Clinical Application ofSomatosensory Rehabilitation and Research:Applying the Scholarship of Practice Model
Bernadette Nedelec, BSc OT(c), PhD[a], [b], [c], Valerie Calva, BSc OT, CSTP®[b], Marie-Andrée Couture, BSc OT, MRéad[b], Chantale Poulin, BSc OT[b], Danielle Shashoua, BSc PT[b], Annick Chouinard, BSc PT[b], Ana de Oliveira, BSc[c], Léo LaSalle, MD[b]
When new or emerging practices become available, there is a need to generate knowledge and evidence to support these novel approaches. Partnerships between clinical or community partners and academic programs have formally developed in occupational therapy (OT) and have been referred to as the Scholarship of Practice Model1,2 or Practice-scholar Programs3. Although these models may take on many different forms, they all value linking the production of theoretical and empirical knowledge to clinically relevant issues in practice. This requires meaningful partnerships between researchers and clinicians. Our publication on somatosensory rehabilitation4 is a concrete example of these partnerships, which we will briefly describe in this editorial.
When challenges arise in practice, which are not adequately addressed by existing evidence, clinically applicable knowledge will potentially arise out of the efforts to address these issues or solve problems in a particular context or with a particular patient population. The novel assessment tools or interventions that develop, therefore, are more likely to be clinically and ecologically relevant, promoting their rapid integration into practice. Somatosensory rehabilitation (SSR) had been described for a number of different conditions, but at the time of our publication4, no peer-reviewed evidence existed for the use of SSR with burn survivors. The School of Physical and Occupational Therapy at McGill University supports the development of meaningful partnerships between our educators, researchers, the students, clinicians, decision-makers and health service consumers. These partnerships have many attributes and benefits, one being that researchers from the School are commonly embedded within clinical sites. This close proximity supports the development of dynamic, synergistic interactions that are mutually beneficial. After the occupational therapists at Villa Medica Rehabilitation Hospital (VC, MAC) received training from Claude J Spicher in the use of the SSR approach (2009 – 2012)5, they believed this approach would potentially be advantageous for burn survivors suffering from neuropathic pain. Although some modifications were required to the SSR approach, to optimally address the unique characteristics of these complex burn injuries, the SSR approach did appear to reduce burn survivors’ pain and increase their ability to engage in functional activities. Since a long-standing partnership existed between the clinicians, and an occupational therapist and researcher (BN) from McGill University, whose research lab is embedded within Villa Medica Rehabilitation Hospital, it was a natural extension of ongoing discussions about evidence-based practice and research, to collaboratively develop a case-series describing the outcomes associated with the application of the SSR approach with burn survivors.
Successful introduction of a novel practice, such as the SSR approach, into the clinical milieu creates a moral obligation to objectively summarize and publish the outcomes so that the foundation for more advanced empirical investigations can be built. However, this can produce an almost insurmountable challenge for busy clinicians who are not traditionally allocated time for scholarly activities. The collaborative clinician-researcher relationship that exists at Villa Medica, took advantage of the clinical data documenting the superior outcomes, and the researcher’s training, experience, and dedicated time for scholarly activities, to produce a retrospective case series. One of the important lessons learned through this experience from the clinicians’ perspective, is the need to generate systematic, structured evaluation and treatment documentation to facilitate retrospective analyses of this nature. Also, for those clinicians intimidated by the prospect of becoming involved in research, this experience reinforced how similar the thinking and processes of research are to clinical practice. Portney and Watkins6 described five steps of the research process :1) identify the research question, 2) design the study, 3) conduct the study, 4) data analysis, and 5) communicate findings. As a clinician, you have a patient with a clinical problem that you discuss with them and evaluate. Based upon your assessment results, knowledge of the literature, personal judgment, clinical experience and expertise, you generate a list of alternative solutions or hypotheses (identify the research question) and then, in conjunction with your patient, you design a treatment plan (design the study). This treatment plan is carried out (conduct the study). You then re-evaluate your client and based upon your interpretation of the assessment results, you determine if you have reached your goals (data analysis). You then complete your documentation (communicate findings). Therefore, if you take a very systematic approach to your clinical practice and documentation, some of your clinical data can readily be applied to answer research questions that have not already been reported in the literature. Thus, a novel case study can be the springboard that catapults the patients, clinicians and researchers toward innovative solutions.
The production of this case series now provides the evidence-building stepping-stone for further exploration. In fact, our collaborative team developed a randomized controlled trial protocol as the next step towards the production of higher-level evidence for the SSR approach with burn survivors. However, interestingly, since that time we have not had an adequate number of burn survivors who developed chronic neuropathic pain to recruit into this trial. Exactly why, is not clear, but it may be an increased awareness of the entire clinical team working with this population that sensory re-education is warranted when a burn survivor presents with hypoesthesia and/or active avoidance of prolonged or intentional stimulation of sites where neuropathic-type sensations are experienced. This early interruption of the cycle of pain production may reduce or eliminate the central nervous system’s learned response that interprets all mechanical stimulation as noxious, as is the case with mechanical allodynia. We believe that it is critically important that the entire team is well-versed in SSR to ensure consistency. However, whether specific practices can prevent the development of chronic neuropathic pain and mechanical allodynia, requires further investigation.
