Best evidence statement (BESt). Vital sign monitoring in children and adolescents who are overweight or obese in the outpatient physical therapy clinic.
General
Guideline Title
Best evidence statement (BESt). Vital sign monitoring in children and adolescents who are overweight or obese in the outpatient physical therapy clinic.
Bibliographic Source(s)
- Cincinnati Children’s Hospital Medical Center. Best evidence statement (BESt). Vital sign monitoring in children and adolescents who are overweight or obese in the outpatient physical therapy clinic. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2013 Feb 21. 6 p. [15 references]
Guideline Status
This is the current release of the guideline.
Recommendations
Major Recommendations
The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of the evidence (1a‒5b) are defined at the end of the “Major Recommendations” field.
It is recommended that vital signs be assessed prior to and during physical therapy treatment sessions in order to monitor cardiovascular system tolerance to an exercise intervention in children and adolescent patients who are overweight or obese (Carletti et al., 2008 [3a]; Gaya et al., 2009 [4a]; Hayes et al., 2011 [4a]; Norman et al., 2005 [4a]; Ribeiro et al., 2003 [4b]).
Definitions:
Table of Evidence Levels
| Quality Level | Definition |
|---|---|
| 1a† or 1b† | Systematic review, meta-analysis, or meta-synthesis of multiple studies |
| 2a or 2b | Best study design for domain |
| 3a or 3b | Fair study design for domain |
| 4a or 4b | Weak study design for domain |
| 5a or 5b | General review, expert opinion, case report, consensus report, or guideline |
| 5 | Local Consensus |
†a = good quality study; b = lesser quality study
Table of Recommendation Strength
| Strength | Definition |
|---|---|
|
It is strongly recommended that…
It is strongly recommended that… not… |
When the dimensions for judging the strength of the evidence are applied, there is high support that benefits clearly outweigh risks and burdens. (or visa-versa for negative recommendations) |
|
It is recommended that…
It is recommended that… not… |
When the dimensions for judging the strength of the evidence are applied, there is moderate support that benefits are closely balanced with risks and burdens. |
| There is insufficient evidence and a lack of consensus to make a recommendation… | |
Note : See the original guideline document for the dimensions used for judging the strength of the recommendation.
Clinical Algorithm(s)
None provided
Scope
Disease/Condition(s)
Childhood and adolescent obesity
Guideline Category
- Management
Clinical Specialty
- Cardiology
- Family Practice
- Internal Medicine
- Pediatrics
- Physical Medicine and Rehabilitation
Intended Users
- Advanced Practice Nurses
- Nurses
- Physical Therapists
- Physician Assistants
- Physicians
Guideline Objective(s)
To evaluate, among children and adolescents who are overweight or obese, if monitoring patient cardiovascular tolerance during a physical therapy session utilizing vital signs versus standard care reduces the risk of adverse events
Target Population
Children and adolescent patients ages 5 to 18 years with body mass index (BMI) >85th percentile in the outpatient physical therapy setting
Interventions and Practices Considered
Monitoring patient cardiovascular tolerance during a physical therapy session utilizing vital signs
Major Outcomes Considered
- Risk of adverse events from physical therapy treatment sessions
- Increased resting heart rate
- Increased arterial blood pressure
- Oxygen saturation
- Increased respiration rate
- Patient safety
- Tolerance to physical therapy
Methodology
Methods Used to Collect/Select the Evidence
- Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence
Search Strategy
- Databases : PubMed, Medline, Cochrane Library, CINAHL, SPORTDiscus.
- Search Terms : Obesity, pediatric, exercise, resistance exercise, rate of perceived exertion, children, youth, adolescents, vital sign(s), physical therapy, physiotherapy. The references of the studies meeting the search criteria were then hand-searched.
