How “Evidence-Based” is Your Therapy?

Evidence Based PracticeTherapy lives, breathes, and dies by one simple phrase: “evidence based practice.”

Those three words encompass all therapeutic disciplines, from pediatrics to geriatrics. In the simplest of terms, it means that the decisions we make as clinicians must be founded in research. The kind of stuff that makes families willing to shell out their hard earned money on co-pays, or that prompts insurance companies to reimburse for all that hard work we have done. This is how each of our professional organizations fight for us to prove that we provide services that work. Services that make us better than some untrained, unskilled person off the street.

So yes, you get it already. Evidence based practice is important. Now, all you therapists out there, I need you to think about your daily treatment sessions. Is it fair to say that at least some of what you do is “because you’ve always done it that way” ? Did you pick something up from someone, who picked it up from someone else, who maybe went to a course a long time ago? Are you working off of anecdotal evidence that just kind of “makes sense”? Of course; it happens all the time. You probably just don’t sit there and question everything you are doing, especially if your clients are making progress and meeting goals. The beauty of being a clinician is that you can use your clinical reasoning to work through many problems. But what about when you are stuck and frustrated because your clients are plateauing, or you just aren’t sure where to go next. Is there something you might be missing?

In an ideal world, we would all be reading and contributing to the latest research, sharpening our skills and staying on the edge of what’s next. However, anyone that’s out there practicing knows that this isn’t always possible. There are many factors that impact our consistent use of evidence based practice in therapy.

Availability and Access to Research:

It would be wimpy of me to just whine that there isn’t enough research out there, because that’s not entirely true. What is true is that we don’t all have access to the latest research. In graduate school, they allow students access to databases that house tons of full research articles. If I tried looking something up now, I would most likely have to pay to get the full article. Yeah, I’m probably not going to do that.

This is why I think it’s nice to have a student at a facility, because as a part of their fieldwork, they typically have to complete a project about whatever their instructor decides upon. This is a great opportunity to breathe some fresh evidence based practice into your clinic or practice setting.

Also, don’t knock those new graduates that are so bright-eyed and bushy-tailed. They probably hold a lot of the latest information due to the fact that they just spent so much time in school scouring research papers for their thesis projects.

Motivation:

I can’t avoid the other obvious here, who really wants to go home from a long, hard day at work and read through tedious research articles? Those things aren’t meant to be thrillers. Don’t blame me if I just want to read a trashy magazine or the latest vampire romance novel. Therapists often struggle to find a work/life balance, and I’ll let you know, most business aren’t going to provide the opportunity to peruse research articles on company time. That’s for billing patient contact hours, people.

Now, the obvious solution to this issue is continuing education. We are all required to complete a certain amount of hours in order to keep our licenses. The problem here? Courses are expensive. I could spend anywhere from a couple hundred to a couple thousand dollars on a course. On top of that, you often have to use vacation time or your weekends to complete these courses, and might even have to travel far away for a course that’s any good. The cheaper courses are sometimes a joke or a complete waste of your time…pretty much a crap shoot. Plus, you may only complete 1 or 2 courses a year; not nearly enough to keep up with an ever-changing caseload.

Personal interpretation of research:

You have to let the research guide your clinical decisions, and interpret it with a critical eye. Look for the limitations and how they apply to your practice setting. Let’s say that one study found that pencil grasps do not ultimately impact handwriting legibility. Does it mean that you should never look at a child’s grasp again? No; it means that you weigh the impact of the grasp on a particular child’s handwriting and determine if it is worth changing (i.e. biomechanical joint stress, weakness, etc). Just reading the articles isn’t going to change your practice unless you interpret it and learn how to incorporate it in your day to day treatment.

Therapist personality types:

I find it interesting that in my time as an OT, I have met many different types of therapists. Some that are flighty, doing a few activities here, a few activities there, without a real “plan” in place. I’ve met people that are insanely rigid in their practice, OT rock stars that are quoting AOTA framework and ICF models. (Yes, these people often track me down on the website and let me know what I’ve been doing “wrong”.) Yikes.

These different personality types are ultimately going to contribute to the therapy they provide. Remember that whole “therapeutic use of self” thing? We can’t change who we are and how we naturally go about solving problems, but we can always try to improve.

So I guess it’s a pretty fair to say that we can never know it all. We really just have to do the best with what we have available to us. Also, we should never be afraid to ask questions and collaborate with those around us.
After saying all of this, am I going to go out and create some ground breaking research? Sadly, probably not. However, I am going to continue to try my best to make sure I can always back up what I’m doing. Stop yourself during a session and think, “Why am I doing this?” In your mind you might think: We are working on proximal stability as well as development of the palmar arches, all while addressing letter memory and sequencing. Bam! Skilled intervention!

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About TheAnonymousOT

Pediatric Occupational Therapist
This entry was posted in Lessons Learned, Occupational Therapy and tagged , , , . Bookmark the permalink.

8 Responses to How “Evidence-Based” is Your Therapy?

  1. SarahG says:

    This is one of my biggest issues as a new grad–finding reliable and easily accessible evidence. Sometimes even going to a course does not guarantee you reliable information, especially with things like reflex integration, therapeutic listening, etc., that lack a lot of peer-reviewed evidence. I have been considering getting an AOTA membership simply for the access to resources. I think it’s a pity that clinics (especially small, privately owned clinics) don’t push therapists more to engage with research. I have friends who have worked for hospitals (still peds) and have been required to complete research and review articles. This sounds like more work that we don’t have time for (because really, who has time for an 80% productivity rate and writing 8-10+ page evals, 30ish notes,creating custom home programming and emailing 10 parents a week? Oh and living your own life…), but we belong a profession who’s credibility and usefulness is often questioned by insurers. A few weeks ago, our biller told me that insurance companies are telling her they won’t cover OT for some kids because they don’t think OT works. (Grant it, this was second-hand information, but still disturbing). We either need to get it together and MAKE the time to produce and read the evidence, or we may not have a profession. Not to be a downer or anything…

    To be honest, I get most of my information from other therapists and some excellent blogs! (Like this one, among about 10 others that I adore). Not that that’s a bad thing, but just because we all have graduate degrees doesn’t mean we are immune to falling for trendy pseudo-therapies and trends. One of the hardest things about peds is that there are few “protocols”. Clinical judgement and experience are usually what we need to fall back on with challenging clients, and that’s when some really great break-throughs happen, but that doesn’t always make it “good” evidence.

