Goal 3:Demonstrate advanced knowledge of orthotic fabrication for complex upper extremity conditions through professional papers.
AOTAs Standard for continuing competence: Knowledge, Critical Reasoning, & Performance Skills
My first research project was a published articled in the Hand Journal called Hand Function Following Simulated Fusion of Thumb MCP and IP joints, I was very proud of this accomplishment because it taught me valuable skills on how to conduct research. On the surface, I learned the process of completing a study and how to work as a team to write a paper in one cohesive voice. In addition, I learned how to recruit participants, obtain grant proposals, and collect and organize data. However, after the completion of my OTD classwork, specifically Advanced Assessment for Practicing Clinicians, Theoretical Foundations for Interventions and Evidence-Based Practice, when I think about this research project, I cringe at how it was conducted.
I was one of three occupational therapists involved in this study in addition to a hand surgeon and fellow. Our responsibilities included recruiting participants and collecting data for each of the following assessments: Jebsen-Taylor Hand Function Test, grooved peg board, 9 hole peg, grip and pinch strength via dynamometer and pinch gauge respectively. I did not know until Advanced Assessment for Practicing Clinicians and Theoretical Foundations for Interventions how important it was to be uniform with all participants in order to avoid bias and error in data collection. I realized how easy it is to overlook potential errors and biases that could affect the data such as allowing a small degree of motion in an orthosis that is supposed to 'immobilize the joint,' not administrating the assessments in the standard fashion, and documenting data accurately. These are all questions I had when taking Advanced Assessment after I completed the research project- I thought back and wondered how careful was I with each participant in the study- was I tired after a full day of work and decided one splint was 'good enough' to immobilize the joint? Did I go out of order during the Jebsen or did I not test grip strength with the dynamometer in the standardized position? I am embarrassed to admit I was biased and made multiple errors. Each OT was responsible for 10 participants, therefore, I asked my friends and family to participate, not knowing I was committing a sampling bias. I completed the assessments in multiple locations- in two different clinics, my parent’s home, and a friend’s apartment, in which I made splints in a cooking pan. CRINGE. At the time, I did not understand how much this variety in setting location could affect the quality of the study.
Another responsibility we had during this research project was to fabricate custom immobilization orthoses for the MCP and IP joint of the thumb. This entailed coming up with a pattern, deciding the material and then molding it to each patient. To come up with the pattern, the three OTs brainstormed together and decided on the best orthotic material for the different joints based off of our clinical experience. Once decided, we focused on the pattern. Our goal was to completely immobilize the joint of concern, IP or MCP, but allow for full range of motion of all surrounding joints. We tried multiple outlines, trialing them on each other until we found one we were satisfied with. We then, thinking we could be more efficient, fabricated 2-3 of the same orthoses that we could use on multiple participants, instead of making an entire new custom orthosis.
I learned in Evidence-Based Practice, that the three pillars of evidence-based practice are individual clinical experience, patient goals, and the best available research. During this research project, we used one out of three pillars- our clinical experience. Inconsistently, I addressed the second pillar: patient goals, by fabricating a new orthosis or modifying it to improve fit. Unfortunately, we did not address the third pillar: utilizing best available evidence. When I really thought about this pillar, I realized I do not consistently use it in practice either. I realized I decide on an orthosis based off of clinical experience and patient goals. Utilizing best available evidence, I believe is a pillar that is missing in a lot of therapists reasoning when fabricating an orthosis. This mistake, changed how I looked at fabricating orthoses in the future.
This realization, prompted the idea of my competence project. My goal was to use best available evidence for orthotic fabrication and then disseminate that knowledge to my colleagues. My hope was to help re-establish the use of all three pillars of evidence-based practice at my clinic. In order to properly do this, I wanted feedback from my colleagues to ensure that I was doing a thorough data search of the common orthoses we use in the clinic. When I was about 50% through my project, I emailed it out to my colleagues asking for feedback. I created a chart for my colleagues to fill out for ease of providing feedback. On this form I asked for feedback on data that was helpful, formatting, and data (new conditions or more details) they would like added. One of my coworkers told me that when her and another colleague opened up a section of my project they laughed and said “wow this is so dense!” At first, I just laughed too knowing how much work I put into it, but when I thought about it more, that comment was so much more meaningful than I thought. What they really meant was this information is so overwhelming that they did not even want to read it thoroughly. This prompted me to change how I presented the material. I therefore condensed the information and split it up into multiple documents. Therefore, if the therapist wishes to know more, they can look at a separate document for resources. This feedback allowed me to successfully disseminate knowledge to my colleagues in a way that was meaningful to them.
With the completion of these two projects, I learned that in order to demonstrate advanced knowledge of orthotic fabrication, it is essential to consider all three pillars of evidence-based practice. In practice, I now consider all areas before deciding on type of orthosis, pattern and material.
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