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
control)
Observational evidence (e.g., cohort, case-
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
ICF
World 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.
Methods
Inclusion 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
CASP
1. 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”.
CASP
3. 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
CASP
6. 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.
CASP
8. 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?