    • Lynette Diaz says:

      I’m a recently graduated COTA, working with an OTR with strong a sensory and reflex integration background. She’s been guiding me, however I ask myself where is the research demonstrating we are really changing someones brain with this type of therapy. I’m happy to do it, but I want to have evidence of its efficacy. I’m about to go on a course about reflex integration tomorrow and have been scouring the internet for evidence based research but of course many research articles are blocked or require payment. It makes me uneasy. If I’m skeptical how much more skeptical will parents be?? Wish me luck! I live in Orlando, perhaps we can get the local universities to help us conduct some research. I want more than anecdotal evidence.

  2. That has to be the most down to earth real view on ongoing education I have ever read and echoes all my thoughts on the subjects. Quite freeing. I love your blog. Its insightful and real.

  3. Deb Wolke, OT/L says:

    This is my first time reading this Blog, and am impressed! I too am bothered by the whole evidenced based stuff…I am also intrigued with research. I do little stuff: child is slowest writer in class, so teacher thinks the boy must need tx…I had the class ( first graders) write name on their paper, then gave them 1 minute to write the lower case alphabet. I used the rules of the ETCH to determine if it was legible and counted each child’s letters- sure enough, the boy in question was slowest! I repeated this with the other 2 first grades. The boy in question…right smack dab in the middle of the pack! I had also read the research article about pencil grasp. I only work on changing painful or stressed grasps, or if their writing is very poor and the grasp isn’t “set”.

  4. Meg says:

    Thank you for writing your thoughts about this subject. I’ve been practicing school based therapy for 15 years and try my best to keep up to date on the latest research. That said, I often feel that I fall short, especially when it comes to sensory interventions. I recently helped out a teacher that had to complete a case study (as part of her licensure requirements). Questions for me included why our student was receiving OT, what sort of interventions I was using and how I knew he needed these specific interventions. It was an excellent exercise for me to have to explain what I was doing and why. When she thanked me I told her that doing this had helped me see that I should be doing this analysis on all of my students! My next step is to cite evidence for the interventions I’m using with this student…

  5. Anonymous OT, you rock! Thank you for taking the time to write articles that make your fellow OT’s think and take stock of what we do 🙂 I am having a ball browsing through your site! I sometimes have clients asking me for “proof that it works” and I always blush when I can;t answer them properly. I get mad when people diss OT or techniques for lack of evidence, but I also don’t have the time to do research 😦 so who am I to complain. Part of me feels like I am spending my time helping people who need to be helped, and if I was doing research, I would not have time to do that (plus my family would suffer right now!!).

    I take my hat off to those who forged the way decades ago and established the principles on which we base our work. But maybe we working OT’s should somehow support and contribute researchers from among us to do the research and provide the evidence to back up what we do. There are some among us who are naturally good at research, and if we could support them to do this, then…what are the possibilities? Imagine OT’s from across the globe supporting research – if we all paid $50 a year to help support research in our field…

  6. Tina says:

    Bravo, I read this with thankfulness for your honesty in an area we of real struggle. I love your blog; it really puts ‘out there’ what many of us think. Congratulations and keep up the good work.

    With regard to the topic at hand; I personally think the emphasis on EBP is overrated. Not that we want lots of loose canons out there riding shotgun, but even with the evidence in hand, there are some that are zealous adherents to SIT and others who are willing to draw blood to shot you down if you are a proponent of the practice – each with their evidence in hand to prove their point. We should at all times be able to give an account for what we are doing and the clinical reasoning behind it, but should not be stalled at the gates in trying something new, something that we know anecdotally works, or something that embraces an eclectic approach because of a dearth of research.

    In a world of EBP, some of the questions that come to mind are:
    how much evidence qualifies as sufficient evidence on which to base your practice
    How much contrary evidence is sufficient to disprove the evidence which supports your practice
    what do you do if there is a lack of evidence but know the treatment approach ‘works’

    I was recently having a discussion on the old Clin Obs sheet (non standardised) but really useful screen for readily identifing development deficits. We used that for years – without any evidence but every practice had a Clin Obs sheet a drawer somewhere. That was before the era of EBP. Do we throw the baby out with the bathwater because we don’t have any evidence that it did what it purported to do, or do we continue to use it because any of us who have used it for years knows what a useful therapeutic screening tool it is? What if the bean counters question its use and our treatment based on its use when there is no evidence to support its use.

    I am not opposed to EBP; in fact I think it useful, but I don’t think we should be hamstrung in our practice because of an inflation in its importance.

  7. smarciepants says:

    I love what you’ve said as it helps me explore my own worries. The other commenters make great points too. I think I could be confident weighing EBP and clinical reasoning if I could keep informed of what is current in the research. If I felt confident that I knew everything EB about a subject I could know how to juggle all factors and come up with the very best treatment. Having lots of students is a good way to achieve that as you said, over time that might work. But meanwhile to look things up, do you know the best pay-sites out there?? Say I do make time to do a search on a research database, it still might not give all research available. Anything out there that you trust??

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