On evidence and practise


An opinion piece to restart my blogging after my lovely holiday…

I’ve been reading ABC Therapeutics blog where Chris Alterio writes in response to a long comment by Michele Karnes suggesting that occupational therapists (and by inference all health care providers) ‘should be made aware of treatments that are offered to clients/patients, whether it is traditional or non-traditional, a long existing treatment or new one. This enables our OT profession and professionals to better educate the people they treat and interact with.’

I don’t have any particular concerns about this part of Michele’s comment – but I do have a problem with this part ‘while Evidence Based Practice is on all of our minds, and ultimately the best to utilize with our patients, if we only used treatments for all of these years we would have missed out on the many treatments that OT’s have historically (and still) use.’ (my emphasis)

It raises some concerning things for me – and while I don’t have answers for all of my concerns, I hope to stimulate some debate at least.

Chris writes in his blog ‘Just because people seek out alternative energy healing interventions doesn’t mean that it constitutes appropriate or ethical practice. In an article published in the Journal of the American Medical Association on this topic an author writes: “Given the extensive use of CAM services and the relative paucity of data concerning safety, patients may be putting themselves at risk by their use of these treatments. Only fully competent and licensed practitioners can help patients avoid such inappropriate use... Physicians can also ensure that patients do not abandon effective care and alert them to signs of possible fraud or danger.“‘

I’d add that licensing in itself does not inevitably lead to patients being helped to avoid inappropriate treatments. I also add this:

I think it also takes a critical and educated mind, a systematic approach to reviewing evidence, and considerable determination not to be swayed by forceful opinion.

Evidence based practice has been lauded as the best approach to finding appropriate treatment for patients, but at the same time has been criticised for failing patients because researched studies are inconclusive; contradictory; don’t exactly match the unique presentation of the individual in front of the health care provider and/or lag behind ‘real’ practice because of the focus on randomised controlled trials.  Probably there are a few other reasons others have come up with too!

As far back as May 1997, Dr Nicholas Hicks from the Department of Public Health and Health Policy, Oxfordshire Health Authority, UK defined evidence based health care as ‘when decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information.” He further discusses this definition on this page in Bandolier. I take this to mean that health providers have the freedom to be innovative and try new approaches provided that they are constrained by valid and relevant information.

What this means to me is that any new treatment should have a sound theory-base and that it has been demonstrated in some form to be effective in a similar situation. I think it’s OK to generalise, for example, exposure-based therapy for kinesiophobia because it has very strong evidence from other conditions where avoidance serves to reinforce the anxiety state, eg spider phobia, social phobia.
Where a treatment really is brand new, let’s think of mirror therapy, laterality training or motor imagery training for CRPS for example, the patients need to be fully informed of the experimental status of the intervention, any potential ill-effects from treatment, and be informed about alternative interventions and the level of evidence for them.  Then they can make an informed decision.

Where things start to get unravelled for me is when a treatment implores us to look beyond conventional scientific knowledge and into mysticism, magical thinking or ‘alternative’ energy, aura, vibrations or whatever. I don’t mean to throw the baby out with the bathwater, I hasten to say, because I’m fully aware there are many things we simply don’t know about in the universe because we don’t have technology to measure them – but the absence of a testable hypothesis means we are required to believe, trust or otherwise suspend critical thinking, and I’m a scientist not an artist!

Even if a treatment did draw on ‘alternative’ dimensions, our patients live in a world where real pain, real disease and real suffering exist. If an ‘alternative’ treatment is not able to demonstrate change that is more than placebo in this real world, then it is simply unhelpful at best, and wasteful or even destructive at worst. We ask no less of conventional health care, why would we ask less of ‘alternative’ interventions?

The upshot of this situation is this: if we are innovative and come up with a fantastic new treatment that we are convinced ‘works’ – we need to be prepared to submit it to a structured and systematic analysis of its effect, making allowances for all the usual confounds that make identifying effects so challenging.

That means in the main, carefully and systematically manipulating each variable in a treatment to be sure that the only factor involved in the effect is that one we think it is. This is hard work! And most of us as clinicians simply don’t have the time to do this in our everyday practise.  And it’s not OK to appeal to the idea that we are somehow denying our patients something important because we can’t use our new improved treatment – because in the absence of evidence, our opinion is that – opinion, conviction, belief, faith.

One of the problems with occupational therapy specifically is the lack of hard evidence to support the ‘many treatments that OT’s have historically (and still) use.’ Sad to say, I don’t find evidence for (or against for that matter) many of the treatments used by occupational therapists. Some of the mainstay treatments I was trained to use such as static splinting for acute rheumatoid arthritis and ‘ergonomic equipment’ for low back pain (even ‘safe manual handling’ to protect from acute low back pain) are no longer supported. Other interventions such as activity scheduling or time-based activity planning have received increasing support – but not from the occupational therapy literature.

