P.I.C.O. (T.T.) Model for clinical questions
P: patient, population or problem
- How would i describe a group of patients similar to mine
I: intervention, prognostic factor or exposure
- Which main intervention, prognostic factor, or exposure am I considering?
C: comparison to intervention (if appropriate)
O: outcome you would like to measure or achieve
T: what type of question are you asking
T: type of study you want to find
Classify studies:
• Observational study: groups are much more larger than experimental study → might be a
problem in the context of revalidation (not many people)
o Case control study
o Cohort study
▪ Following up participants to observe who ‘develops’ the outcome of interest
▪ High risk for selection bias and confounding factors
▪ Long follow-up: risk of important losses to follow up
▪ Appropriate design to analyse associations
▪ Problematic design when used to evaluate therapeutic interventions
o Comparison of groups doesn’t mean it is an experimental design!
• Experimental study: causal relationship and effect
o Shorter in time than observational study (you can’t control a situation for a long
time)
o Bias is still possible
o Randomization: How type of randomization was used and whether the
randomization was concealed (blind randomization)
o Blinding: lack of blinding is less a problem with objective outcome measures than
with subjective
o Usually: High internal validity but low external validity!
1. Number of participants: not the most important information for quality of a study
2. Study design: most important information for quality of a study
3. Power analysis/ sample size estimation: most relevant to asses if number of participants is
enough
4. Assessment of subjects: objective/subjective → self-assessment, questionnaire, independent
test
5. Characteristics of the participants: information about the participants
6. Inclusion/exclusion criteria → Participant selection described in ‘Methods’ External validity
reduced: because group is so select you must question if the outcome is valid for other
people
,Leading questions for the CAT
➢ Does the study address a clearly focused question
➢ Did the study used valid methods to address this question
o Random error: affects the precision of the results
o Systematic bias: selection of participants, data collection, data analysis and
interpretation
➢ What are the results
➢ Are these valid, important results applicable to my patient or population
Reliability = precision of measurement
Validity = accuracy → absence of systematic errors: absence of bias
CAT: try to explain the negative and positive aspects of the studies, NOT give a number!
Lecture 2 – Cerebral Palsy
Cerebral Palsy = non progressive with progressive musculoskeletal pathology
- Brain damage due to different reasons
- Damage can be at different places in the brain
- Depending on the location of damages it can lead to different symptoms
Etiology, incidence/prevalence
- Most common pediatric neurological disorder (2-3/1000 live births)
- Diagnosis based on abnormal movement and posture
- Etiology: non-progressive brain injury
- Symptoms: change over time
- Umbrella term: large range of brain injuries and functional limitations.
- CP prevalence decreases with increasing gestational age
Cause and timing
Congenital CP: born with CP → Genetic abnormalities, congenital brain malformations, maternal
infections/fevers, or fetal injury.
Acquired CP: begins after birth → Brain damage/infections, problematic blood flow to the brain
➢ Periventricular leukomalacia (PVL):
o White matter damage
o Gaps in brain tissue
➢ Cerebral dysgenesis:
o Abnormal development of the brain
o Can cause brain malformation
➢ Intracranial hemorrhage:
o Brain bleeding by fetal stroke
➢ Asphyxia:
o Lack of oxygen in the brain
o Oxygen supply cut off for lengthy period → hypoxicischemic encephalopathy
(destroyed tissue in the cerebral motor cortex and other areas of the brain)
,Risk factors
- Multiple births
- Infection during pregnancy
- Blood type (Rh) incompatibility between mother and child
- Exposure to toxic substances
- Mothers with thyroid abnormalities, intellectual disability, excess protein in the urine, or
seizures
Signs and symptoms: The symptoms of CP differ in type and severity, and may change over time.
- Ataxia: Lack of muscle coordination during voluntary movements
- Spasticity: Stiff or tight muscles and exaggerated reflexes
- Weakness in one or more arm or leg
- Walking on toes, crouched gait, or a “scissored” gait
- Variations in muscle tone: hypertonia & hypotonia
- Excessive drooling or difficulties swallowing or speaking
- Shaking (tremor) or random involuntary movements
- Delays in reaching motor skill milestones
- Difficulty with precise movements
- Impaired vision or hearing
- Communication issues
- Some have a certain level of intellectual disability
Diagnosis
- No definite test for CP
- Severe cases: diagnosis after birth
- Milder cases: wait until major brain maturation (5 yrs)
- Average age of diagnosis: around 2 years.
- Difficult diagnosis because;
o It may take years for clear signs to appear
o Many children with brain damage make a recovery
o Levels of severity vary greatly
o Signs of CP resemble other disorders
- MRI, Cranial ultrasound, Computed tomography (CT), Electroencephalogram (EEG)
Accompanying issues
- Delayed growth and development
- Seizure disorder
- Spinal deformities and osteoarthritis
- Speech and language disorders
- Drooling: poor control of muscles of the throat, mouth, and tongue
- Incontinence
- Abnormal sensations and perceptions
- Infections and long-term illnesses
- Contractures
- Malnutrition
- Dental problems
- Inactivity
- Epilepsy
- Osteopenia
- Pain
, Treatments
- Therapeutic
o Physical therapy
o Occupational therapy: improving posture
o Recreational therapy
o Speech and language therapy
- Pharmaceutic
o Botulinum toxin-A
o Intrathecal baclofen
- Surgical
o Orthopaedic surgery
o Selective dorsal rhizotomy (SDR)
Classify CP
- Type of movement disorder
o Spastic: 90% of the children! → “stiff” type of movement
▪ Unilateral > congenital hemiparesis/hemiplegia
▪ Bilateral > diplegia, quadriplegia
o Dyskinetic → “involuntary movement”
▪ Unilateral/bilateral > variable topography
▪ Dystonic > reduced activity and increased tone, repetitive and twisting
motions
▪ Athetoid > fluctuating muscle tone (from stiff to floppy), slow twitching and
wriggling involuntary movements. Diminishes when at rest and increase
during attempts to move.
▪ Chorea > rapid and sudden movements
o Ataxic → “shaky” posture and movements
▪ Unilateral/bilateral > variable topography
▪ Low muscle tone and poor coordination
▪ Execute fine movement is impaired
- Anatomic/topographic distribution of symptoms
o Unilateral / Bilateral
- Activity limitation
o GMFCS = gross motor function classification system
▪ 5 levels (totally independent level 1 – totally dependent level 5)
▪ 5 age bands (<---12)
• Since recently 12-18 (GMFCS E&R)
▪ Activity level of ICF is assessed
o MACS = manual ability classification system
▪ Bilateral function of hands
▪ 5 levels:
• Level 1= handles objects easily and successfully
• Level 2 = doesn’t handle objects and severely limited ability to
perform simple actions
▪ Level determined based on knowledge about the child’s actual performance
in daily life (done by asking someone who knows the child and how that child
performs typically)
o CFCS = communication
Activity limitation: Impact of impairments on activities
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