Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article

Degree

Doctor of Philosophy

Program

Health and Rehabilitation Sciences

Supervisor

Dr. MacDermid, Joy C

Abstract

Fractures of the distal radius are common and can cause substantial either transient or permanent impairment and disability.

Clinical practice guidelines (CPGs) are systematically developed statements or recommendations based on the best available evidence and aimed at assisting health care practitioners in clinical decision-making. Many professional organizations have developed practice guidelines for common clinical conditions. The overall objective of this thesis is to evaluate the therapist's perception of the clarity and implementability of rehabilitation relevant recommendations from The American Academy of Orthopaedic Surgeons (AAOS) CPG for distal radius fractures (DRF) and to identify the quality of CPG related to DRF. To address my study objective, first, I categorized the AAOS DRF CPG using the International Classification of Functioning Disability and Health (ICF) and International Classification of Diseases ICD-10 using linking procedures and compare the content codes of the CPG with the ICF hand core sets as the reference standard. Then I conducted a cognitive interview study to understand the therapist's perceptions of the clarity and implementability of the recommendations.

To further understand the implementability of the AAOS DRF CPG, I conducted a cross-sectional survey on the implementability of the AAOS DRF guidelines using the guideline implementability appraisal tool (GLIA). And we conducted a systematic literature review to identify and appraise CPGs relevant to the management of DRF s using the AGREE II tool.

The results of the thesis indicate that the AAOS DRF CPG focuses on surgical interventions and has minimal linkage to the constructs of the CF constructs (activity or participation) and the ICF Hand Core Set. In my qualitative study, I found that eight of ten recommendations sampled from the AAOS DRF CPG were considered vague and unimplementable by therapists in their clinical practice, due to the lack of clarity and information on what to implement, how to implement, and to measure the adherence and outcomes of the recommendation. In the systematic review I found that for the selected CPGs developed by professional organizations in the UK, Canada, USA, Denmark, and Norway, the AGREE score for the scope and purpose domain ranged from 61% to 94% and the stakeholder involvement domain ranged from 13% to 97%. The rigor of the development domain score ranged from 38% to 95%. and for the clarity of the presentation domain score ranged from 63% to 83%. Scores were lowest on the domain of applicability and ranged from 18% to 60% and the score for the editorial independence domain ranged from 54% to 79%

This work implicates that CPG that focus on rehabilitation after DRF are needed and improving the implementability of the CPG recommendations by making them more specific and actionable while providing resources would assist with the implementation. Therapists need to be aware and understand variability existing in quality, the rigor of development, and the applicability of these guidelines. The future guideline should consider implementation during development including ready access to the details about the level recommended in intervention reporting guidelines.

Summary for Lay Audience

Clinical practice guidelines (CPG) are tools that are used to help patients and health professionals how to manage health conditions using the best available research evidence. A broken wrist, called a distal radius fracture, is the most common broken bone that requires patients to attend an emergency clinic. From this initial visit through to rehabilitation, many decisions must be made. Clinical practice guidelines should assist with those decisions and help to keep patients informed about whether they are getting the best care. However, this is dependent on ensuring that the recommendations within such guidelines are evidence-based, easy to interpret, provide clear guidance, and can be reasonably implemented. An international group of orthopedic surgeons (American Academy of Orthopaedic Surgeons) has developed a guideline for how these injuries should be managed. It is important that we understand whether this guideline is understood and used.

In this thesis work, I interviewed the health professionals who involved in helping patients recover from these fractures and found out detailed information about how they interpret the recommendations, their intention on implementing them, and the barriers and facilitators to doing so. In one of the studies in this thesis work, I found that eight of ten recommendations sampled from the American Academy of Orthopaedic Surgeons guidelines to treat the broken wrist were considered vague and difficult to implement by therapists in their clinical practice, as they are not easy to understand and information on what to implement, how to implement were not clearly informed. This thesis finds that CPG that focuses on rehabilitation after a broken wrist is needed and improving the applicability of the CPG recommendations by making them more specific and actionable while providing resources would assist with the implementation.

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