Práticas comuns nem sempre são baseadas em evidências

Confidence intervals should be reported

What It Means When a Child Has Special Needs

When parents refer to their child as being “special needs,” it can be confusing for some. Those who do not have any children with mental, physical or emotional issues do not always understand what this term means. Special need is a term that refers to so many different diagnoses, which is why it can be difficult for parents to explain. Saying a child is special needs means they fall under that umbrella, regardless of their individual condition or issue. It may be a food allergy, terminal illness, mental condition or emotional issue.

Limitations

Being special needs generally means there are limitations to what a child can accomplish at school and with their peers. It highlights the qualities a child may not possess or goes over the activities they cannot be a part of. Foods are banned, activities are not possible, and some experiences are denied. It is how life can go for some families with a special needs child. And while some parents can get caught up in all those “notes,” other parents prefer to look at the bright side. There is still so much their child can accomplish, provided they get a great education.

Finding childcare for special needs children is so difficult, especially if the child’s issues are more serious. Daycare centers are reluctant to take such children, as they do not want them messing with the equilibrium of all the other kids. Or they may not have the resources to dedicate someone to watch the child all the time, and catering to their needs. Parents usually have to go with in-home daycare or nannies – and it must be someone who has experience with special needs children. Whether it is a medical or behavioral issue, it can become serious in an instant, which is why the person taking care of the child must have experience in how to handle the matter.

Learning Issues

For some children, being special needs is not just about how they can be difficult to handle at a young age. It can mean serious learning and developmental disabilities, which is why so many schools now offer proper special needs educators to help these children. It is estimated that anywhere from 13 to 15 percent of kids in the United States school system are special needs. Each of these kids has their own issue, but they all fall under the same umbrella, as they cannot be managed in the same way as the other 85 to 87 percent of kids.

Parents may think they are in for a life of struggle with their special needs child. But it does not have to be that way. If you can find great daycare, a wonderful school and a support system to help you through the process, your child can still have a fulfilling and wonderful life. It is all about managing each difficult moment and learning from them. Special needs kids can make wonderful progress in life, so long as they are treated in the right way when they are younger.

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Fair comparisons with few people or outcome events can be misleading

The Demographics of Video Gaming

In 2015 nearly $91.5 billion was spent on video games and gaming products around the globe, with the United States accounting for nearly a quarter of that ($22 billion). In the same year, global movie box office revenue brought in only $38.3 billion. Gaming these days is just as popular as pet ownership—two-thirds of American […]

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Is Acupuncture an effective treatment for chronic low back pain?

This blog is a critical appraisal of the following randomized trial: Acupuncture in patients with chronic low back pain

Background

Lower back pain (LBP) is one of the most common Musculoskeletal (MSK) conditions and there are many different methods and techniques that are utilized to treat LBP. Acupuncture, a treatment that has its history rooted in ancient Chinese medicine, has in recent years been distilled to an acceptable form of complementary or alternative medicine for pain relief.

This study aims to add to the ongoing discussion within physiotherapist circles as to the efficacy of acupuncture as a modality of treatment.

What was the study?

The Randomised Control Trial (Brinkhaus et al., 2006) investigated the use of acupuncture in treating chronic LBP over an eight-week period, with the control group being either superficial needling or a waiting list control. The primary outcome variable was a visual analog scale (VAS) ranging from 0-100 mm.

There were a total of 298 participants of which 67.8% were female and 32.2% male.  The acupuncture was administered by specialist acupuncture physicians (defined as having at least 140 hours of acupuncture training) in 30 outpatient hours of acupuncture training centres in which each patient had 12 sessions over the 8 week treatment period.

Results

The difference for the intervention vs. sham acupuncture was 5.1 mm (95% confidence interval, −3.7 to 13.9 mm; P = 0.26) which in terms of this study is statistically insignificant. However, the acupuncture group vs the waiting list group highlighted a statistically significant difference of 21.7 mm (95% confidence interval, 13.9-30.0 mm; P<.001).

