Supported Standing and Supported Stepping Devices for Children with Non-Ambulant Cerebral Palsy: An Interdependence and F-Words Focus.

Children functioning at Gross Motor Function Classification System (GMFCS) levels IV-V cannot maintain an aligned standing position or take steps without support. Upright positioning and mobility devices have psycho-social significance for these children and their families, enhancing use of vision, communication, functioning and emotional well-being. Standers and supported stepping devices facilitate opportunities for biomechanical loading, potentially helping to build and maintain muscle and bone integrity, and they promote physical development. However, families are often required to choose between these two devices for their young child. This study aims to synthesize evidence for use and benefits of both supported standing and stepping devices through the lens of two contemporary theoretical frameworks to support clinical reasoning and implementation. The F-words for childhood development (functioning, family, fitness, fun, friends, future) and the interdependence-Human Activity Assistive Technology (iHAAT) models were combined to illustrate the complex interactions between the child, family, caregivers, peers and contextual factors when implementing standing and stepping devices with children at GMFCS levels IV and V. Supported standing and stepping devices provide complementary benefits, and both may be necessary starting at 9-15 months. We propose they both be included ON-Time, along with other age-appropriate positioning and mobility devices, to promote more equitable developmental opportunities for children with non-ambulant cerebral palsy.

Identifying Opportunities for Early Detection of Cerebral Palsy.

This study aimed to evaluate assessment and referral practices for the early detection and diagnosis of children at risk for or with cerebral palsy (CP) by health care and education providers in Maryland and Delaware. A secondary aim was to identify barriers for using early detection tools and identify opportunities for change to support early diagnosis and improve care. Seventy-two participants answered ≥ 50% of the survey questions. Most were occupational or physical therapists (86%) working in early intervention (61%). Eighty-eight percent indicated awareness that CP can be diagnosed by 12 months. Though 86% stated they typically suspect a diagnosis of CP between 0 and 12 months, only 19% reported that their patients received a CP diagnosis < 12 months. The Developmental Assessment of Young Children (73%) and the Peabody Developmental Motor Scales-2 (59%) were used most. Many respondents indicated never using magnetic resonance imaging (70%), the General Movements Assessment (87%), or the Hammersmith Infant Neurological Exam (69%). Participants identified clinical signs and symptoms prompting a referral for the diagnostic assessment of CP, most commonly stiffness in legs (95%), excessive head lag (93%), and persistent fisting (92%). Policy and organizational change, clinician education, and training are needed to support the implementation of CP early detection guidelines.

Identifying and Evaluating Young Children with Developmental Central Hypotonia: An Overview of Systematic Reviews and Tools.

Children with developmental central hypotonia have reduced muscle tone secondary to non-progressive damage to the brain or brainstem. Children may have transient delays, mild or global functional impairments, and the lack of a clear understanding of this diagnosis makes evaluating appropriate interventions challenging. This overview aimed to systematically describe the best available evidence for tools to identify and evaluate children with developmental central hypotonia aged 2 months to 6 years. A systematic review of systematic reviews or syntheses was conducted with electronic searches in PubMed, Medline, CINAHL, Scopus, Cochrane Database of Systematic Reviews, Google Scholar, and PEDro and supplemented with hand-searching. Methodological quality and risk-of-bias were evaluated, and included reviews and tools were compared and contrasted. Three systematic reviews, an evidence-based clinical assessment algorithm, three measurement protocols, and two additional measurement tools were identified. For children aged 2 months to 2 years, the Hammersmith Infant Neurological Examination has the strongest measurement properties and contains a subset of items that may be useful for quantifying the severity of hypotonia. For children aged 2-6 years, a clinical algorithm and individual tools provide guidance. Further research is required to develop and validate all evaluative tools for children with developmental central hypotonia.

Supported standing and stepping device use in young children with cerebral palsy, gross motor function classification system III, IV and V: a descriptive study.

