news feed
Appendix A (I) : The development process - choice of topic
The development process - choice of topic
Is the topic high volume, high risk, high cost?
The incidence of sport-related injury has been highlighted in the introductory section of this document, providing evidence of high volume. Whilst not constituting high risk in the conventional sense, it is generally accepted that effective early management of soft tissue injury aimed at ameliorating the inflammatory response will reduce the risk of prolonged morbidity and recurrence of injury. The potential cost of sport-related injury related to time off work has been estimated at £405 million each year in England and Wales alone (Nichols et al, 1991), indicating the high cost of these injuries and emphasising the need for effective management.
Are there large or unexplained variations in practice?
The use of PRICE (Protection, Rest, Ice, Compression and Elevation) has been generally accepted, but there is great diversity of practice, particularly with respect to the frequency and duration of ice application and the degree of protection and rest as opposed to early mobilisation.
Is the topic important in terms of the process and outcome of patient care?
Soft tissue injuries are common, both in the context of sport- and non-sports-related activities, and occur in a variety of environments. Consequently, the first person to deliver some form of management in the critical period immediately following injury may be a chartered physio-therapist, a doctor, a coach, a team-mate, a work colleague or indeed the injured person himself. Clear guidelines will assist the practitioner, his colleague and/or the patient to make appropriate decisions and take effective action during this critical period, thus influencing the process of patient management and ultimately the outcome.
Is there potential for improvement?
When there is wide variation in practice, it is inevitable that some elements of practice will be convention rather than evidence-based. The identification of evidence for practice, where it exists, will provide potential for improvement.
Is the investment of time and money likely to be repaid?
If improvements in practice associated with these guidelines result in improved efficacy of treatment, length of time off work and/or sport should be reduced with consequent socio-economic benefits.
Is the topic likely to hold the interest of team members?
The selection of the topic involves an area of practice which is extensively used (and advised) by all chartered physiotherapists in sport. As such, all members of the development group were familiar with the topic, were aware of the diversity of practice and were aware of the need to provide evidence (where it exists) to support practice.
Is consensus likely?
Members of the initial development group were in agreement that where evidence exists, this should form the basis for practice. Where no evidence exists in the literature, the group agreed that consensus should form the basis for the guidelines.
Will change benefit patients?
Any move towards evidence-based practice should benefit our patients.
Can change be implemented?
The guidelines for practice as presented in this document are likely to result in a more focussed and consistent approach to the application of PRICE. With the dissemination of these guidelines, it should be possible to implement an alteration in the emphasis of current practice. Connections within ACPSM and in the wider context of those involved in the management of soft tissue injuries should provide a useful network for the dissemination and implementation of the guidelines.
Appendix A (II) : The development process - membership of the group
The development process - membership of the group
Do we have the right people in the group?
The original membership of the group consisted of members of the physiotherapy profession, all of whom are members of ACPSM. At a later stage, when the first draft of the guidelines is complete, representatives of other interested parties (chartered physiotherapists not involved with the development of the guidelines, medical practitioners, etc.) will be included to evaluate the guidelines for accuracy and ‘user friendliness’.
Can we involve other appropriate people?
Due to the close working relationship and connections of practising members of the group with other professionals involved in sport and sports medicine, appropriate consultation with others can be assured. For the development of the supporting leaflets, the development group will be expanded to include potential users of the summarised guidelines. This will involve sports centre staff, athletes, coaches/trainers, and patients.
Do we have appropriate skills?
The group consisted of chartered physiotherapists with extensive experience of sports physiotherapy, some whom are currently in practice but also with recent academic experience, and others currently working in an academic environment. This provided the necessary mix of specialist experience in practice and experience in reviewing and analysing literature. The group leader has extensive experience in both clinical practice and academic work and is experienced in practicalities of research and the dissemination of findings.
Are there too many or too few of us?
The group identified key areas integral to the development of these guidelines and assigned individuals to take responsibility for each of the areas. Tasks therefore revolved around three major areas of literature, development, distribution and analysis of a questionnaire, management of finances and a co-ordinator to collate the information and take responsibility for producing the guidelines document. The original group had a membership of six, which has allowed dissemination of the load but which is small enough to facilitate ease of communication.
Have we included representatives of those expected to implement the guidelines?
All members of the group are members of ACPSM which is the major target group for implementation of the guidelines. However, as mentioned above, chartered physiotherapists not involved in the development of the guidelines and other appropriate people will be added to the group to advise on the final presentation and composition of the guidelines documentation.
Appendix A (III) : The development process - development of the guidelines
The development process - development of the guidelines
Have we clearly defined the subject of the guidelines?
The subject of the guidelines has been clearly defined as the management of soft tissue injury with Protection, Rest, Ice, Compression and Elevation during the first 72 hours.
Do we have access to guidelines already produced on this subject?
We are unaware of any existing guidelines on this subject.
Have we approached likely sources of advice?
As the initiator of the development of clinical practice guidelines in physiotherapy, the Chartered Society of Physiotherapy was approached for guidance and advice on the development of these guidelines.
Do we need to undertake a literature review?
It was agreed that a review of the literature was necessary to identify evidence for practice. A computerised review was undertaken, using the following data bases: Physiotherapy Index, Rehabilitation Index, Complementary Medicine Index, the CSP Research and Documents databases, Medline, CINAHL and BIDS / Embase.
Is the evidence for defining the components of the guidelines available for those responsible for their construction?
Although it was relatively easy to define the basic components of the guidelines as they constituted accepted practice, the amount of clear evidence to support the individual elements was inconsistent.
How shall we take this forward?
With the knowledge that the supporting evidence was either limited or inconclusive, and that the overall approach was widely accepted in current practice, it was decided to produce guidelines based on evidence (where this exists) and on consensus based on expert opinion.
What type of guidelines do we want to produce?
The guidelines should be clear and unambiguous but should avoid being totally prescriptive to preserve the autonomy of experienced clinicians who wish to exercise clinical judgement. As the guidelines are targeting groups with mixed knowledge bases, the summary documents will take this into consideration.
Have we clearly defined the end users of the guidelines?
The end users will be health professionals (chartered physiotherapists, doctors), sports professionals (coaches, trainers, athletes, sports centre staff) and patients.
Appendix A (IV) : The development process - presentation of the guidelines
The development process - presentation of the guidelines
Is the problem clearly defined?
The problem has been clearly stated in terms of the high incidence and socioeconomic cost of injury and the need to provide evidence-based guidelines to support practice.
Is our presentation clear and unambiguous?
The guidelines have been presented in the form of clear statements pertaining to each element of practice.
Is the evidence for the statements presented or readily available?
The evidence as it exists is discussed in general with respect to each of the elements of practice. The nature of the evidence is presented alongside each statement.
Is there a rationale for the guidelines? what is the estimated impact?
The guidelines (complete document or summary) will be distributed to all members of ACPSM (approximately 1,000), to all members of BASM (approximately 1,000), to sport and coaching bodies, and to sport/leisure venues.
- what are the current variations and uncertainties?
Current variations in practice have been identified through the literature and through the findings of the questionnaire.
If options are available, are the decision-making factors clear?
The critieria for options have been clearly presented in the document and in the appendices.
How should we present them? Which format will be most appropriate for their proposed use?
There will be three main means of presentation - the complete bound document which may be used for reference purposes, a durable leaflet which may be carried around for immediate reference and a simple instruction leaflet which may be given to the injured individual.
Will the chosen medium be sufficiently durable for its proposed use?
Guidance will be sought as to the most effective and durable medium/material for presentation / dissemination.
Are the authors acknowledged or stated?
The authors have been stated and acknowledgements made to other contributors.