1. Effective evidence-based occupational therapy
An inspiring implementation challenge
Dr. Esther Steultjens

2. Where systematic reviews lead me

3. Systematic reviews by Steultjens et al.
Efficacy of OT for RA
Efficacy of OT for stroke
Efficacy of OT for MS
Efficacy of OT for children with CP
Efficacy of OT for community dwelling elderly
Overview of systematic reviews
Steultjens E, 2002, 2003, 2004, indexed in Pubmed

4. Conclusions PhD thesis
Evidence in OT exists!
High methodological quality studies show efficacy of OT interventions
There are evidence gaps
Systematic (Cochrane) reviews can be performed in OT
Methodological challenges occur
Steultjens E, NIVEL VU University Amsterdam NL

5. OT practice High quality OT is: Effective Client centred
Evidence based
Occupation based
Efficient

6. Content From systematic review to evidence-based guideline
Into systematic reviews
Best Practice

11. Guidelines level 1
Using meaningful activities as tool in OT treatment leads to higher functional abilities and participation.
Training self-maintenance activities does not lead to better performance in leisure activities
Leisure activities need to be trained to raise satisfaction with performing leisure activities

12. Themes Client centeredness Occupational performance
Multi-disciplinary collaboration
Caregivers and social context
Organisation of healthcare

13. One year after dissemination
Changes in OT practice
One year after dissemination
60% active implementation of client centeredness
70% active implementation of occupation based treatment
Focus on caregiver, multi-disciplinary collaboration, organisation of care need more attention
Implementation Stroke OT guideline, 2006, HVA, Amsterdam

14. 3 years after dissemination
Changes in OT practice
3 years after dissemination
70% implemented guideline
90% changed practice
98% use meaningful activities as treatment tool
90% collaborates with client and caregiver in treatment goal decision
Evaluating the stroke OT guideline, 2008, HVA, Amsterdam

15. Conclusion Systematic reviews change practice OT becomes more
Client centred
Evidence-based
Occupation-based
Efforts in developing and implementing guidelines are necessary.

16. Into systematic reviews
From chaos to confidence

17. Experienced difficulties with Evidence-based Practice
53% perceive using evidence as requiring too much effort
70% reported difficulty in evaluating quality of evidence as greatest barrier
60% did not think research is written in an understandable manner
C. Döpp et al, 2008

19. Systematic review Research question relevant to practice
Inclusion criteria stated
Patient characteristics
Intervention or situation characteristics
Comparison intervention or situation
Outcome
Search strategy replicable
Databases searched
Keywords used
Dates of search

20. Systematic review Inclusion process reliable
Transparent
Independent
Data extraction process reliable
Presentation of key characteristics
Synthesis process transparent
Description of statistical analyses and best evidence syntheses
Implications for practice

21. An example
Steultjens et al. Efficacy of OT for MS (Cochrane review). first published 2003, issue 3
Baker et al. The effectiveness of physical, psychological and functional interventions in treating clients with multiple sclerosis: a meta-analyses. Am J Occup Ther. 2001;55:

22. An example
Efficacy of OT treatment vs efficacy of OT related treatment
Inclusion criteria:
Clear definition of OT vs multidisciplinary, physical, psychological and social work interventions
Searches till December 2002 vs searches till 2000
Inclusion of:
3 studies (1 RCT, 1CCT, 1 not controlled design) vs 23 studies (RCT and CCT only)

23. Conclusion inclusion of literature
Big differences between reviews
Results based on 3 studies evaluating specific OT interventions
Results based on 23 non-specific OT related interventions

24. An example 2
Qualitative best-evidence synthesis for 3 studies incorporating heterogeneity
Meta-analyses of 23 studies without addressing issue of heterogeneity

25. Implications for practice?
An example 2
No conclusions can be stated whether occupational therapy improves outcome in multi-sclerosis patients
Overall medium effect size of 0.52
Implications for practice?

26. A professional reasoning perspective
Best Practice
A professional reasoning perspective

27. Implementation phases
Acquiring new knowledge
Knowing acquired change
Positive attitude to change
Changing process
Established new care

28. Professional reasoning
Process of OT treatment
Content of OT treatment
Decision making process
Explicit Professional reasoning

30. Explicit reasoning model
Thinking:
When
What
HOW

31. Evidence-based decision Bio-psychosocial state
CCEBE-Model
Client
society
society
Evidence-based decision
Experience and expertise of client and therapist
Bio-psychosocial state
Scientific evidence
society
Logister, 2007

32. Who is the OT?

33. Self-esteem