The presence of researchers within the clinical setting has benefits that extend far beyond this one example. One of the goals of McGill University’s OT and PT Programs is to create scholarly practitioners, that is, therapists who provide theory-driven and evidence-based services. However, knowledge and confidence gaps have been identified as major barriers to evidence-based practice7 and these gaps are not readily addressed by classroom learning, rather require more experiential learning. Having a researcher embedded in the clinical milieu may facilitate the provision of evidence-based services by stimulating high-level, theory-driven discussion and reflective practice that is contextually informed by the patients, the practice culture and the system. These discussions include clinicians, researchers, students, patients and administrators, and are supported by regular formal or informal meetings and open communication, which is made far more fluid when the researcher is embedded within the clinical milieu. This personal relationship may be particularly transformative for the patients who commonly feel disenfranchised and alienated from the research process. The continuous evaluation of evidence-based practice by clinicians, as it applies to burn survivor rehabilitation or other areas of practice, is predicated on their capacity to actively engage in the knowledge translation process8,9. The close proximity of researchers to clinicians provides a framework to nurture the knowledge translation capacity amongst clinicians and researchers, by bringing people together to co-create knowledge and tools that are rigorous and applicable to their clinical communities. It is not simply the close proximity that provides the rich relationship building opportunities, rather a plethora of multi-level, diverse interactions. In collaboration with the OT and PT programs at McGill University, clinicians from both the private and public sector can choose to be involve in clinician-driven Master’s Professional Entry Level research, apply for knowledge translation grants, apply for nil salary faculty lecturer appointments that provides access to online library resources as well as other benefits participate in clinical trials, and en-gage in student teaching and supervision opportunities. Direct involvement of clinicians in research projects can also progressively evolve and take on multiple forms, such as recruitment of participants for researcher led projects, providing an active treatment role in clinical trials, generating research questions that are modified by the researcher for student projects, or becoming the project leader on a funded study. From the researcher’s perspective, their research program benefits from their informed awareness of the clinical milieu’s strengths, opportunities, and distinct attributes. Being embedded within their clinical reality ensures that all stakeholders can confirm that the research questions are pertinent and it enables the integration of patients, and their personal experiential knowledge, into all stages of the research process so their needs, preferences and priorities are addressed.
Thus, collaborative clinician-research partnerships directly benefit the patients by embedding scholarly activities in practice, whereby practice informs research and research informs practice. These activities ultimately produce knowledge and outcomes that are significant and relevant, which subsequently reduces the predicted time lag10 for knowledge transfer into practice. The resources, strengths, and attributes that each partner contributes, allows for learning, knowledge, and products to be created, that neither party could have generated without the other. In order to advance the science of SSR, and all rehabilitation approaches, we would suggest that these partnerships be encouraged and concretely supported, so that the evidence to support clinical practice can be optimized.
References
1. Braveman BH, Helfrich CA, Fisher GS. Developing and maintaining community partnerships within "a scholarship of practice". Occupational therapy in health care. 2002;15(1-2):109-125.
2. Hammel J, Magasi S, Mirza MP, et al. A Scholarship of Practice Revisited: Creating Community-Engaged Occupational Therapy Practitioners, Educators, and Scholars. Occupational therapy in health care. 2015;29(4):352-369.
3. Crist P, Munoz JP, Witchger Hansen AM, Benson J, Provident I. The practice-scholar program: an academic-practice partnership to promote the scholarship of "best practices". Occupational therapy in health care. 2005;19(1-2):71-93.
4. Nedelec B, Calva V, Chouinard A, et al. Somatosensory Rehabilitation for Neuropathic Pain in Burn Survivors: A Case Series. Journal of burn care & research : official publication of the American Burn Association. 2016;37(1):e37-46.
5. Spicher CJ. Handbook for Somatosensory Rehabilitation. Montpellier, France: Sauramps Médical 2006.
6. Portney LG, Watkins MP. Foundations of Clinical Research: Applications to Practice. 3rd ed. Upper Saddle River, New Jersey: Pearson Education, Inc.; 2009.
7. Thomas A, Law M. Research utilization and evidence-based practice in occupational therapy: a scoping study. The American journal of occupational therapy : official publication of the American Occupational Therapy Association. 2013;67(4):e55-65.
8. Cramm H, White C, Krupa T. From periphery to player: strategically positioning occupational therapy within the knowledge translation landscape. The American journal of occupational therapy : official publication of the American Occupational Therapy Association. 2013;67(1):119-125.
9. Bennett S, Whitehead M, Eames S, Fleming J, Low S, Caldwell E. Building capacity for knowledge translation in occupational therapy : learning through participatory action research. BMC medical education. 2016;16(1):257.
10. Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. Journal of the Royal Society of Medicine. 2011;104(12):510-520.
[a] School of Physical and Occupational Therapy, McGill University
[b] Hôpital de réadaptation Villa Medica
[c] Centre de recherche, Centre hospitalier de l’Université de Montréal (CRCHUM)
Montreal, Quebec, Canada.
Address correspondence author : Prof Bernadette Nedelec, PhD, McGill University, Faculty of Medicine, School of Physical and Occupational Therapy, 3654 Promenade Sir William Osler, Montreal, Quebec, Canada, H3G 1Y5.
e-mail: bernadette.nedelec@mcgill.ca
