A systematic review of interventions for children with cerebral palsy: state of the evidence

Rohini R Rattihalli

19.11.13

Why this paper• Relevant to practice• Good learning points re: practical aspects of EBM

Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence

Treatment benefits:

1. Systematic review of randomized trials or n-of-1 trials

2. Randomized trial or observational study with dramatic effect

3. Non-randomized controlled cohort/follow-up study

4. Case-series, case-control studies, or historically controlled studies

5. Mechanism-based reasoning

Grading of Recommendations, Assessment, Development and Evaluations (GRADE)

GRADE score: high (4), moderate (3), low (2), or very low quality (1 or less)

Quality of evidence on – outcome of interest – in our population of interest.

Initial score based on type of evidence

+4 RCTs/ SR of RCTs, +/– other types of evidence

+2 Observational evidence (e.g., cohort, case-control)

Grading of Recommendations, Assessment, Development and Evaluations (GRADE)

Quality: Based on

Blinding and allocation process, Follow-up and withdrawals, Sparse data, Other methodological concerns (e.g., incomplete reporting, subjective outcomes)

0 No problems

–1 Problem with 1 element

–2 Problem with 2 elements

–3 Problem with 3 or more elements

Similar +/- regarding Consistency, Directness, Effect size

ICFWorld Health Organization’s International Classification of Functioning, Disability and Health

Classification of health and health-related domains• body functions and structure (BF), • activity (A) • Participation (P), • environmental factors (E), • Personal factors (P)

Background: Interventions in CP• 40% no reported evidence- based • 20% ineffectual, unnecessary, or harmful.

MethodsInclusion criteria• Level 1 preferred• Level 2 to 4 only if

– No level 1– New level 2 after most

recent level 1

Full search strategy available on request

Methods

Results- Green

Results-Amber

Results: Red

Neurodevelopmental therapy

CASP1. Did the review ask a clearly focused question?

– Clear, but not focused (but this was intentional)

2. Did the authors look for the appropriate sort of papers?– Full description of search strategy not available in the

paper, but assumed to be “yes”.

CASP3. Do you think important relevant studies were included?

– Yes (assumed)

4. Did the review’s authors do enough to assess the quality of the included studies?

– Yes (GRADE recommendations)

5. If the results of the review have been combined, was it reasonable to do so?

– NA

CASP6. What are the overall result of the reviews?

– Majority of the interventions in CP were “Amber”. This was mainly due to no sufficient evidence.

7. How precise are the results? – Precise within the constraints of information available to the

authors.

CASP8. Can the results be applied to the local population?

– Yes

9. Were all important outcomes considered?– Yes (and divided as per WHO International Classification of

Functioning)

10. Are the benefits worth the harms and costs? – NA

Bottom line• Green and Red interventions helpful, but majority of

interventions are Amber:– Evidence of inadequate effect OR Lack of evidence

• What is the realistic possibility of having Level 1, Strong High quality, strong recommendation evidence for all interventions? So what is the solution?