Monday, December 04, 2006

random thoughts on superstition, tradition, conviction and evidence-based practice in occupational therapy

For various reasons I have been called to task regarding an analysis of what I believe in - and I thought that the philosophical definitions are important so I wanted to yell them to the rafters, so to speak. Issues of internal consistency are important to me, so I was interested to find that my work vs. non-work need for evidence was quite different. I'm still not entirely sure how to resolve that issue – perhaps it is not important.


Superstitions often stem from folklore or historical reinforcement of confusion between causation and correlation. Common response experiences and confounding variables contribute heavily to confusion that is then reinforced through repetition. In this sequence of events, superstition translates to mythology and there is high risk for it to be further transmitted into tradition. I am aware of the debate, but count me among those who believe that 'folk psychology' is real. I know that eliminative materialists will take me to task, but I think hobbits know all about folklore. Even though superstition might be a true psychological model it probably is not be the best vehicle for scientific progress. We have lots of superstitions in OT - most notable is our historical explanation of what sensory integration exactly IS. I have recently referenced that we are making some progress on neurophysiological correlates of sensory processing disorders, but up until recently we had very little to say about real causative factors. Instead we have generated a lot of superstition around sensory interventions - from weighted vests to brushing protocols.

Beyond superstitions people also sometimes believe things because of tradition. Traditions are customs and practices that are passed on from generation to generation. The reason for continuing tradition is often for tradition's sake. Tradition is what Tevye uses to keep his family moving forward. Traditions contribute to identity and they certainly feel good - but again they are also probably not the best model for scientific progress. OT has lots of traditions too - like why splinting is perpetuated in our scope of practice. Tradition makes occupational therapists focus on upper extremities and physical therapists focus on lower extremities. Tradition, in part, perpetuates craft use as a therapeutic modality. Traditions can be good or bad; they can be restorative and generative or consumptive and pathological.

Conviction is a fixed or strong belief. I think the best synonym is surety - from the Latin securus - secure. I always like conviction, but the only problem is that conviction can be belief in anything, even if it is dreadfully wrong.

Evidence-based practice, as it is broadly defined, is the systematic methodology designed to integrate research evidence into the clinical reasoning process (Tickle-Degnen, 1999). Concern has been raised about application of a medical model of evidence-based practice to occupational therapy (CAOT, 1999). Where much of evidence-based practice in medicine is based upon broad epidemiological studies, the application to occupational therapy is more specific in that evidence-based practice should help clinicians “to make decisions about interventions that are effective for a specific client" (Law & Baum, 1998, p.131). This approach that combines evidence-based practice with the concept of client-centeredness has been reported in the occupational therapy literature (Egan, M., Dubouloz, C.J., von Zweck, C., & Vallerand. J., 1998).

Critical appraisal is a significant component of evidence-based practice (Crombie, 1996, pp. 1-2). Critical appraisal is the analysis of data that allows for a practitioner to engage in evidence-based practice. Where evidence-based practice is an end, critical appraisal supplies a means.

Tickle-Degnen (2000) identified the steps that clinicians must take in integrating evidence into practice, but it is evident that many clinicians are not fully participating in the process (Rappolt & Tassone, 2002; Dysart & Tomlin, 2002). This is important to the profession of occupation therapy because of the longstanding contract that we have with those who ‘consume’ our services. Patients and reimbursement systems both expect high quality, effective, and efficient care. Occupational therapy is at risk of becoming irrelevant unless the profession is able to convince consumers that clinical decision making is based on sound and rationale scientific data, and that this data is meaningfully applied to the individual’s life experiences.

The task of teaching skills of critical appraisal for evidence-based practice to clinicians is daunting. Clinicians are faced with time constraints, varying degrees of administrative support, challenges in being able to access ‘evidence,’ and lack of training in how to conduct critical appraisal (Tickle-Degnen, 2000; Ottenbacher, Tickle-Degnen, Hasselkus, 2002). I believe that we have a better opportunity for teaching evidence-based practice to students, as they are approaching their learning with more of a ‘tabula rasa.’ It is much more challenging for clinicians to ‘unlearn’ years of practice that is often based upon superstitions, traditions, or negative convictions. Still, all of our students do ultimately pass through clinical sites for their training, and for this reason it will be critical to send students to fieldwork sites that incorporate concepts of ‘best practice’ and who use models of evidence-based practice.

These are important issues – I think everyone should spend some time visiting them.


Canadian Association of Occupational Therapy (1999). Joint position statement on evidence-based occupational therapy. Canadian Journal of Occupational Therapy, 66, 267-273.

Crombie, I.K. (1996). The Pocket Guide to Critical Appraisal. London: BMJ Publishing Group.

Dysart AM & Tomlin GS (2002). Factors related to evidence-based practice among U.S.
occupational therapy clinicians. American Journal of Occupational Therapy. 56, 275-84.

Egan, M., Dubouloz, C.J., von Zweck, C., & Vallerand, J. (1998). The client-centred evidence-based practice of occupational therapy. Canadian Journal of Occupational Therapy, 65, 136-143.

Law, M., & Baum, C. (1998). Evidence-based occupational therapy. Canadian Journal of Occupational Therapy, 65, 131-135.

Ottenbacher KJ, Tickle-Degnen L, & Hasselkus BR (2002). Therapists awake! The challenge of evidence-based occupational therapy. American Journal of Occupational Therapy, 56, 247-9.

Rappolt S; Tassone M. (2002). How rehabilitation therapists gather, evaluate, and implement new knowledge. Journal of continuing education in the health professions, 22, 170-80.

Tickle-Degnen, L. (1999). Evidence Based Practice Forum: Organizing, Evaluating, and Using Evidence in Occupational Therapy Practice. American Journal of Occupational Therapy, 53, 537-539.

Tickle-Degnen, L. (2000). Evidence-based practice forum: Gathering current research evidence to enhance clinical reasoning. American Journal of Occupational Therapy, 54, 102-105.

Tickle-Degnen, L. (2000). Evidence-Based Practice Forum: Teaching Evidence Based Practice. American Journal of Occupational Therapy, 54, 559-560.


Aschwin -NL- said...

Hello Chris,
just a short comment about how your random thoughts about ebp hit my thoughts over here in the Netherlands. I am a student OT, learning to become an OT by following a quick thorough course of 2,5 yrs in Amsterdam. And struggling with ebp how it is thought by the tutors and how ebp is in the practices. Glad to know I am not the only one who has got thoughts about this. Anyway your blog has inspired me to start my own...
thanks, Aschwin

Chris said...

I'm so glad that you decided to write your own blog! Please share the link here so we can all visit..

Winston Smith (from Orwell's 1984) thought that "to mark the page was the decisive act..." I have always that writing was a life-altering activity -

Best of luck,

Anonymous said...

I'm glad to hear this! I'm graduating soon, and I heard about evicende based practice but never actually got to see it. I live in Argentina, and we're very few OTs with a lot of work to do. In fieldwork, I always wonderded how the OT knew if the strategy they were using was effective or not. And the goals were sometimes too general.
On the other hand, it's really difficult to use evidence based practice here because sometimes you have too many patients at the same time, institutions don'e give you enough material (you have to do it all by yourself), and the time is very little.