OT and RCT: Why the Evidence is not Piling Up

Intent: To explore possible reasons why better results in terms of promoting and supporting occupational science and occupational therapy are not being obtained from the evidence based studies already published. Argument: The goal of evidence based practice research should be to document the effectiveness and efficiency of occupational science theory and occupational therapy intervention process and procedures. A review of the techniques used to achieve the goal both within and without the profession suggests several obstacles or barriers which may explain why the evidence is not “piling up.” Among these are: 1) problems in translating theory to intervention, 2) assessments that focus on diagnosis but do not guide specific intervention, 3) use of many different assessments in research studies making comparison of outcome results difficult in addition to the mechanics of designing RCT studies. 4) lack of agreed upon protocols for intervention and 5) use of many different interventions to address the same problem or set of problems. Regarding theory, Parham, Cohn, Sitzer et al. (2007) have spoken to the problem of deciding whether to study the structural elements or the process elements of a theory such as sensory integration. Regarding assessment, the author has identified over 450 assessments developed in part or in whole by occupational therapists. The major rationale for development is diagnostic, that is, to better identify that a problem or problems exist but are not designed to directly tie problem identification to a specific intervention process known to address the problem(s). Instead therapists are expected to use clinical reasoning to “connect the dots” between assessment and delivery of intervention. As a result many approaches are used in intervention and must be studied independently to determine effectiveness and efficiency. We (as practitioners) multiple our (as researchers) work and may not significantly improve the delivery of effective intervention through occupation in the process. Regarding intervention, van den Ender, Steultjens, Bouter, & Dekker (2006) speak of clinical heterogeneity, that is the diversity of interventions which often lack consistent protocols and outcome measures as an issue which reduces the likelihood that conclusions from systematic reviews can be drawn in either physical or occupational therapy. Relevance: Occupational science researchers and occupational therapy practitioners need to examine the barriers and problems identified in the literature that inhibit building a significant body of literature to support evidence based theory and practice using occupation as a central unifying concept for study and application. This presentation identifies issues, asks some pertinent questions and offers possible solutions. Discussion questions: Can research studies be focused more on the process of how intervention using occupation “works” rather than on what tools to use (Parham, Cohn, Spitzer et al, 2007)? Can we design assessment to help us and our clients clarify their own needs and goals as opposed to those that only “diagnose” the problem from the theoretical perspective (Burridge, Wood, Hermens et al, 2005)? Can we identify and use a consistent set of assessments (in addition to others) in the research design to facilitate cross comparison of results (Cohen, La Greca, Blount et al, 2008)? Can we work collectively to meet the challenges of RCT design which require carefully designed studies to yield evidence of effectiveness (Butler & Darrah, 2001)