This study described and compared use of supported-standing and stepping devices by young children with cerebral palsy, Gross-Motor Function Classification System (GMFCS) levels III-V following power mobility introduction. Data was collected at two time-points, 5-6 months apart, for 42 participants, aged 18-80 months, using the Home Use of Technology for CHildren (HUTCH). Supported-standing and stepping device choice, and time in each device remained stable over 6 months. Associations between device use and three functional classifications were examined. Children with more impaired motor, postural and manual abilities were more likely to use a supine stander rather than a prone/upright stander or no stander. Children at GMFCS V tended to use hands-free stepping devices, while support-arms stepping devices were more common for children at GMFCS IV. Only children at GMFCS III used convertible stepping devices. Using power mobility, standers and supported-stepping devices was feasible and 19/34 classified at GMFCS IV/V used all three devices over 6 months. A key finding was that introduction of power mobility did not reduce use of supported-stepping devices at any GMFCS level. Use of multiple upright positioning and mobility devices may assist children with limited mobility to be actively engaged and participate in daily life.

RESNA position on the application of power mobility devices for pediatric users.

This paper serves as an update to the previous RESNA Position on the Application of Power Wheelchairs for Pediatric Users with more current and additional scientific literature. This document contains typical clinical applications and best evidence from the literature supporting the application of power mobility (PM) for young children and to assist practitioners in decision-making and justification. It is RESNA' s position that age, limited vision or cognition, behavioral issues, and the ability to walk or propel a manual wheelchair short distances should not, in and of themselves, be used as discriminatory factors against providing PM for children. RESNA recommends early utilization of PM for children with mobility limitations as medically necessary, to promote integration and psycho-social development, reduce passive dependency, and to enhance participation, function, and independence.

Exploring change in young children's power mobility skill following several months' experience.

PURPOSE: To measure and compare progression in children's power mobility skill among process and task-based measures following a loan of one of four early power mobility devices. Additionally, to explore different power mobility learner groups and skill development trajectories. METHODS: In this pre-post study, children were purposefully sampled and power mobility skill was measured from video taken pre-post several months' experience (mean 192.40; SD 42.79 days) using the Assessment of Learning Powered mobility use (ALP) and two task-based measures. Associations among power mobility skill measures were examined. Child and environmental factors influencing ALP phase at loan-end were explored. RESULTS: Forty-six children aged 13 - 68 months (mean 40.40; SD 15.60) participated, with cerebral palsy being the most common condition (n = 33; 71.74%). ALP change scores ranged from -2 to +4 ALP phases (median 1.0). Wilcoxon signed rank test was significant for pre-post differences with a large effect size (z = 5.50, p < 0.001; r = 0.57). End-of-loan Spearman correlations between ALP and two task-based paediatric measures were excellent (rs = 0.92). Kruskal-Wallis test revealed significant effect of device, access method, diagnostic group and communication abilities on loan-end ALP phase. CONCLUSION: Positive change was demonstrated with most children (n = 39; 84.78%) changing at least one ALP phase during the study. Positive change was seen with children at all phases of tool-use, using all devices and access methods. Process and task-based measures were highly correlated, but differed in application for different learner groups. Different trajectories of skill development may be associated with different child profiles and access abilities.IMPLICATIONS FOR REHABILITATIONChildren at all phases of tool-use can demonstrate positive change in power mobility skill using different devices and switch as well as joystick access methodsThe Assessment of Learning Powered mobility use (ALP) is useful for assessing tool-use and learning process skills for young children across the power mobility skill continuum.Task-based measures may also be helpful for guiding training and recording progress; The Power Mobility Training Tool (PMTT) is most useful for children exploring cause-effect and direction (ALP Phases 1-5), while the Power Mobility Program (PMP) is most useful for functional learners and those progressing from exploring direction to functional use (ALP Phases 5-8).Access method may influence power mobility learning trajectory and training.

Supported-standing interventions for children and young adults with non-ambulant cerebral palsy: A scoping review.

AIM: To describe the evidence, outcomes, and lived experience of supported standing for children and young adults with cerebral palsy aged 25 years or younger, classified in Gross Motor Function Classification System levels IV and V. METHOD: This scoping review included searches in eight electronic databases and manual searching from database inception to May 2020 and updated on 21st February 2022. Two of three reviewers independently screened titles and abstracts and extracted and appraised data. Methodological quality and risk of bias were appraised using tools appropriate to study type. Content analysis and frequency effect sizes were calculated for qualitative and descriptive evidence. RESULTS: From 126 full-text references, 59 citations (one study was reported over two citations) were included: 16 systematic reviews, 17 intervention studies reporting over 18 citations, eight analytical cross-sectional studies, five descriptive cross-sectional/survey studies, five qualitative studies, and one mixed-methods study were identified, along with six clinical guidelines. Maintenance of bone mineral density and contracture prevention outcomes were supported by the most experimental studies and evidence syntheses, while evidence supporting other outcomes was primarily quasi-experimental or descriptive. Qualitative evidence suggests that programmes are influenced by attitudes, device, child, and environmental factors. INTERPRETATION: Individualized assessment and prescription are essential to match personal and environmental needs. Although experimental evidence is limited due to many factors, lived-experience and cohort data suggest that successful integration of standing programmes into age-appropriate and meaningful activities may enhance function, participation, and overall health. WHAT THIS PAPER ADDS: Supported-standing interventions may provide an important psychosocial and physical change of position. Supported standing is not passive for those classified in Gross Motor Function Classification System level IV or V. Supported standing may enhance social participation, functional abilities, and fitness. Children need choice in where and when to stand.

