Post-COVID-19: Issues and challenges for occupational therapy and the need for clinical trials

All over the world, occupational therapists have rapidly adjusted to new ways of working. The impact of COVID-19 has meant that therapists have moved to working from home more than ever before, working in new environments within the constraints of personal protective equipment (PPE), providing rehabilitation while social distancing, and using video conferencing and telephones to deliver interventions that they had previously only provided in person. They have developed, and are developing, new skills and practices to keep themselves and their clients/patients safe, while ensuring that they continue to deliver occupational therapy to their clients and patients (Scott, 2020). Aside from changing practice in terms of how they treat and manage their clients/patients, occupational therapists are also learning how to operate within their own teams virtually or within social distancing measures, and they are setting up local, regional and national webinars to exchange practice ideas and share resources. Moving forwards, however, it is vital that we continue to examine our occupational therapy practices to ensure we continue to provide evidence-based care. We must not simply slide into rolling out new ways of working in the long term without appropriate evaluation.

Changes in practice need to be considered with a long-term lens. In many aspects of life, people are reporting that there have been fundamental changes in their working routines and they do not want to change back to previous practices. However, for occupational therapists there are fundamental questions that need to be addressed in order to achieve a balance: Are the new ways of working effective? Are they as effective as methods used previously (for example as effective as providing occupational therapy face to face)? Importantly, are they cost-effective? There is a huge danger of sleep walking into keeping new ways of working which arose because of external factors, rather than implementing changes that arise incrementally, over time, based on measured feedback, longitudinal evaluation or clinical trial evidence. Ultimately, we need to consider what is best for patients/clients and for carers: we need to think how best to deliver rehabilitation. The ideal way of evaluating this is still using randomised controlled trial (RCT) methodology.

RCTs remain the gold standard method of determining the efficacy of an intervention or treatment (that is – does it actually work?) (Altman et al., 2002). Of course, it is important to find out if treatments are acceptable to patients/clients and indeed to therapists – but the main questions centre around – does the treatment result in either maintaining or improving a condition? Is this treatment (intervention) better than another? Is the treatment worth pursuing (both in terms of delivery and cost)? The RCT design was originally developed to evaluate medical, specifically drug, interventions but has evolved to address evaluating complex interventions – such as rehabilitation – and the Medical Research Council have set out clear guidance on how this should be achieved (Craig et al., 2019).

The number of RCTs in occupational therapy and in related rehabilitation topics has increased exponentially over the past 20 years. Previous key trials have provided evidence to argue for funding services (e.g. Hay et al., 2002), to show the efficacy of occupational therapy interventions (e.g. Adams et al., 2014; Clemson et al., 2012) or to provide data about interventions which we should not use or which may need adjustments (e.g. Lannin et al., 2007; Voigt-Radloff et al., 2011). It is essential to underline that it is equally important to demonstrate that a treatment does not have the effects anticipated, or has other implications which have not been considered or appreciated, as well as showing efficacy. The profession moves forward by understanding what does not ‘work’ as well as what does.

Occupational therapists need to examine their practice, and to steer future practice based on evidence, rather than simply assuming changes are for the best. Indeed, occupational therapists have an acknowledged professional responsibility to support research and to educate themselves about the latest research which underpins practice (Nelson and Mathiowetz, 2004). During this period of rapid change, we must not lose sight of this responsibility.

One of the most remarkable consequences of COVID-19 has been embracing a ‘can do’ culture. This has been clear both clinically and in research. In research, protocols have been fast-tracked and approved in record times – a huge change from previous performance times. There is new mood music to push research forward – although this is accompanied by palpable concerns around current funding streams. However, occupational therapists must lead the way in pushing forward their research agenda. Necessity due to COVID-19 really has been the mother of invention for many therapists, but these changes must now be examined critically and prompt a greater emphasis on developing high quality research evidence for the profession.