitation treatment in a local setting: a case study of prosthetic rehabilitation

OBJECTIVE

To contribute to the discussion on the research-practice gap by illustrating obstacles and opportunities that arise in an evidence-informed improvement process of prosthetic rehabilitation in a local setting.

SETTING

Dutch rehabilitation centre. PRESUPPOSITION: The improvement process was considered as a two-way translation process rather than a unidirectional process of knowledge transfer between science and practice.

METHOD

Case study and participatory research methods comprising documentary analysis, treatment observations, individual and focus groups interviews, and literature studies. A qualitative software program (Atlas-ti) was used to triangulate the collected data.

RESULTS

The main concern of local practitioners was identified to be the post-discharge decline in functional capacity in elderly amputees. This was related to a predominantly biomedical and biomechanical approach, and accompanying traditional therapist-patient interactions. The content and underpinnings of prosthetic treatments were scarcely specified in either the scientific literature or the local setting. Generic principles and practices from other fields were useful for treatment innovation for post-discharge problems, such as task- and context-specific training and self-management education. A circuit training focused on motor learning and a problem-solving training focused on social learning were developed by integrating amputation-specific knowledge.

CONCLUSION

Improving rehabilitation practice with the use of available evidence is a heterogeneous and multifaceted scientific enterprise. Such an enterprise requires as much self-reflexivity from researchers as from practitioners.