Critical Analysis

The primary outcome variable was the change in VAS and this was measured via standardized questionnaires before treatment and at 8, 26 and 52 weeks after randomization. VAS is often used in clinical settings to gauge pain levels. It allows for the patient to decide whether or not their pain has increased or decreased and the self reporting aspect of VAS is an acceptable outcome measure.

Patients were randomized in a 2:1:1 (acupuncture: minimal acupuncture: waiting list) ratio by a centralized telephone randomization procedure. The randomization method is considered thorough and thus eliminated the potential for selection bias, however, the population that were used may have already been bias in favour of acupuncture. The majority of recruitment of participants was done by an advertisement in a newspaper. Those that applied to receive treatment may have had a preconceived idea of the effectiveness it would have on them and therefore the population used may not have been objective.

It was blinded as far as possible for the patient and the study acknowledged that it would not be possible to blind the physicians due to the nature of the intervention; however the outcome measures were assessed independently.

The intervention group and comparator were indeed relevant in so far as the study acknowledges and recognizes that there may already be a psychological aspect to going through the procedure to receive acupuncture and accounts for this by having two control groups.

Whilst there was a semi-standardized approach for the treatment, acupuncture is taught such that there are specific parts of the body in which the needles need to be placed to reduce pain. There could be reliability issues as to the placement of the needles as each practitioner is autonomous. Despite guidelines of zones that would not be used there is the chance that the placement of needles would greatly differ. That being said, this would be a prevalent problem for any study examining acupuncture in which more than one rater was being used. The results of this study would suggest that the location of the needles would be somewhat irrelevant in producing a desired result and that rater bias wouldn’t make a difference.

One of the strongest points for the study was the number of participants (which was at 289) completed data available for 284 of these participants. This is a relatively high number of participants for a trial of this nature.

Conclusion

Whilst the population used puts the results into question, the study is one of the most robust in terms of its procedure, number of participants and response to the study. However, it still begs the question as to whether or not acupuncture is an effective treatment. What this study does do is highlight the strong psychological element involved as there was no significant difference in reduction of pain from those who received the acupuncture and those who received the sham acupuncture.

More research is required in determining the impact acupuncture has on chronic pain. This study paves the foundation for further studies to be conducted and sets a well formulated example that could be replicated. This study may aid those who already practice acupuncture as a treatment modality to continue using this in their clinic; however, the study does not address other modalities of treatment such as massage or exercise which may reduce pain more effectively than acupuncture. Therefore, those that wish to use this as an example to introduce acupuncture into their practice should do so cautiously.

Reference

Brinkhaus, B., Witt, C., Jena, S., Linde, K., Streng, A., Wagenpfeil, S., Irnich, D., Walther, H., Melchart, D. and Willich, S. (2006). Acupuncture in Patients With Chronic Low Back Pain. Archives of Internal Medicine, 166(4), p.450.

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Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain

This blog is a critical appraisal of the following randomized trial: Ferreira ML et al (2007). Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: A randomized trial

Background

Nonspecific low back pain (NSLBP) is defined as symptoms without any specific cause and is the most common form of back pain. It is stated by Tulder and Koes (2010, p. 71) as “pain, muscle tension or stiffness localised below the costal margin and above the inferior gluteal folds, with or without leg pain”.

There are three different stages within NSLBP: acute (less than 6 weeks), subacute (between 6 weeks and 3 months) and chronic (lasting longer than 3 months) (Airaksinen et al. 2006).

The Study

The researchers collected 240 participants with non-specific low back pain who met the set criteria and participants not eligible were excluded prior to randomisation. They were randomised by one investigator who used blocked randomisation with sizes of 6, 9 and 15. They were allocated into groups that received 8 weeks of either general exercise (GE), motor control exercise (MCE) or spinal manipulative therapy (SMT). The primary outcome measures used in this study were Patient- Specific Functional Scale (PSFS) which looks at three activities which each individual find most difficult and Global Perceived Effect Scale (GPE) which addresses progress in perceived pain. The secondary outcomes used were Visual Analogue Scale (VAS) and Roland Morris Disability Questionnaire (RMDQ). The data was collected during follow up appointments at 8 weeks, 6 months and 12 months, comparing the baseline measured prior to randomisation.

