In the second guest blog of our new series Evidence for Everyday Allied Health (#EEAHP), ‘lapsed orthotist’ and University of Exeter Medical School researcher Chris Morris looks at the challenges, and importance, of ensuring everyday practice is evidence-based.
I am a lapsed orthotist – no longer licensed to use the title, as I am not now registered with the Health and Care Professions Council. However I was an orthotist for 20 years, and for 10 of those I trained in health services research.
When I started out on my clinical career orthotists were more commonly called ‘surgical appliance fitters’ and we simply made and fitted what was prescribed by learned others. As orthotists became more academically trained, and recognised formally as allied health professionals, the role evolved into prescribing, or advising on prescription as part of multidisciplinary teams.
I write the following to encourage orthotists (and our prosthetist cousins) to use evidence everyday in the pursuit of an evidence-based practice.
What is evidence-based practice?
There is often confusion about what evidence-based practice means. Evidence-based practice is the use of current best evidence in making decisions about the care of individual patients (Sackett et al., 1996). However it’s not only about research evidence; practising evidence-based health care also incorporates the experiences of the clinician and the preferences of the patient and their carers.
So, to pursue evidence-based practice you have to know where to find evidence about interventions, and also how to critically appraise it. But first, you need to know how to structure a question about whether an interventionA treatment, procedure or programme of health care that has the potential to change the course of events of a healthcare condition. Examples include a drug, surgery, exercise or counselling. is effective (O’Connor et al., 2011; NICE, 2014). This involves thinking about the patient group (e.g. diagnosis, age) and the key outcome the intervention aims to achieve, as well as any alternatives. Once you have an answerable question using the patient-intervention-comparison-outcome (PICO) format, then you can look for evidence efficiently in resources where people have already done much of the work for you, such as The Cochrane Library, or under ‘secondary evidence’ in the TRIP Database, or guidance from the National Institute for Health and Care Excellence and NHS Evidence.
Why is evidence-based practice important?
People may often think that providing an orthosis as a treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. may well be ‘worth a try’, after all what harm could it do? Well, aside from wasting scarce resources an ineffective orthosis can also waste patients’ time and in some cases cause psycho-social harm. To illustrate, have a look in your favourite search engine for images of some of the orthoses that were designed to increase containment of the hip to treat children with Legg-Calvé-Perthes disease. Imagine how these orthoses affected their experience of childhood and adolescence, especially in the context that we no longer (as far as I am aware) provide these devices as they were relatively ineffective compared to surgery. The same may well be true for orthoses we do still commonly provide, for instance spinal orthoses for girls with adolescent idiopathic scoliosis. So it is imperative that orthotists identify whether the interventions they are providing have been evaluated and shown to be effective in well-conducted studies.
Trends for new orthoses also have implications for evidence-based practice. For instance Lycra-like materials have been advocated in the design of orthoses for children with cerebral palsy. So, what’s the evidence? Our childhood disability research group summarized the evidence on whether Lycra orthoses (splints) improve function and movement ability in children with hemiplegia, or other types of cerebral palsy? (Peninsula Cerebra Research Unit, 2013). This may be useful for families as much as clinicians.
What are the barriers?
There are numerous barriers to evidence-based practice, many of which are not unique to orthotists (time and effort). However, one specific barrier is that when you look for evidence about effectivenessThe ability of an intervention (for example a drug, surgery, or exercise) to produce a desired effect, such as reduce symptoms. of orthoses, the evidence is so scant. Using the terms “orthos?s or orthotic” (in which the ? means both ‘orthosis’ and ‘orthoses’ are included) to search The Cochrane Library identifies 34 Cochrane ReviewsCochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research., another 75 results refer to non-Cochrane reviews, although some of these are protocols for reviews yet to be completed. Even when the reviews have been completed the evidence is hardly persuasive, as the individual primary studies included are rarely high quality controlled clinical trialsClinical trials are research studies involving people who use healthcare services. They often compare a new or different treatment with the best treatment currently available. This is to test whether the new or different treatment is safe, effective and any better than what is currently used. No matter how promising a new treatment may appear during tests in a laboratory, it must go through clinical trials before its benefits and risks can really be known.. Searching the National Institute for Health Research (NIHR) project portfolio and the Europe PubMed Central biomedical grants database for current orthotic related studies suggests a paucity of ongoing clinical trials in the pipeline.
A couple of years ago we spent several months developing a research studyAn investigation of a healthcare problem. There are different types of studies used to answer research questions, for example randomised controlled trials or observational studies. protocol to evaluate the effectiveness of Lycra-based sleeve/glove orthoses to improve the bimanual ability of children with spastic hemiplegia. However we were unable to secure funding; reviewers of the proposal identified weaknesses in study design, including the difficulty of placebo-effect. To some extent one of the barriers was that we were competing with research proposals evaluating interventions that might save children’s lives and other unarguably more important health outcomesOutcomes are measures of health (for example quality of life, pain, blood sugar levels) that can be used to assess the effectiveness and safety of a treatment or other intervention (for example a drug, surgery, or exercise). In research, the outcomes considered most important are ‘primary outcomes’ and those considered less important are ‘secondary outcomes’.. Thus the [relatively small] health benefits from orthoses to improve gait or other functional ability, when weighed against other studies, makes these proposal uncompetitive to funding agencies. Evaluating orthoses and other equipment aiming to prevent deformity has the additional challenge that deformity develops over several years, meaning that studies would have to run over long periods, hence making them expensive.