Standing power wheelchairs and their use by children and youth with mobility limitations: an interrupted time series.

: Standing power wheelchairs (PWSDs) expand positioning and mobility options for individuals with motor impairments. Although more available, little is known about how PWSDs are used in everyday life. PURPOSE: to describe children's use of PWSDs in the first three months post-wheelchair delivery and the impacts on satisfaction with participation in daily life. MATERIALS AND METHODS: An interrupted time series of purposefully sampled children aged 5-18 years who were receiving a PWSD. The Wheelchair Outcome Measure for Young People (WhOM-YP) documented satisfaction with patient-reported meaningful participation outcomes. Data loggers objectively measured wheelchair mobility outcomes including distance travelled, bouts of mobility, and duration. Data were measured over two sessions pre-wheelchair-delivery and at one week, one month and three months post-wheelchair-delivery. RESULTS: Six children aged 7-18 years participated, four diagnosed with cerebral palsy, two with spina bifida. Analyses of individual data illustrated positive change in overall WhOM-YP satisfaction scores after PWSD provision though change varied across time, as did, distance, bouts of mobility and duration of use. Participants identified 14 in-home and 16 out-of-home unique participation outcomes, although several commonalities existed. CONCLUSION: PWSDs hold promise for increasing children's satisfaction with participation in daily life, in addition to possibly increasing mobility outcomes. IMPLICATIONS FOR REHABILITATIONFor children with mobility limitations, PWSDs may promote participation in daily life and increased mobility.Data logger technology provides valuable information about children's PWSD use and how this varies over time.Benefits and challenges exist with implementing PWSD and data logger technologies.When implementing PWSD use, it is critical to consider context, training and support needs of clients and caregivers.

Parents' and Therapists' Satisfaction with Four Early Childhood Power Mobility Devices.

Background. Little is known about satisfaction with power mobility devices used by young children. Purpose. Parents' and therapists' satisfaction with four early childhood power mobility devices were examined. Method. A two-phased study, comprising Trial Phase cross-sectional design and Loan Phase one-group pretest-posttest design. Parents and therapists of children 9 months to 6 years with mobility limitations completed the Quebec User Evaluation of Satisfaction of Assistive Technology 2.0 Device Subscale (QUEST8) plus an additional device Aesthetics rating. Findings. Seventy-four parents and 42 therapists from 18 child development and rehabilitation centres participated. Parent and therapist median QUEST8 and Aesthetics scores varied across devices when trialled and over the six-month loan. Favourable median ratings had no statistically significant differences between parents and therapists. Parent ratings decreased statistically over loan period although therapists' ratings did not. Device dimensions, safety, and aesthetics were highly rated. Implications. Similarities and differences exist among parent and therapist ratings.

Evidence-informed clinical perspectives on postural management for hip health in children and adults with non-ambulant cerebral palsy.

Postural management is a multi-disciplinary approach incorporating a comprehensive schedule of daily and night-time positions, equipment and physical activity to help maintain or improve body structures and function and increase activity and participation. Postural management may play a role in preventing contracture, deformity, pain, and asymmetry. This article provides an overview of the evidence supporting use of postural management to positively influence hip health in individuals with cerebral palsy, functioning as Gross Motor Classification System (GMFCS) levels IV or V. Sitting or lying without changing position for more than 8 hours, unsupported supine lying and asymmetrical or windswept postures are associated with pain and hip subluxation/dislocation. Although high-quality experimental research is still limited by many factors, there is limited evidence of harm, and most individuals at GMFCS IV or V require positioning supports to enable participation and function and ease caregiving. Clinical recommendations combining research and clinical opinion support the early use of comfortable positioning routines and/or equipment to reduce time spent in sustained asymmetrical or potentially harmful sitting and lying positions. Supported standing, active weightbearing and stepping are recommended to promote active movement and position change when possible, depending on individual, family and caregiver routines and preferences.

