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• W3020852285 abstract "It is with a great sense of satisfaction (and relief) that I present to my fellow hand therapists this special issue of the Journal of Hand Therapy on evidence-based practice. I hope you find that this issue raises your interest and awareness with respect to the process of evidence-based practice. I also hope you find the systematic reviews outlining the current state of evidence in our field to be useful. I am immensely indebted to the authors who contributed to this issue by conducting these systematic reviews. These individuals include first-time authors who were familiar with evidence-based practice, not hand therapy; and experienced hand therapy authors, who were new to the systematic review process. The issue draws on the great knowledge and experience of my colleagues at McMaster University, where evidence-based practice was founded, as well as the great knowledge and experience of hand therapists in dealing with complex clinical questions and controversies in the hand therapy literature. I am sure the authors now have a personal appreciation for the need for informed consent to be truly “informed.” I am not sure whether they feel that they were adequately informed of the task in front of them when I requested their contribution to this issue of JHT—and I dare not ask. Conducting a systematic review is a time-consuming process that requires attention to detail as well as the ability to adapt rigorous methodologies and to account for all data/decisions in a systematic way. I appreciate the substantial efforts the authors made in this regard, and I feel they have made an important contribution to the scientific foundations of hand therapy. This issue of JHT illustrates a number of aspects of evidence-based practice and the development of literature synthesis. In my introductory article, I tried to provide a broad overview and practical guide to evidence-based practice for the hand therapist. Just as the practicing hand therapist faces dilemmas when attempting to incorporate the principles of evidence-based practice into “real-life” practice, so too did the other authors and I. The lack of a substantial supply of high-quality evidence is a challenge to us all. I felt that the best way to meet this challenge was to provide instruments that would allow the authors in this issue a mechanism to evaluate studies other than randomized controlled trials. This issue includes those (two) tools, developed to evaluate either effectiveness or diagnostic test studies. Upon introducing the effectiveness evaluation instrument in a pre-conference workshop at the 2003 Annual General Meeting of the American Society of Hand Therapists (Hollywood), I noticed that the instrument was quite helpful to hand therapists in guiding their critical appraisal of research articles. My hope is that a side benefit of this issue will be the dissemination of these instruments, which may assist hand therapists in forming journal clubs that focus on both critical appraisal of literature and clinical reasoning as a means to advance their skills. This issue of JHT provides excellent examples of different approaches that authors might take when conducting a systematic review to synthesize clinical literature. The majority of the authors used both Sackett's level of evidence and my quantitative critical appraisal form to review included studies. Feehan and Bassett's paper on metacarpal fractures provides an example of a slightly different method of classifying the levels of evidence. Authors can define the clinical question for systematic reviews in different ways. The papers in this issue on rotator cuff exemplified different ways of framing study questions. Michener and colleagues provide an excellent review of interventions that can be used to treat patients with shoulder impingement. As they limited their review to only those papers that included a specific clinical syndrome, this work is a valuable contribution to our understanding of how to treat these disorders. Previous systematic reviews have tended to use shoulder pain as an entry criterion and have included diverse pathologies. The importance of this is further illustrated in the paper by Gibson et al., which demonstrates that both content and quality of evidence are much different for shoulder instability than for other disorders causing shoulder pain. A much broader perspective was taken by Grant et al., who looked at literature evaluating rotator cuff disorders—including both surgical and rehabilitative interventions. This type of article provides perspective on the relative indications/benefits of these two approaches that might not be evident in a narrower review. Michlovitz et al. looked at interventions for a specific clinical problem (stiffness). Although there is insufficient evidence with respect to managing this problem for any single diagnosis or joint, by evaluating interventions across conditions/joints a better perspective was provided. Where there is sufficient evidence on a single topic for a single condition, then a very focused systematic review can be conducted. An example of this approach is Harniman and colleagues' work on shock wave therapy. Together these systematic reviews provide a