All data for the interventions was analysed on an intention to treat (ITT) basis, but no attempt was made to impute values for the missing data.

The Results

For the results, the primary outcome measures showed that the mean improvements for the PSFS, motor control exercise and spinal manipulative therapy conducted somewhat better short-term function and perceptions with a difference between 3.8 and 5.0 points. As for the GPE, the mean difference varied between 3.8 and 4.4 and this in relation to the baseline values with 95% confidence intervals. As for the secondary outcome measures, no statistically significant effects were seen after 8 weeks. For the long-term effects, there were no evident differences between any of the groups in either of the outcomes.

Positives and Negatives

To investigate this study in more depth and to get a broader understanding, the CASP RCT tool will be used as a guideline. The study did address a clearly focused issue relating to population, interventions, comparator and outcome measures (PICO).

Due to the nature of interventions in this study, it was not possible to blind the physiotherapists delivering the treatment, but patients and all other investigators were blinded. Due to the therapist not being blinded it could lead to possible rater bias as the therapists may have different skill levels and the way of delivering treatment may differ between the therapists.

Out of the 240 participants, 16 patients withdrew before the 8-week follow up and all in all there were 29 patients who withdrew. As there were no attempts made to impute the values for missing data, there was no threat to the validity of the study.

For most baseline characteristics, the groups were similar although there were some differences linked to socio-economic backgrounds where participants either worked full-time or were not working. This could have had an effect on motivation, such as to get back to work as well as the activity level before and after injury. On the other hand more females were included in this study which relates to the wider population as Depalma (2012) mentions that females are more prone to suffer with chronic lower back pain than males.

As for the 3 interventions, the GE and MCE programmes were taught in groups, however it does not mention what kind of exercises were administered which makes it harder to reproduce. The SMT were administered on a one to one basis which can make the outcomes differ from an intervention delivered on a group basis with less one to one contact. The feedback of motor control exercise involved the use of ultrasonography – it is not mentioned how they used this in respect to body position, angles or duration. Due to this, error may be present and it is important to have a standardised procedure (Henry and Westervelt 2005).

Participants in both the GE and MCE groups were given advice to continue with certain exercises at home whilst the participants in the SMT group only received joint manipulation techniques and were advised to avoid pain aggravating movements. If they recovered before the 12 sessions their treatment would stop compared to the two other groups who fulfilled the 12 sessions regardless of the extent of their recovery. This could lead to a difference in the results as some participants may have ended their treatment earlier than others.

Conclusion

The results of this study show that for the long-term effects of either intervention there were no statistically significant differences, however for short-term effects both the SMT and MCE groups showed greater improvement. Therefore these results can contribute to a professional’s clinical reasoning in practice.

 

References

AIRAKSINEN, O., BROX, JI., CEDRASCI, C., HILDEBRANDT, J., KLABER-MOFFETT, J., KOVACS, F., MANNION, AF., REIS, S., STAAL, JB., URSIN, H. and ZANOLI, G. 2006. European guidelines for the management of chronic nonspecific low back pain. European spine journal. March, pp. 200-2010.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3454542/pdf/586_2006_Article_1072.pdf

CRITICAL APPRAISAL SKILLS PROGRAMME (CASP) – MAKING SENSE OF EVIDENCE., 2013. CASP Randomised Controlled Trial Checklist [online]. [Viewed 14 December 2017]. Available from: http://media.wix.com/ugd/dded87_40b9ff0bf53840478331915a8ed8b2fb.pdf

DEPALMA, J., KETCHUM, JM. And SAULLO, TR., 2012. Multivariable analysis of the relationships between age, gender and body mass index and the source of chronic lower back pain. Journal of pain medicine. Vol. 13, no. 4, pp. 498-506.

