Sorry... new to this forum so I am not sure if I did this correct....
As an clinician, I feel that EBP actually expands the options of intervention as it forces us to examine our own personal "theory" or causal model of the specific clinical problem and explore the client's beliefs about the their problem. Moreover, it brings to the for front the need to be able to document the client's change through specific data points that have been hypothesized in my causal model to influence the illness trajectory. On a sad note, my clinical experience (20+) matches what the research has found- the intervention selection due to the therapist's causal model and more likely will not be based on evidence. It also may not be based on achieving outcomes that have been documented in local data.
As most problem that we see in the clinic as OTs are what I call "messy problems"- clinical issues that develop out of many related and possibly unrelated factors, (think......Dynamical Systems/ Ecological; Person/Task/Environment) I need EBP in order to identify which factors are more likely to be involved and more likely to be remediable to intervention in the time-dependent-constrained system that I work in. I have to say that is has been my searching for evidence in order to answer my clinical questions which led me to consider more options for intervention.......In other words, the EBP model has shaped my causal model for a clinical problem by allowing me to understand what has been identified in all professions that are exploring this clinical problem and not just from my own professional paradigm.
I would give handwriting intervention as a specific example- when I started practice, we would do mazes, and core strengthening, and in-hand manipulation skills with minimal or direct instruction on handwriting. I could never understand why my kiddos were not improving with their handwriting- through EBP, I found that at the population level, visual perceptual skills, in-hand skills, and core/UE strength are typically adequate for handwriting. The most commonly used tool to identify handwriting dysfunction was the VMI, but research found that this tool is not able to identify or predict "poor or dygraphic" handwriters. Wow- what was I to do- I was forced to continue to examine what the evidence was saying were potential factors about handwriting/written language dysfunction. This lead me to develop a very different causal model and highlighted very different factors as more likely involved. On the research front, our understanding of orthographic depth, motor learning, and other non-motor issues also highlighted the need to change instructional practices. In my one job, by directly changing how teachers were teaching handwriting, we significantly reduced the number of students who were identified as "poor handwriters". We also significantly reduced the number of students who were even referred as most were able to receive the interventions that have been demonstrated to work, but, critically, were not found in typical interventions. On the negative side, we still see Handwriting Without Tears as one of the most commonly used interventions, even though it is missing critical components that have been demonstrated to significantly improve written language skills.
Angela Benfield, PhD OTR
University of Wisconsin-La Crosse
[log in to unmask]
|