An alternative description of my Critically Appraised Topic on Neurodevelopmental treatment when used on children with cerebral palsy. This presentation focuses more on the process of the research.

1. Evidence-Based Practice The Effectiveness of Neurodevelopmental Therapy in Improving Gross Motor Function of Children with Cerebral Palsy Dani Cowan, OTS

2. Introduction Objectives: Understand the results of a critically appraised topic regarding NDT and its use for children with cerebral palsy. Understand how a critically appraised topic is completed. Overview of what will be covered: What is an evidence-based question? Parts of a PICO question. Overview of the types of evidence-based questions. How does this relate to your facility? How was the research done? How I chose which articles to review specifically Results of my review My PICO Question: Is neurodevelopmental therapy more effective in improving gross motor function of children with spastic cerebral palsy when compared to alternative or no therapy

3. What is an evidence based question? PICO Question Types of Evidence Based Questions How is this relevant to this facility?

4. PICO Question Is NDT more effective in improving gross motor function of children with spastic cerebral palsy when compared to alternative or no therapy? PICO Question A focused clinical question with the following parts: P: Patient or client group Children with spastic CP I: Intervention or assessment NDT C: Comparison intervention Alternative/No Therapy O: Outcome Improve Gross Motor Function

5. Types of Evidence Based Questions:Effectiveness of the Intervention Therapy Of the interventions available, which Does more good than harm? Is worth the effort and cost? Are there specific aspects of the intervention that determine if most clients are likely to experience benefits? Prevention Can the occurrence of future problems be changed by an intervention that is directed a one or more risk factors? Does participation in Fit for Life Programs by elderly women with osteoporosis reduce the risk for falls? Does participation in community programs by children with disabilities increase the likelihood that they will sustain friendships during elementary school?

6. Types of Evidence Based Questions Continued:Defining or Describing a Clinical Problem Prevalence/Presentation How often are specific profiles seen in clients caused by a clinical disorder or impairment? What is the prevalence of anxiety in children on the autism spectrum? Clinical Assessment What are the most reliable and valid ways to collect and interpret information about the client’s strengths, hindrances, and concerns? What assessment tools are the most accurate to identify developmental delays in children with ADHD? Causes What are the possible causes of my client’s problem? Of these, which are most likely? What methods are best at determining which cause is most likely? What is the best method to determine if the child’s difficulty with attention in school is due to sensory deficits?

7. What is likely to be the course for my client over time (clinically or developmentally)? Are there any possible complications? What are they? What factors are related to the possible outcomes? What is the likelihood that this two-year-old with severe mobility disabilities will be walking by the age of six? Types of Evidence Based Questions Continued:Predicting Client Outcomes

8. What methods are most effective for understanding the client’s experience? How does the client’s meaning or understanding influence their participation and their outcome? What are the most common concerns of parents of children with autism? Is the COPM an effective tool to help create goals that will result in client satisfaction compared to standard methods? Types of Evidence Based Questions Continued:Client Experience and Meaning

9. How is this relevant? Mayo Rochester 400 patients with CP treated each year with a majority being at the Rochester location NDT is commonly used in OT and is often taught to the patient care team to use with client’s in order to achieve best results Children’s Hospitals and Clinics Cerebral palsy is a common diagnosis treated at this facility NDT is commonly used in OT and is often taught to the patient care team to use with client’s in order to achieve best results

10. Locating Evidence Databases Used Databases Available to Mayo/Children’s

11. Databases

12. Example Page from UWL http://libguides.uwlax.edu/healthprofessions

13. Example Page from Website http://otseeker.com/search.aspx

14. Databases Available at Mayo/Children’s

15. Evaluating the Literature Levels of Evidence Threats to Validity

16. Levels of Evidence:American Occupational Therapy Association Level 1: Randomized Control Trials Level 2: Non-randomized control groups (two groups) Level 3: Non-randomized control groups (one group) or crossover designs Level 4: Single-subject/Repeated Measures Designs Level 5: Qualitative, Case Study

17. Threats to Internal Validity History/Multiple Treatment Events in the world that may effect results (war, epidemic, etc) Not a threat in this CAT. Treatment Time Is there equal treatment time between groups? Possibly a threat in the RCT’s reviewed. Maturation/Natural Healing Are results due to the intervention or to the development or natural healing of the participants? Always a possibility with children as the population. Control groups are used to prevent this threat. Or dispersing the threat to all (participants of the same age)

18. Threats to Internal Validity Continued Testing/Instrumentation Do the instruments used in the study have strong psychometric properties? (validity, reliability, etc) GMFM-66 or GMFM-88 Participant Effects Did the participants “try harder” because they are part of a study? Did the attention from the experimenter cause better performance? Controlled for by blinding participants from which group Hard to blind with the intervention used, however this is not a likely threat in the articles reviewed

19. Threats to Validity Continued Non-Equivalent Groups: Start of Study Are the groups equivalent in demographic characteristics at the beginning of the study? Statistical analysis Non-Equivalent Groups: During/End of Study Are the groups equivalent in demographic characteristics at the end of the study? Statistical analysis Drop outs/death?

20. Threats to Internal Validity Continued Experimenter Effects Does the experimenter know who is receiving which treatment? Blinding, not possible with the article reviewed Does the researcher support one of the interventions? Unknown in the articles reviewed Did the experimenter conduct the testing? Not a threat in the articles reviewed

21. To Prevent/Improve Threats to Internal Validity Remove the threat Disperse threat to all participants Statistically remove the threat In statistical analysis account for the threat

22. Threats to External Validity People: different countries, ages, etc. Place: Where is the treatment done? What country? Setting? Time: Was the treatment done at a peculiar time? Early morning? Late at night?

23. Results My PICO Question Clinical Bottom Line Implications for Practice, Education, and Future Research

24. PICO Question Is neurodevelopmental therapy more effective in improving gross motor function of children with spastic cerebral palsy when compared to alternative therapy or no therapy? P: Children with spastic cerebral palsy ages 5 months-15 years I: Neurodevelopmental therapy C: Alternative or no therapy O: Improvement in gross motor function

25. Evidence Total of 16 Articles Found Relevant 3 Articles were Reviewed

26. Clinical Bottom Line There is strong evidence that NDT is not more effective in improving gross motor skills of children with spastic cerebral palsy when compared to alternative or no therapy.

27. Boundaries Generalizable to a variety of cultures and ages (5 months to 15 years). Iran (SIT) Israel (Adeli suit) United States Cannot generalize these results to NDT being used for any other outcome. Variability in treatment strategies and techniques so be cautious before generalizing these results to all aspects and techniques of NDT. None of the three articles reviewed in this paper made it clear as to whether or not protocols were standardized or if equal treatment time was given. Larger sample sizes may be more effective in generalizing results.

28. Implications for Practice, Education, and Future Research Practice: Critically think: Why is NDT being used over alternative therapies that may be equally or more cost effective? Extra training and cost of NDT Not concluding that NDT is not effective.

29. Implications for Practice, Education, and Future Research Future Research Deconstruct the aspects of NDT being used What is helpful? What is not? Various Outcomes Education Ensure students understand the research behind the intervention

30. Questions?