FERREIRA, LM., FERREIRA HP., LATIMER, J., HERBERT, DR., HODGES WP., JENNINGS DM., MAHER, GC. And REFSHAUGE MK., 2006. Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: a randomised controlled trial. International association for the study of pain, pp. 31-37

HENRY, SM., and WESTERVELT, KC., 2005. The use of real-time ultrasound feedback in teaching abdominal hollowing exercises to healthy subjects. Orthopaedic sports physiotherapy. Vol. 35, no. 45, pp. 338.

KAMPER, SJ., OSTELO, RWJG., KNOL, DL., MAHER, CG., DE VET, HCW. and HANCOCK, AJ., 2010. Global perceived effect scales provided reliable assessments of health transition in people with musculoskeletal disorders, but ratings are strongly influenced by current status. Journal of clinical edidemiology. July, vol. 63, no. 7, pp. 760-766.

PHYSIOPEDIA., 2017. Patient specific functional scale [online]. [Viewed 5 January 2018]. Available from: https://www.physio-pedia.com/Patient_Specific_Functional_Scale

VAN TULDER, M and KOES, B., 2010. Chronic low back pain. Evidence-Based Chronic Pain Management.

 

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What qualifications do you need to be a special needs teacher?

“Special needs” has become an umbrella term that is used to describe children who have any number of physical, emotional or mental issues that may prevent them from learning at the same pace as their peers. While it can be easy to think that special needs children are a very small minority, it is not the case.

Statistics show that around 54 million Americans have some type of special need. In terms of percentages, the National Center for Education Statistics estimated that in 2014/2015 that around 13 percent of children who were being educated in the system had some type of special need. That shows the figure is not some tiny minority. It is not one or two percent of children, but a whopping 13 percent who need special needs while going to school. That is why so many school districts are eager to hire special needs teachers.

For professionals who want to help special needs children, it can be a challenge to figure out how to best qualify for such positions. Here is our guide.

Requirements for Special Needs Teachers

The first part of the process is to gain the necessary qualifications to become a teacher. That means having a bachelor’s degree, preferably in special education. Even an education degree would be sufficient if it were supplemented by specific classes involving special education. It is also appropriate to have a teaching internship that is focused on special education. If it is in a classroom of special needs children, it is all the better.

Each state will have a required set of tests that would-be educators must pass. There are special tests for teachers who want to go into this line of work. Helping special needs kids is different from teaching a regular class, which is why the tests are different for special needs educators.

When the tests are passed, it is time to obtain a teaching license. After getting the license, teachers can start applying for positions that require a special needs educator.

Necessary Skills for Special Education

Every teacher must possess great qualities if they are going to help their students. Even teaching a class full of students with no special needs is a challenge. But special needs students can be even more difficult, even if it is not their intention. That is why any special needs educator must show greater patience, calmness, organization, inspiration, and acceptance than regular teachers. Special needs children come from different backgrounds, and all of them have different disabilities or issues that prevent them from learning at the same pace as other kids. Teachers must be able to effectively communicate with the students, their parents and the school to ensure progress is being made.

It is not easy being a teacher. It is even harder being a special needs educator. But the rewards are even greater. It is an incredible feeling to help children who may not have enjoyed the most success at other schools or with other teachers. The appreciation you will get from those kids and their parents are hard to beat in any other profession.

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What’s Your Money Personality?

Do you keep a budget and set savings goals, or do you splurge more than you put away?

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Insights from the Shark Tank: Why I Chose the Cheaper Graduate Program

It’s a question I’ve been asked many times: “What was the hardest part of the grad school application process?” For some it’s the dreaded standardized testing, for others the endless essay prompts or just trying not to sweat profusely during a heart-pounding admissions interview. For me, in May 2013 with four acceptance letters in hand, […]

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