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Taking these two factors into account purchase levlen 0.15 mg without prescription, it is easy to see why manualised approaches and protocols are not common features of practice discount 0.15 mg levlen visa. Furthermore, as we discuss in the following section, very little is understood about the active ingredients of interventions. There are, therefore, significant barriers to the development of protocols or manualised interventions for this population. One exception is interventions for the management of a specific presenting need and within a specific population. For these situations, interviewees did cite more routinised approaches, such as the management of hemiplegia by constraint induced movement therapy, and the management of spasticity in children with cerebral palsy. As a result, clinical decision-making is typically highly individualised and becomes increasingly so the more complex and severe the presenting needs. The principle of professional autonomy, and the factors therapists reported as influencing clinical decision-making in the management of a particular case, are described in Chapter 4. However, other factors were reported as significantly influencing the decision made. A key issue, and one driven by the role parents often play in the implementation of therapy programmes, was family characteristics and resources. Therapists consistently reported that this influenced their decision-making about what interventions they selected and the intensity of their delivery. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 93 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. DISCUSSION Chapter 4 also described the wide range of factors influencing which interventions a therapist might bring to that decision-making process. These included their training, overall approaches to therapy interventions, practices learnt from colleagues, personal preferences, clinical guidance and what they were permitted to do by commissioners or service leads. Thus, a picture is painted of highly individualistic practice, the outcome being that different therapists may choose to work with the same child in very different ways. Objectives 5 and 6: understanding therapy interventions and their active ingredients Objectives 5 and 6 were: 5. Therapies as complex interventions Our opening sections of Chapter 6 presented the notion of physiotherapy, occupational therapy and speech and language therapy as complex interventions,31 and described the existing conceptualisations of the active ingredients of non-pharmacological interventions. Both have highlighted the challenges of identifying, defining and measuring the active ingredients of complex, non-pharmacological interventions, and this offers an explanation of why, to date, the active ingredients have been poorly reported. In essence, the argument is made that the following interconnecting features of complex, non-pharmacological interventions make it difficult and complicated to identify their active ingredients. First, there was clear consensus that a therapy intervention comprises the therapist, the work that therapist does and the work that others do under the training or supervision of the therapist. This includes the overall approach that they adopt (deficit vs. We used this term to define elements such as the capacity of the wider therapeutic team (e. Certainly, both the lack of an understanding of active ingredients, which ones matter most, 94 NIHR Journals Library www. Findings relating to this objective were presented in Chapter 7, with relevant material also appearing in Chapters 4 and 5. Although these outcomes were global, parents strongly believed in the potential of therapy interventions in supporting their achievement. Thus, improvements in physical functioning, acquiring new motor skills and having access to equipment were regarded as necessary, but intermediate, outcomes to the achievement of higher-level outcomes. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 95 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. However, as we reported in Chapter 5, some parents reported that therapists may not explicitly refer to these higher-level goals, and can appear to be focused on specific aspects of functioning, etc. As reported in Chapter 4, the ICF framework16 and the concept of participation were adopted by the professions a number of years ago, although understanding of the meaning of the concept varied. The specifics of definition aside, participation was consistently regarded as a complex and multifaceted concept. Furthermore, it was clear that some study participants felt that further critical, conceptual work was required to clarify its definition, and the way in which it should be operationalised by the therapies. Some helpful developments to the concept were, however, offered during our interviews. There was also a clear view that participation had to be something defined by the child and/or their wider family, and that assumptions should not be made about what constitutes participation for an individual child.

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