Evidence-based practice, practitioner versus student, smack-down.

I recently received a comment with constructive criticism regarding how I present OT to the masses. I wanted to write about my perspective regarding how I share OT. First I'll start by addressing Anita's comments, then go into further detail.

I was a little worried when I saw that you wrote:  “I am going to try a TENS unit on the forearm in the acupuncture points of Li3 and Li10 I think it is??” I don't know about TENS or acupuncture, so I'm not telling you what is right or wrong. What I thought when I read this was “what evidence is this based on? What knowledge and skills does this OT have here?” etc. This was because the way you wrote this left me with the impression that you might simply try it and see without having done any research to know if it would be appropriate for a person with post-burns pain. Of course this wouldn't be the case at all, I just worry that a lay person might read this and think “wow, I could do what an OT does, it sounds very eclectic, and really quite simple”.

I could see after Anita pointed it out, how what I wrote looked as if I was saying “I have no idea, let's try this”. That's one of the down-sides of blogging, it rarely occurs to me people will read things in a spirit quite differently than intended. In reality, I have taken a special course in physical agent modalities that included the use of TENS [transcutaneous electrical nerve stimulation] for multiple uses, including pain reduction, based on the gate theory of pain. It is appropriate for the use of pain reduction in a post-burns pt as long as I'm not directly covering the burns with the electrodes. TENS units, to the best of my knowledge, do have supportive evidence to back their use as a common physical agent modality. Anecdotally, using the TENS units on specific acupuncture points (such as Li3 and Li10 which are located on the upper extremities), helps more than just using the TENS in random locations. A very experienced physical therapist I work with has used the TENS units specifically on acupuncture points with great success in pain reduction. When I used the question marks in “Li3 and Li10 I think it is??”, I was referring to not remembering the NAMES of the two specific acupuncture points – I knew exactly where to place them, just wasn't positive I had properly remembered their names. Regarding evidence-based practice, using the TENS was warranted, and whether it was on an acupuncture point or not may HELP but would not harm. I should check to see if any evidence-based articles exist regarding the use of TENS on acupuncture points.

As a new practitioner with somewhat limited local resources due to my geographic area, I try hard to be evidence-based when approaching new areas of practice (new to me). For example, I recently had a pt with chemotherapy-induced peripheral neuropathy, and I found three different articles in medical journals that I had the library get for me. I read those to get a better understanding of what to expect/know about this specific issue, and that is where I learned about pseudo-athetosis and severe sensory ataxia, both of which were relevant to what I was handling. I've also researched and gotten multiple (I think SIX?) articles on shoulder subluxation after stroke, to better grasp best treatment protocols. For basic treatment, I often rely heavily on what I have seen other therapists perform, or what I have received advice about, or learned while in school, or observed in fieldwork, etc….I do not approach each treatment with “I didn't find an article on this so I have no idea if it's evidence-based”….I rely on clinical judgment and the professional expertise of others, my research/resources from schooling, fieldwork, and recent experiences, to determine whether I am providing basic appropriate treatment. When I get into more new issues or want to explore alternate routes, I start researching.There are times when I want to explore what would happen if I took a common treatment protocol in one area and applied it to another – for example, taking the surgical brushing of the Wilibarger protocols of sensory integration, and determining whether it would be a feasible or appropriate treatment for the peripheral neuropathy….hard to know in cases like that. I definitely never experiment on my pts in harmful ways.

Anita also commented that when I blog I often do not act as if I have solid evidence-based foundations to draw from, and am rather just experimenting. She suggested I approach blogging in a more professional manner in regards to presenting questions about interventions.

When it comes to my blogging as a new practitioner, I do tend to have a very student-like approach of trying to “learn out loud', pondering my options, looking through my books, asking questions of others. I do tend to be very informal in my presentation, and I guess it can appear that OT is an easy/simple profession where we just use common sense. It's not my intention to make it sound like OT is not a skilled profession (you have to have at least a Master's degree now) – but it is my intention to make OT seem like a possible and fascinating career for perspective OTs. I'm not always so great (okay, NEVER great) about using a lot of professional terminology and acting very professional in my blogging presentations.

I very much like the idea of performing evidence-based research then coming on here and asking for more specific thoughts from other therapists, but realistically it's unlikely. When I do have specific questions of practitioners, I tend to use the OT Connections blog which i know is read almost exclusively by therapists. I tend to use this blog for getting out my jumbled thoughts and for giving the general public an idea of what sorts of things OT might see – it's less for other OTs than for prospective OTs or OT students. I guess some could argue I do the profession injustice/harm by my haphazard blogging as an occupational therapist, but based on the e-mails/comments I've received over the last few years, I've helped many people with making their final decisions to enter the profession or not, and/or to help them determine whether it's potentially a pathway to follow. 

I do believe overall it's important to aim for evidence-based practice – evidence of the highest power when possible, such as meta-analysis and systematic review and not just case studies. When I have the time and energy or need to research myself, I do. I also do believe in the anecdotal evidence of more experienced therapists who have used interventions with great success – in those cases there probably is evidence to back up the interventions that I just haven't yet taken the time to research. When I have specific questions I tend to ask on OT Connections, and when I am just sharing my thoughts and letting them flow out my fingers, I tend to come here. If some OTs read this blog and are horrified at my informality and how it may appear that I'm not really sure of what I am doing, then I am sorry because it's not my intention to appear clueless – just learning, the same as I did when I was a student. Even as a new practitioner, I don't see a reason to blog differently than I did as a student, as the learning process is the same – it's just that how I use the information is different as it will be applied to real clients.

So in conclusion I appreciated Anita's comment (which can be found on the post 2 below on the pediatric SI post), and also appreciated Donna's comment on criticism being necessary for growth (see one post below). I'm going to try harder to not sound quite so hesitant or questioning when blogging, and to possibly take her advice and occasionally do my research then ask specific questions. But I'm also still going to write my crazy jumbled rambling posts where I'm pondering what to do wi
th clients – but may try to be better about clarifying I do know my basic practice standards/interventions, and am just trying to decide how to best apply them.

Some days I cringe regarding my blogging jumbles, other days I am proud of them. I do occasionally get critical comments that I can grow from, and then I get a lot of comments that make me happy regarding people realizing how much they love the profession of OT after following my blogs. I'm Facebook friends with several now-OT students who I first met as prospective students through this blog. I love watching their journey, and I love introducing people to OT, and I still need to work on increasing professionalism, but I'm always going to be crazy as well. 🙂 I may not be a very experienced occupational therapist, and I sometimes have fewer local resources than I'd like, but overall I have great relationships with my patients and I work INCREDIBLY HARD to do research and read and prepare for my clients so that they get the best possible treatment.

I got a text the other day from a friend who reads my blog who said he would be horrified if I did in fact use proper grammar in a blog post (like I threatened in this previous post), so hopefully he won't have a heart attack. Not used to GRAMMAR! I'm a txter! Srsly. Anyway – enough being serious….Anita, hope I addressed your comments….I'm going to try to be better, but probably not as good as you hope, as if I have to start behaving myself, it will take too long to write up! Haha.

Now it's time to go cuddle with my hideously ugly cat Lester! I gave him a partial haircut today, it's very ripply. Maybe I'll write again tomorrow with new thoughts on things (I want to do some more research on hand and trunk dysfunction from a hand dysfunction book I found, plus I found an OT goals book that had great goals in it I want to use for pediatric pts!)

May 23, 2010 | Category: Occupational Therapy | Comments: 7