DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY
EDITORIAL
Translating evidence into practice Translational medicine and evidence based practice (EBP) are key principles that have guided clinical applications of research over the past two decades, helping to transform research on disease and disability. There is less evidence that clinical practice has shifted by similar dimensions. As a clinician and clinical manager turned researcher, I have seen clinicians struggle to integrate research evidence into what are often quite inflexible clinical pathways. I may also have dampened the enthusiasm of clinicians with reminders to consider cost-effective evidence; thereby unwittingly contributing to the persistence of traditional models of care. With often onerous processes of health care management, the evidence and inspiration behind proposed changes not only get diluted but critical aspects of an intervention can get lost, thus undermining the capacity to optimize care for individuals. Diane Damiano1 has highlighted the need to move beyond group means in trying to understand the evidence and implications for clinicians, with a timely reminder of Sackett’s 1996 definition of EBP to enable clinicians to make decisions about the care of individual patients.2 But how do clinicians marry up the evidence when confronted with an individual? In considering obstacles and facilitators to the uptake of EBP, Grimshaw et al.3 suggest that the basic unit of knowledge translation is an up-to-date systematic review to synthesize research findings. Yet these usually include trials which inherently use group means to define treatment effects, inevitably losing the individual. This is particularly so in the case of therapies for children with neurodisability where considerable inter-individual responses to interventions have been reported. Damiano1 has correctly identified the need for research strategies that can distinguish/predict responders in order to consider what treatment works best for whom. There remains, however, the need to assist clinicians in understanding how to implement the best treatment protocols. Sufficient details of the intervention, including the theoretical and empirical evidence of the mechanisms by which the intervention work, are missing from many efficacy studies to enable clinicians to consider the logistics of translation. Translation requires the transformation of one entity to another. This requires definition of the original entity alongside the context and culture of the translated version to determine what has shifted and whether any discrepancies exist that may influence/explain a particular
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individual’s response to that intervention. This may well be at the individual level (child outside inclusion criteria of the literature), environmental level (intervention did not conform to evidence, e.g. facility, expertise of staff) as well as at procedural levels (including timing, dosing, and duration of intervention).3 In reality, few studies clearly define important elements of interventions, nor provide a fidelity checklist to consider how closely the protocol was adhered to across participants/research sites. Translational roadblocks defined by Woolf4 consider firstly the transfer of basic science to new methods of diagnosis, therapy, and prevention and secondly the ‘translation of results of clinical trials into everyday clinical practice and health decision making’. The second of these is important where the responsibility of implementation often falls on practitioners other than health care professionals. A number of recent intervention studies epitomize this dilemma. For example, is it the duration of constraint of the hemiplegic hand for children with hemiplegia, type or extent of repetition of activities, or skill of the supervisor in shaping and scaffolding task practice during constraint-induced movement therapy (CIMT) that distinguishes group results? According to the originators, CIMT is defined as a family of therapies of which constraint is only part of a multifaceted intervention including repetitive, task-oriented training through shaping and practice, and adherence-enhancing behavioural strategies (including home diaries and daily schedules).5 Methods of application and adherence to these other aspects of the therapeutic protocol are rarely articulated clearly. Researchers have a responsibility to define the salient ingredients of interventions and acceptable modifications in order to enable clinicians to consider how particular protocols can be implemented in their service with or without translation. Clinicians have a responsibility to ensure they are able to deliver the evidence with acceptable veracity, with sufficient documentation across a number of outcomes of relevance, to support understanding of response to treatment at the individual as well as service level. The challenge Damiano has set is for researchers and clinicians to work together to promote individualized evidence-based rehabilitation.
DIDO GREEN Centre for Rehabilitation, Oxford Brookes University, Oxford, UK. doi: 10.1111/dmcn.12625
© 2014 Mac Keith Press
REFERENCES 1. Damiano DL. Meaningfulness of mean group results for
3. Grimshaw JM, Eccles MP, Lavis JN, Hill SJ, Squires JE.
5. Morris DM, Taub E, Mark VW. Constraint-induced
determining the optimal motor rehabilitation program for
Knowledge translation of research findings. Implement Sci
movement therapy: characterising the intervention proto-
an individual child with cerebral palsy. Dev Med Child
2012; 7: 50.
col. Eura Medicophys 2006; 42: 257–68.
Neurol 2014; 56: 1141–6. 2. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Rich-
4. Woolf SH. The meaning of translational research and why it matters. JAMA 2008; 299: 211–3.
ardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996; 13: 71–2.