It is time to increase the awareness of all health professionals, not just occupational therapists, of the need to develop and actively use critical thinking to make decisions about treatments that should be used.  This doesn’t just mean training our newer members of the professions during their training, but more importantly, seriously addressing the knowledge shortcomings of our more senior members of the professions. For a brief summary of this, head to Bandolier again.

These are the people making important decisions about what treatments should be used, which treatments should be funded, and ensuring health professionals within organisations are given adequate time to do the ongoing learning and reviewing of the literature that is essential.  It’s health managers who decide how therapist time is spent, and the current focus on face-to-face time with patients as the only aspect of treatment delivery that is counted means that therapists don’t get adequate time to develop or review their treatments.  But that is another post!

How can I, as a health professional with a science background, influence these senior clinicians?  There is no single way, but two immediately come to mind

  1. Ask questions about treatment effectiveness. Does it work? Who does it work for? How do we know it works? Is it the most effective way to treat this person?  And do something about measuring and writing about outcomes.
  2. Publicise the need to be a critical thinker (and show them how).  I do this by blogging, but it’s not the only way.  Conducting peer reviews, reviewing our own practice and talking about it, taking inservice education, facilitating a discussion, letters to the editor, completing quality forms – all of these are steps we can take to raise awareness that “Evidence based health care takes place when decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information.”

2 comments

  1. First of all, thank you for your thorough explanation and focus on evidence based treatment. I couldn’t agree with you more. I still maintain that we should be knowledgeable about what treatments are being offered in not only the alternative therapies, but in as many areas as we can keep up with. By attending an education session, it is just that, learn, question, evaluate with your own mind. AND, it is not to say that by attending you are going to be turned into a provider of anything after 2 hours, but merely a source of information for our clientele. I guess I am thinking in a different way, and I will do my best to explain
    1. I remember when I first started hearing about tai chi for MS patients, I didn’t know enough about Tai chi, and I was not sure I would support it as a tool for therapy. Now that I have learned, reviewed the evidence, and witnessed the continued expanding body of evidence, I agree that it is a valuable tool for a variety of patients. It took the initial knowledge gathering phase to start this process for me. I may have been one to steer my patients away from something I didn’t even understand much less weigh and evaluate.
    2. In 1986 (I think that was the year), I treated a native American woman who was in a coma. Being the smart 22 year old that I was, I thought modern medicine was it of course. Upon entering the ICU, I noticed “rocks” spread out around the patient. I asked the nurse what was up with that and learned about healing crystals. While I still do not perscribe but concede I don’t know too much about it but am intrigued about the beliefs of using healing crystals. Doesn’t mean I will start using them in OT i did, however use that as a valued peice of information for respecting what my patient and the family believed. That is where I think we need to open our minds to just learn about things. Again, not converting anyone to non-evidence based practice. AND, if we do something that we do beleive works-do some research!!
    That is where my thoughts are coming from, and I would love to hear other arguments both for and against this.
    I also agree that we have to be careful of throwing the baby out with the bathwater. Extremes can be found in many treatment areas, I think of SI. Yet, I still value that it as useful even though that is a pretty hot topic when you talk evidence based too.
    I would like to thank you and all of the contributors and hope we can keep this spirited topic alive. In my current research on continuing competency (ther reason for the continuing ed. requirements in most professions), I am finding many more questions than answers and I think the OT community can both benefit and contribute. The pressure continues to mount in providing evidence based treatments and remaining competent at what we know and do.
    Thanks for the space.

  2. Hi Michele,
    Thanks so much for taking the time to comment – what you’ve said here sounds much more like what I end up doing every day!
    There are a couple of things that worry me about ‘recommending’ treatments such as crystals or falun gong – while we might learn a little about them in a 2 hour workshop, we’re not going to have sufficient information to recommend them to anyone, and in my practice I’m not keen on recommending anything that doesn’t have an evidence base. But yes, a workshop will give us a little insight into the approach.

    I still don’t specifically recommend tai chi for people with chronic pain – but I do say that tai chi, pilates, yoga and other gentle stretch-based exercise has some evidence for helping people remain active (actually I’m more likely to say that there is little evidence that any specific exercise is better than another in chronic pain, so find something you like – you’ll probably do it!).

    I’m more inclined to ask the individual about their beliefs about whatever ‘treatments’ (conventional or not) than rely on a workshop, however, because people vary so widely in why they try a new approach – this has more impact in terms of individualising treatment than knowing in some general sense what Reiki, for example, proposes happens in the course of a session. And to me, in chronic pain management it’s much more important to understand what the person is looking for than what the approach actually advertises that it ‘does’!

    I suppose my concern about attending a seminar or workshop and then providing information is that I don’t want to be the source of information on unconventional approaches. Goodness I have so much to find out about conventional evidence-based treatments that I don’t have much time left over to learn about and/or dispute the proposed benefits or mechanisms in unconventional approaches!

    But anyway, I don’t think we’re all that far apart really – and I do thank you for contributing to this discussion!
    cheers
    Bronnie

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