Beginning power mobility: parent and therapist perspectives.

PURPOSE: To explore parent and therapist experiences of early power mobility following participation in a Power Mobility Day - a 60-90 min play-based session where children with mobility limitations (<6 years of age) experienced four different early power mobility devices. METHOD: Participants were purposefully selected from parents and therapists who took part in Power Mobility Days as part of a larger cross-sectional study. One semi-structured interview with each participant was conducted via telephone. Interviews were audio-recorded, transcribed, and analyzed using a content analysis approach. RESULTS: Of 35 adults approached, 11 parents and 11 occupational or physical therapists completed interviews averaging 20 min (range 10-45 min), one week to three months after the session. Participants were parents or therapists of children aged 12 to 48 months of age with a variety of neuromotor diagnoses from different areas of the province. The overarching theme Empowering Children and Families to Explore was developed from themes: Earlier Experiences; A Novel Introduction; and Moving Forward. CONCLUSION: Power Mobility Days provided a welcoming and inclusive child- and family-led introduction to power mobility. This novel approach may help change both therapists' and families' perception of child potential and perspectives on power mobility as an intervention.IMPLICATIONS FOR REHABILITATION:Exploratory sessions can provide a novel introduction to power mobility interventions.Child enjoyment has a reciprocal impact on family engagement with early power mobility.Experiential child- and family-led learning can increase awareness of power mobility options and possibilities.

Beginning power mobility: An exploration of factors associated with child use of early power mobility devices and parent device preference.

OBJECTIVES: Describe and compare young children's use of four early power mobility devices and examine associations between child and environmental factors that may influence power mobility use and parent device preference. DESIGN: Cross-sectional observational study. METHODS: Power Mobility Days introduced four devices: Wizzybug, Bugzi, Tiger Cub, and a switch-adapted ride-on toy car in a single 60-90 min, play-based session. RESULTS: A convenience sample of 74 children, aged 9-68 months (mean: 32.45, SD: 14.08) with mobility limitations, and their parents participated. Children had a range of motor, postural and communication profiles, with cerebral palsy being the most common condition (n = 55; 73.33%). Assessment of Learning Powered mobility use phase achieved ranged from 1 to 6; mean: 2.34; median: 2. For children who tried all four devices (n = 51), Friedman test (χ2: 8.27, p = 0.04) suggests Assessment of Learning Powered mobility use phase differs across devices. Of 73 parents who identified a device preference, 43 (59%) chose Wizzybug. Regression analyses suggest that access method and communication function may influence children's power mobility use, while age, access and postural support requirements may influence parent device choice. DISCUSSION: Parent impressions of an early power mobility device may be influenced by many factors, yet be less influenced by child performance.

American and Canadian therapists' perspectives of age and cognitive skills for paediatric power mobility: a qualitative study.

Purpose: To explore the views of paediatric occupational therapists and physical therapists in Canada and the USA related to (1) the rationale for the age at which power mobility is considered for children and (2) the cognitive skills considered when trialling power mobility.Materials and methods: This study was part of a larger web-based survey study and analyzed responses to two open-ended survey questions: one related to age and one related to cognitive skills. Data were analyzed using the constant comparative method.Results: Analysis revealed four unique themes in the question related to age: (1) 'Power Mobility Should be Introduced at a Specific Age or Stage'; (2) 'Child Requirements'; (3) 'Developmental Impact of All Forms of Independent Mobility'; and (4) 'Benefits of Power Mobility'. In the question concerning cognitive skills, two unique themes were identified: 'Cognitive Skill Requirements?' and 'Non-Cognitive Requirements'. Two additional themes were identified in both questions: ('Non-child Requirements' and 'Power Mobility Trials, Use, and Options Are Dependent on Age and Goal').Conclusions: Data indicate wide variability in respondents' views related to the provision of power mobility. Additional research is needed to explore both therapists' reasoning regarding power mobility use for children and how to best facilitate knowledge translation in this area.Implications for RehabilitationWide variability exists related to the provision of power mobility for children.Children's age or stage in life influences therapists' consideration of power mobility.Many respondents considered cognitive skills when trialling power mobility but some did not.