broader understanding of how to manage shoulder problems. They also illustrate the importance of designing a research question that meets one's objectives prior to conducting a literature retrieval. Each of the authors made decisions based on the clinical questions of their study and the quantity/quality of the literature they retrieved through systematic searching. The authors of the systematic reviews dealing with interventions for carpal tunnel syndrome (Muller et al.) and lateral epicondylitis were able to locate a sufficient number of quality articles that they could make relatively specific and clear recommendations. In fact, it was necessary to divide the literature on lateral epicondylitis into two separate systematic reviews. Borkholder, Hill, and Fess provided a very comprehensive review of splinting approaches, whereas the remaining therapies were evaluated by Trudel et al. Other authors were not so fortunate. Searching for literature on workplace interventions for upper extremity disorders was difficult and Williams et al. produced a sparse supply of widely divergent papers. Inconsistencies in terminology complicated retrieval. In this case, it was less possible to make comprehensive recommendations with respect to intervention, and the need for further research was emphasized. Conversely, when Wessel and I used a systematic review process to retrieve and evaluate articles regarding diagnostic tests for carpal tunnel syndrome, we were overwhelmed with the quantity of evidence, much of which had substantial methodological problems. Thus, we were forced to devise additional rules that directed the methods we used to summarize the available evidence and to develop specific conclusions from that evidence. I had a unique experience to be writing two articles concurrently on the topic of diagnostic tests in carpal tunnel syndrome—one a systematic review and the other a narrative review. This process highlighted for me some of the inherent strengths and weaknesses in both approaches. Systematic reviews provide a rigorous process to capture and synthesize data from clinical literature so that recommendations/results are unbiased. However, by design, they do not include ancillary physiological/theoretical/observational/biological concepts that might impact on the interpretation of study findings. At times, these ancillary issues may be informative. Therefore, my recommendation to therapists is that they should attempt to locate systematic reviews that are relevant to their clinical practice wherever possible. However, they should also read theoretical papers and narrative reviews to provide a more comprehensive understanding on any given topic. I feel that this issue makes a great step forward by providing substantial evidence upon which to base clinical practice. The article on clinical practice guidelines points out the need to incorporate an evidence-based approach in the development of future clinical guidelines. The systematic reviews published in this issue may serve as a starting point for such guidelines. The authors in this issue were diligent in pointing out the need for further research and usually made specific recommendations about the directions that research should take. I hope that clinicians and academics who are in a position to conduct clinical research will use this background work to guide and justify their upcoming research ventures. As pointed out in my introductory article, there are number of avenues through this journal, through the American Society of Hand Therapists, and through the American Hand Therapy Foundation for clinicians to get support and mentorship, if they choose to take up the challenges posed. When I sit back and look at the substantial body of work included in this issue by a small pool of dedicated authors with limited resources, I am encouraged to think about the great research that will come from these (ad)ventures. Joy MacDermid, BScPT, PhD, Career Scientist (Ministry of Health), Co-director of the Hand and Upper Limb Centre Clinical Research Lab, St. Joseph's Health Centre, London, Ontario, and Assistant Professor in Rehabilitation Science at McMaster University, Hamilton, Ontario, Canada. Dr. MacDermid is a hand therapist and epidemiologist. Her hand therapy experience includes both acute care and management of chronic work injury. She teaches upper extremity clinical skills and evidence-based practice at McMaster University. Her research interests include development/evaluation of outcome measures, evaluating the effectiveness of hand therapy interventions, and determining factors that predict outcomes—including physical, psychosocial, and environmental factors. She has developed outcome measures to allow patients to self-report upper extremity pain and disability attributable to elbow or wrist/hand problems. These measures are used in patient care and clinical research. She is a member of the Journal of Hand Therapy Editorial Board, the Division Director of Research for the American Society of Hand Therapists, and Secretary for the American Hand Therapy Foundation. She has won the prize for best scientific paper at the Annual Meeting of the American Society of Hand Therapists on two occasions." @default.
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