Editorial
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Copyright of Developmental Medicine & Child Neurology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
EDITORIAL
Translating evidence into practice Translational medicine and evidence based practice (EBP) are key principles that have guided clinical applications of research over the past two decades, helping to transform research on disease and disability. There is less evidence that clinical practice has shifted by similar dimensions. As a clinician and clinical manager turned researcher, I have seen clinicians struggle to integrate research evidence into what are often quite inflexible clinical pathways. I may also have dampened the enthusiasm of clinicians with reminders to consider cost-effective evidence; thereby unwittingly contributing to the persistence of traditional models of care. With often onerous processes of health care management, the evidence and inspiration behind proposed changes not only get diluted but critical aspects of an intervention can get lost, thus undermining the capacity to optimize care for individuals. Diane Damiano1 has highlighted the need to move beyond group means in trying to understand the evidence and implications for clinicians, with a timely reminder of Sackett’s 1996 definition of EBP to enable clinicians to make decisions about the care of individual patients.2 But how do clinicians marry up the evidence when confronted with an individual? In considering obstacles and facilitators to the uptake of EBP, Grimshaw et al.3 suggest that the basic unit of knowledge translation is an up-to-date systematic review to synthesize research findings. Yet these usually include trials which inherently use group means to define treatment effects, inevitably losing the individual. This is particularly so in the case of therapies for children with neurodisability where considerable inter-individual responses to interventions have been reported. Damiano1 has correctly identified the need for research strategies that can distinguish/predict responders in order to consider what treatment works best for whom. There remains, however, the need to assist clinicians in understanding how to implement the best treatment protocols. Sufficient details of the intervention, including the theoretical and empirical evidence of the mechanisms by which the intervention work, are missing from many efficacy studies to enable clinicians to consider the logistics of translation. Translation requires the transformation of one entity to another. This requires definition of the original entity alongside the context and culture of the translated version to determine what has shifted and whether any discrepancies exist that may influence/explain a particular
1132
individual’s response to that intervention. This may well be at the individual level (child outside inclusion criteria of the literature), environmental level (intervention did not conform to evidence, e.g. facility, expertise of staff) as well as at procedural levels (including timing, dosing, and duration of intervention).3 In reality, few studies clearly define important elements of interventions, nor provide a fidelity checklist to consider how closely the protocol was adhered to across participants/research sites. Translational roadblocks defined by Woolf4 consider firstly the transfer of basic science to new methods of diagnosis, therapy, and prevention and secondly the ‘translation of results of clinical trials into everyday clinical practice and health decision making’. The second of these is important where the responsibility of implementation often falls on practitioners other than health care professionals. A number of recent intervention studies epitomize this dilemma. For example, is it the duration of constraint of the hemiplegic hand for children with hemiplegia, type or extent of repetition of activities, or skill of the supervisor in shaping and scaffolding task practice during constraint-induced movement therapy (CIMT) that distinguishes group results? According to the originators, CIMT is defined as a family of therapies of which constraint is only part of a multifaceted intervention including repetitive, task-oriented training through shaping and practice, and adherence-enhancing behavioural strategies (including home diaries and daily schedules).5 Methods of application and adherence to these other aspects of the therapeutic protocol are rarely articulated clearly. Researchers have a responsibility to define the salient ingredients of interventions and acceptable modifications in order to enable clinicians to consider how particular protocols can be implemented in their service with or without translation. Clinicians have a responsibility to ensure they are able to deliver the evidence with acceptable veracity, with sufficient documentation across a number of outcomes of relevance, to support understanding of response to treatment at the individual as well as service level. The challenge Damiano has set is for researchers and clinicians to work together to promote individualized evidence-based rehabilitation.
DIDO GREEN Centre for Rehabilitation, Oxford Brookes University, Oxford, UK. doi: 10.1111/dmcn.12625
© 2014 Mac Keith Press
REFERENCES 1. Damiano DL. Meaningfulness of mean group results for
3. Grimshaw JM, Eccles MP, Lavis JN, Hill SJ, Squires JE.
5. Morris DM, Taub E, Mark VW. Constraint-induced
determining the optimal motor rehabilitation program for
Knowledge translation of research findings. Implement Sci
movement therapy: characterising the intervention proto-
an individual child with cerebral palsy. Dev Med Child
2012; 7: 50.
col. Eura Medicophys 2006; 42: 257–68.
Neurol 2014; 56: 1141–6. 2. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Rich-
4. Woolf SH. The meaning of translational research and why it matters. JAMA 2008; 299: 211–3.
ardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996; 13: 71–2.
Editorial
1133
Copyright of Developmental Medicine & Child Neurology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