Power mobility for children: a survey study of American and Canadian therapists' perspectives and practices.

AIM: To explore the views and practices of paediatric occupational therapists and physical therapists in Canada and the USA regarding the implementation of power mobility for children with mobility limitations. METHOD: This descriptive study utilized a web-based survey that included questions pertaining to therapists' decisions to trial and use power mobility, agreement or disagreement with statements developed from published practice considerations regarding power mobility, and the frequency of performing tasks related to power mobility prescription and training. RESULTS: Most respondents reported that child characteristics (e.g. cognition, safety awareness) were important factors in decision-making about power mobility, whereas other child characteristics (e.g. communication abilities, age) were not as important. Family resources and home accessibility were also not considered important. The average age at which respondents considered power mobility for children was 2 years 3 months. The majority of respondents agreed with statements developed from published practice considerations and most frequently performed various power mobility tasks twice a year or less. INTERPRETATION: Although most respondents appeared to have positive views regarding power mobility, few appeared to actively perform power mobility tasks in their practice. Resources to support therapists in the early introduction of power mobility may be beneficial. WHAT THIS PAPER ADDS: Occupational and physical therapists positively view early introduction of power mobility for children with mobility limitations. Few therapists actively provide early power mobility experiences. Power mobility training and monitoring power mobility devices are important therapist roles.

Interventions to improve sensory and motor outcomes for young children with central hypotonia: A systematic review.

OBJECTIVE: To evaluate evidence supporting physical and occupational therapy interventions used to improve sensory and motor outcomes for children 0-6 years with central hypotonia. METHODS: Four electronic databases were searched from 1996 to March 2017. Level of evidence and study conduct was evaluated using American Academy of Cerebral Palsy and Developmental Medicine criteria. Traffic lighting classification identified interventions that were green (proven effective), yellow (possibly effective) or red (proven ineffective or contraindicated). RESULTS: Thirty-seven articles were included. Nine studies measured orthotic interventions while four distinct studies published over nine articles measured treadmill interventions. Remaining studies measured impact of compression garments, massage, motor and sensori-motor interventions, positioning and mobility interventions. CONCLUSIONS: Green light evidence supports treadmill training (to promote ambulation and gait characteristics) and massage (to positively affect muscle tone, motor development and use of vision) for infants with Down syndrome. These interventions are considered Yellow (possibly effective) for other populations. Green light evidence supports impact of orthoses on foot alignment for ambulatory children with hypotonia, while impact on gait characteristics is Yellow light and motor development may be negatively impacted (Red light) in pre-ambulatory children. All other interventions rated Yellow (possibly effective) and therapists should monitor using sensitive outcome measures.

Power mobility skill progression for children and adolescents: a systematic review of measures and their clinical application.

AIM: To identify and critically appraise standardized measures of power mobility skill used with children (18y or younger) with mobility limitations and explore the measures' application for 'exploratory', 'operational', and 'functional' learners. METHOD: Five electronic databases were searched along with hand-searching for peer-reviewed articles published in English to July 2017 (updated 31st August 2017). Key terms included power(ed) mobility, power(ed) wheelchair, and database-specific terms. Studies included at least one child with a disability, and a detailed description of the measure of power mobility skill. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed with inclusion criteria set a priori. Two reviewers independently screened titles, abstracts, and full-text articles. RESULTS: Of 96 titles, 24 articles met inclusion criteria, describing nine measures of power mobility skill. The Wheelchair Skills Checklist, the Powered Mobility Program (PMP), and the Power Mobility Training Tool were augmented by three adaptations of the PMP. Two additional measures were further developed to create a third, the Assessment of Learning Powered mobility use. Validity evidence related primarily to content development while reliability evidence was reported on only two measures. INTERPRETATION: All measures are in the initial stages of development and testing. Research investigating the measures' appropriateness for different types of learners and environments is warranted. WHAT THIS PAPER ADDS: There are four distinct measures of paediatric power mobility skill: three task-based, one process-based. Power mobility learners may be divided into three groups: exploratory, operational, and functional. Application of measures of power mobility skill differs for these three groups.

Physical risk factors influencing wheeled mobility in children with cerebral palsy: a cross-sectional study.

