September / October 2000 Table of Contents
In this Article
"What we have to learn to do, we learn
by doing."
Aristotle, Nicomalean Ethics - Book II
by Laurie Snider
Who really cares about evidence-based
practice in occupational therapy? Is it only meaningful to graduate students, academics or other people whose major preoccupation is jumping through academic hoops?
I don't think so.
I believe that occupational therapists take pride in their professionalism and in the credibility of their practice. One group which continuously confirms this belief for me is the Occupational Therapy Evidence-Based Practice Group at McMaster. You've heard from this hardworking group before in this column (OT Now, May 1999). A sampling of their many initiatives appears on their web site at http://www-fhs.mcmaster.ca/rehab/ebp/ and a visit is definitely worth the click.
What do Mary Law, Debra Stewart, Nancy Pollock, Lori Letts, Jackie Bosch, Muriel Westmorland and Angela Philpot do that's so noteworthy? They show us how to develop the critical appraisal skills to promote evidence-based practice. By posting the group's literature reviews pertaining to occupational therapy on the web site, the step by step process of critical review is clearly and carefully identified. The outlines for both qualitative and quantitative reviews are straightforward, needing little or no explanation, making them ideal for the occupational therapist with a need to know.
Chronic Pain Review
A recent review looked at the effectiveness of cognitive-behavioral interventions with people with chronic pain, an interesting question in itself, since occupational therapy intervention in this area tends to take place within the context of the multi-disciplinary team. Asking the question was the first step: What is the effectiveness of cognitive-behavioral interventions in improving occupational performance (function) for people with chronic pain? The group identified a secondary question: What is the effectiveness of cognitive-behavioral interventions in improving performance components, environmental components and/or pain-related outcomes for people with chronic pain? Great questions! Then they were off to the lit review...
Stating the first question helped the group to define the types of studies to be reviewed. All studies which reported an effect of the cognitive-behavioral approach to adult chronic pain were included in the descriptive critical review. A variety of methodologies were included: random control studies, cohort designs, cross sectional designs and case studies to name a few. After an initial search, which turned up a 1500 title response to the main key words, 51 titles plus 20 more articles located through hand searching were included in the initial descriptive review. A final total of 29 articles were accepted for review. The details of the descriptive critical review were summarized in a table which identified the purpose of the study, the outcomes, results and the reviewers' conclusions. Articles which included randomized (or quasi-randomized) clinical trials were eligible for a systematic review via the Cochrane Collaboration, using Review Manager software, to compare the key outcomes and to determine the direction and the strength of the effect. Ten studies within the final selection of 29 articles met these criteria.
The answer to the first question? It depends. When compared to no intervention, cognitive-behavioral intervention for adults with chronic pain seems to have a beneficial effect on occupational performance. Group treatment seemed to be somewhat better than individual treatment. When comparing the intervention to other forms of treatment the reviewers were unable to draw strong positive conclusions because of weak methodology and the use of multiple outcomes across the various studies.
The reviewers' suggestions for future directions gave occupational therapists a clear mandate to form their practice in cognitive-behavioral interventions from the available evidence. They suggested:
- Focus on functional outcomes related to quality of life and participation in activities and
- Choose established outcome measures and functional outcomes to allow for comparison between studies.
After going through the review, I not only had a great understanding of the process the reviewers went through to reach these conclusions, but I had learned a lot more about the effectiveness of cognitive-behavioral interventions on occupational performance. I also was even more confirmed in my admiration of the painstaking and coherent work of the Evidence-Based Practice group of McMaster University.
Thank you!
What tools do we need?
1. Qualitative/ Quantitative Review Forms
2. Review Manager software (found on the Cochrane web site)
Click on Guidelines, Manuals and Software /Review Manager software (RevMan 4.0.4) to download.
Steps to follow in a Critical Review Process
1. Ask a question about a relevant, meaningful topic.
2. Conduct a thorough literature review, including and excluding articles according to your established criteria.
3. Using the quantitative and qualitative critical review protocols, carry out a descriptive review of the articles which meet your inclusion criteria.
4. Conduct a systematic review of the experimental and quasi-experimental studies in your descriptive review. Review Manager software will summarize the key characteristics of the included studies and compare the key outcomes for you.
Laurie Snider, Ph.D., OT(C) is the Director of the Occupational Therapy
Program at McGill University, in Montreal, Quebec. She is a member of
the CAOT Editorial Board and the editor of this column.
September / October 2000 Table of Contents
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