Huh, so how can ‘we’ overcome barriers to evidence-based practice?
A small group of people involved in orthotic research and education met in the USA in 2009 to discuss the barriers and the strategies to overcoming them. The report and recommendations of that meeting are still pertinent and transferable to the UK and the NHS (Geil and Michael, 2009). Key among the recommendations were to promote the importance of orthotists engaging with research (as I’m trying to motivate you do here), and to teach and support both individual research skills as well as creating the collective capacity to carry out substantive evaluative research.
Another strategy proposed was to enhance the active involvement of practicing clinicians to identify topics for research, i.e. those things we’re uncertain if they’re a good idea to prescribe/provide or not. A relatively recent initiative in the UK is the NIHR James Lind Initiative research Priority Setting Partnerships. As part of these any clinician or patient or carer is able to suggest topics for research. There’s one starting, focusing on scoliosis, maybe someone will put in that uncertainty about whether plastic spinal orthoses are effective for adolescent idiopathic scoliosis?
One final reason to engage with evidence-based practice and research is the (oft neglected, but still rather fundamental) NHS Constitution. This commits all clinicians working in the NHS to “…the promotion, conduct and use of research to improve the current and future health and care of the populationThe group of people being studied. Populations may be defined by any characteristics e.g. where they live, age group, certain diseases..”
In my latter years as a practicing orthotist I became more confident to inform patients and their carers (often a child’s parents) about the lack of evidence for a specific orthotic intervention. That enabled a frank discussion about the pros and cons of different orthotic treatment options. In this way the decision may have swayed towards relying on clinical experience and patient preferences, but does explicitly acknowledge evidence (or lack of it). And if we had infrastructure and funding to support clinical trials, that explicit acknowledgement of uncertainty (equipoiseA state of uncertainty where a person believes it is equally likely that either of two treatment options is better.) about treatments would provide an opportunity to recruit people into a research study. [maybe one day…]
Chris Morris has nothing to disclose.
Evidence for Everyday Orthotists by Chris Morris is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License. Images have been purchased for Evidently Cochrane from istock.com and may not be reproduced.
Links
Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996 13;312(7023):71-2. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2349778/pdf/bmj00524-0009.pdf
O’Connor D, Green S, Higgins JPT (editors). Chapter 5: Defining the review question and developing criteria for including studies. In: Higgins JPT, Green S (editors), Cochrane Handbook of Systematic ReviewsIn systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. of Interventions. Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org
National Institute for Health and Care Excellence. Chapter 4: Developing review questions and planning the evidence review. In: Developing NICE guidelines: the manual. [NICE pmg20]. London: National Institute for Health and Care Excellence; 2014, October. Available from:
Peninsula Cerebra Research Unit. What’s the Evidence? Lycra orthoses for cerebral palsy. Exeter: Peninsula Cerebra Research Unit, University of Exeter; 2013. Available from: http://www.pencru.org/media/universityofexeter/medicalschool/subsites/pencru/pdfs/WTE_Lycra_orthoses_April_2013.pdf
Peninsula Cerebra Research Unit. Do Lycra-based sleeve/glove orthoses improve the bimanual ability of children with spastic hemiplegia: protocolThe plan or set of steps to be followed in a study. A protocol for a systematic review should describe the rationale for the review, the objectives, and the methods that will be used to locate, select, and critically appraise studies, and to collect and analyse data from the included studies. The protocols for Cochrane Reviews are available in the Cochrane Library. for an exploratory randomized controlled trialA trial in which the people taking part are randomly divided into groups. A group (the intervention group) is given the intervention being tested (for example a drug, surgery, or exercise) and compared with a group which does not receive the intervention (the control group).. Exeter: Peninsula Cerebra Research Unit, University of Exeter. Available from: http://www.exeter.ac.uk/media/universityofexeter/medicalschool/subsites/pencru/pdfs/amr_protocol_website.pdf
Geil MD, Michael JW, (editors). Advanced Education and Research Training Initiative 2009: Final Report. Washington, DC: American Academy of Orthotists and Prosthetists; 2009, October.
Health and Care Professions Council: http://www.hcpc-uk.co.uk/
The Cochrane Library: www.cochranelibrary.com
The Trip (Turning Research into Practice) Database: https://www.tripdatabase.com/
National Institute for Health and Care Excellence: NICE guidance: https://www.nice.org.uk/guidance
National Institute for Health and Care Excellence: Evidence Services: NHS Evidence (provides access to selected and authoritative evidence in health, social care and public health): https://www.evidence.nhs.uk/
National Institute for Health Research Evaluation, Trials and Studies: Project Portfolio: http://www.nets.nihr.ac.uk/projects
Europe PubMed Central: Grant Finder (to find active and expired grants awarded by Europe PMC Funders): http://europepmc.org/grantfinder?
National Institute for Health Research James Lind Alliance Priority Setting Partnerships: http://www.jla.nihr.ac.uk/priority-setting-partnerships
Department of Health, England. Guidance: The NHS Constitution. London: Department of Health, England; 2015, October. Available from: https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england
This work is licensed under a Creative Commons Attribution 4.0 International License.