BACKGROUND: There is a lack of understanding of the factors that influence independent mobility and participation in meaningful activities. The purpose of this study was to analyse physical factors influencing independent use of manual and power wheelchairs in a total population of children with cerebral palsy (CP). METHODS: A cross-sectional study based on the most recent examination of all children with CP, born 2002-2013, reported into the Swedish cerebral palsy registry (CPUP), from January 2012 to June 2014. There were 2328 children (58 % boys, 42 % girls), aged 0-11 years, at all levels of gross motor function and hand function. Hazard ratios adjusted for age and sex were used to calculate the risk for not being able to self-propel based on Gross Motor Function Classification System (GMFCS) levels, upper extremity range of motion and hand function including Manual Ability Classification System (MACS), House functional classification system, Thumb-in-palm deformity, Zancolli (spasticity of wrist/finger flexors) and bimanual ability. RESULTS: In total 858 children used wheelchairs outdoors (692 manual, 20 power, 146 both). Only 10 % of the 838 children self-propelled manual wheelchairs, while 90 % were pushed. In contrast 75 % of the 166 children who used power mobility outdoors were independent. Poor hand function was the greatest risk factor for being unable to self-propel a manual wheelchair, while classification as GMFCS V or MACS IV-V were the greatest risk factors for not being able to use a power wheelchair independently. CONCLUSIONS: The majority of children with CP, aged 0-11 years did not self-propel manual wheelchairs regardless of age, gross motor function, range of motion or manual abilities. Power mobility should be considered at earlier ages to promote independent mobility for all children with CP who require a wheelchair especially outdoors.

Comparison of the inertial properties and forces required to initiate movement for three gait trainers.

The purpose of this study was to evaluate the inertial properties and forces required to initiate movement on two different surfaces in a sample of three commonly prescribed gait trainers. Tests were conducted in a laboratory setting to compare the Prime Engineering KidWalk, Rifton Pacer, and Snug Seat Mustang with and without a weighted anthropometric test dummy configured to the weight and proportions of a 4-year-old child. The Pacer was the lightest and the KidWalk the heaviest while footprints of the three gait trainers were similar. Weight was borne fairly evenly on the four casters of the Pacer and Mustang while 85% of the weight was borne on the large wheels of the mid-wheel drive KidWalk. These differences in frame style, wheel, and caster style and overall mass impact inertial properties and forces required to initiate movement. Test results suggest that initiation forces on tile were equivalent for the Pacer and KidWalk while the Mustang had the highest initiation force. Initiation forces on carpet were lowest for the KidWalk and highest for the Mustang. This initial study of inertia and movement initiation forces may provide added information for clinicians to consider when selecting a gait trainer for their clients.

Facilitating interprofessional evidence-based practice in paediatric rehabilitation: development, implementation and evaluation of an online toolkit for health professionals.

PURPOSE: Lack of time, competencies, resources and supports are documented as barriers to evidence-based practice (EBP). This paper introduces a recently developed web-based toolkit designed to assist interprofessional clinicians in implementing EBP within a paediatric rehabilitation setting. METHODS: EBP theory, models, frameworks and tools were applied or adapted in the development of the online resources, which formed the basis of a larger support strategy incorporating interactive workshops, knowledge broker facilitation and mentoring. RESULTS: The highly accessed toolkit contains flowcharts with embedded information sheets, resources and templates to streamline, quantify and document outcomes throughout the EBP process. Case examples relevance to occupational therapy and physical therapy highlight the utility and application of the toolkit in a clinical paediatric setting. Workshops were highly rated by learners for clinical relevance, presentation level and effectiveness. Eight evidence syntheses have been created and 79 interventions have been evaluated since the strategy's inception in January 2011. CONCLUSIONS: The toolkit resources streamlined and supported EBP processes, promoting consistency in quality and presentation of outputs. The online toolkit can be a useful tool to facilitate clinicians' use of EBP in order to meet the needs of the clients and families whom they support. Implications for Rehabilitation A comprehensive online EBP toolkit for interprofessional clinicians is available to streamline the EBP process and to support learning needs regardless of competency level. Multi-method facilitation support, including interactive education, e-learning, clinical librarian services and knowledge brokering, is a valued but cost-restrictive supplement to the implementation of online EBP resources. EBP resources are not one-size-fits-all; targeted appraisal tools, models and frameworks may be integrated to improve their utility for specific sectors, which may limit them for others.