- Filters : English language, no date filter
- Search Dates : July 26, 2012-November 8, 2012
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
- Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Table of Evidence Levels
| Quality Level | Definition |
|---|---|
| 1a† or 1b† | Systematic review, meta-analysis, or meta-synthesis of multiple studies |
| 2a or 2b | Best study design for domain |
| 3a or 3b | Fair study design for domain |
| 4a or 4b | Weak study design for domain |
| 5a or 5b | General review, expert opinion, case report, consensus report, or guideline |
| 5 | Local Consensus |
†a = good quality study; b = lesser quality study
Methods Used to Analyze the Evidence
- Systematic Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
- Expert Consensus
Description of Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Table of Recommendation Strength
| Strength | Definition |
|---|---|
| It is strongly recommended that… It is strongly recommended that… not… | When the dimensions for judging the strength of the evidence are applied, there is high support that benefits clearly outweigh risks and burdens. (or visa-versa for negative recommendations) |
| It is recommended that… It is recommended that… not… | When the dimensions for judging the strength of the evidence are applied, there is moderate support that benefits are closely balanced with risks and burdens. |
| There is insufficient evidence and a lack of consensus to make a recommendation… |
Note : See the original guideline document for the dimensions used for judging the strength of the recommendation.
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
- Peer Review
Description of Method of Guideline Validation
This Best Evidence Statement has been reviewed against quality criteria by 2 independent reviewers from the Cincinnati Children’s Hospital Medical Center (CCHMC) Evidence Collaboration.
Evidence Supporting the Recommendations
References Supporting the Recommendations
- Carletti L, Rodrigues AN, Perez AJ, Vassallo DV. Blood pressure response to physical exertion in adolescents: influence of overweight and obesity. Arq Bras Cardiol. 2008 Jul;91(1):24-30. PubMed
- Gaya AR, Alves A, Aires L, Martins CL, Ribeiro JC, Mota J. Association between time spent in sedentary, moderate to vigorous physical activity, body mass index, cardiorespiratory fitness and blood pressure. Ann Hum Biol. 2009 Jul-Aug;36(4):379-87. PubMed
- Hayes HM, Eisenmann JC, Heelen KA, Welk GJ, Tucker JM. Joint association of fatness and physical activity on resting blood pressure in 5- to 9-year-old children. Pediatr Exercise Sci. 2011 Feb;23(1):97-105. PubMed
- Norman AC, Drinkard B, McDuffie JR, Ghorbani S, Yanoff LB, Yanovski JA. Influence of excess adiposity on exercise fitness and performance in overweight children and adolescents. Pediatrics. 2005 Jun;115(6):e690-6. PubMed
- Ribeiro J, Guerra S, Pinto A, Oliveira J, Duarte J, Mota J. Overweight and obesity in children and adolescents: relationship with blood pressure, and physical activity. Ann Hum Biol. 2003 Mar-Apr;30(2):203-13. PubMed
Type of Evidence Supporting the Recommendations
The type of supporting evidence is identified and graded for each recommendation (see the “Major Recommendations” field).
Benefits/Harms of Implementing the Guideline Recommendations
Potential Benefits
Monitoring vital signs during a physical therapy treatment session to ensure children and adolescents are below the lactate threshold, are within target heart rate, and are within safe ranges of systolic and diastolic blood pressure may allow greater tolerance to exercise. With monitoring vital signs, the therapist will be able to track if certain exercises are increasing vital signs too rapidly and in turn, decrease the ability of the patient to perform the exercise. With the therapist monitoring the vital signs and subjective rate of perceived exertion (RPE), the therapist can ensure that the patient’s physiological and psychological response is within an appropriate range for the goal of the treatment session.
Potential Harms
There is minimal harm in an appropriately trained physical therapist clinician monitoring vital signs of overweight and obese children and adolescents during a treatment session.
Qualifying Statements
Qualifying Statements
This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at the time of their formulation. This Best Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.
Implementation of the Guideline
Description of Implementation Strategy
Applicability Issues
Vital signs can be used to monitor tolerance of exercise and guide outpatient physical therapy treatment for children and adolescents that are overweight or obese. For example, if a patient’s blood pressure, heart rate, and respiration rate rise unexpectedly and their rate of perceived exertion (RPE) is higher than the goal for that treatment session, a rest break may be warranted or a change in level of exercise to return vital signs to the patient’s baseline level. With monitoring vital signs, the therapist will be able to track if certain exercises are increasing vital signs too rapidly and in turn, decrease the ability of the patient to perform the exercise. With the therapist monitoring the vital signs and subjective RPE, the therapist can ensure that the patient’s physiological and psychological response is within an appropriate range for the goal of the treatment session.
Cost: There may be cost associated with obtaining manual blood pressure cuffs, stethoscopes, or electronic (oscillating) blood pressure devices and training staff to use a RPE scale.
Staff Education: Physical therapists and physical therapist assistants are currently trained in vital sign measurement through their Master or Doctor of Physical Therapy programs or their physical therapist assistant program as part of the requirements established by their governing organization, the American Physical Therapy Association. Physical therapists will need to be trained in administering and monitoring a RPE scale.
Equipment: Examples of equipment needed include an oscillometric machine (e.g., Dinamap), electronic forearm blood pressure cuff, or manual blood pressure cuff with stethoscope. Obese children and adolescents may need an adult size blood pressure cuff or a thigh cuff to ensure a good fit and accurate measurement.
Implementation Tools
- Audit Criteria/Indicators
Institute of Medicine (IOM) National Healthcare Quality Report Categories
IOM Care Need
- Getting Better
IOM Domain
- Effectiveness
- Safety
Identifying Information and Availability
Bibliographic Source(s)
- Cincinnati Children’s Hospital Medical Center. Best evidence statement (BESt). Vital sign monitoring in children and adolescents who are overweight or obese in the outpatient physical therapy clinic. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2013 Feb 21. 6 p. [15 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Date Released
2013 Feb 21
Guideline Developer(s)
- Cincinnati Children’s Hospital Medical Center - Hospital/Medical Center
Source(s) of Funding
Cincinnati Children’s Hospital Medical Center
Guideline Committee
Not stated
Composition of Group That Authored the Guideline
Group/Team Leader : Amber Boyd, PT, DPT, CSCS, Team Leader, Division of Occupational Therapy and Physical Therapy; Mark V. Paterno, PT, PhD, MBA, SCS, ATC, Division of Occupational Therapy and Physical Therapy
Support/Consultant : Barbara K. Giambra, PhD(c), MS, RN, CPNP, Evidence-Based Practice Mentor, Center for Professional Excellence, Research and Evidence-Based Practice
Financial Disclosures/Conflicts of Interest
Conflict of interest declaration forms are filed with the Cincinnati Children’s Hospital Medical Center Evidence-based Decision Making (CCHMC EBDM) group. No financial or intellectual conflicts of interest were found.
Guideline Status
This is the current release of the guideline.
Guideline Availability
Available from the Cincinnati Children’s Hospital Medical Web site.
Availability of Companion Documents
The following are available:
- Judging the strength of a recommendation. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2008 Jan. 1 p. Available from the Cincinnati Children’s Hospital Medical Center.
- Grading a body of evidence to answer a clinical question. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 1 p.
- Table of evidence levels. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2008 Feb 29. 1 p. Available from the Cincinnati Children’s Hospital Medical Center.
In addition, suggested process or outcome measures are available in the original guideline document.
Patient Resources
None available
NGC Status
This NGC summary was completed by ECRI Institute on May 22, 2013.
Copyright Statement
This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:
Copies of this Cincinnati Children’s Hospital Medical Center (CCHMC) Best Evidence Statement (BESt) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of the BESt include the following:
- Copies may be provided to anyone involved in the organization’s process for developing and implementing evidence based care.
- Hyperlinks to the CCHMC website may be placed on the organization’s website.
- The BESt may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents.
- Copies may be provided to patients and the clinicians who manage their care.
Notification of CCHMC at EBDMInfo@cchmc.org for any BESt adopted, adapted, implemented or hyperlinked by the organization is appreciated.
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