1. intro to research

7/30/2019 1. Intro to Research

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POTH 4 0 1

Resear ch Met h od s

Introduction to Research

Dr. Ana Maria Rodriguez

Acknowledgement to Dr. Nancy Mayoand Dr Judith Soicher


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Learning Objectives

Understand the role of research inevidence-based practice

Identify different types and spheres ofrehabilitation research

Understand the stages of the health

research cycleIdentify the components and formulate

clinical and research questions related torehabilitation


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W hy do r esea rch?

Hyppocratic Oath (460-370 BC):

I will apply measures for the benefit ofthe sick according to my ability andjudgment; I will keep them from harmand injustice.


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Ev id en ce- based Pr act ice

Health professionals must use the best practicesavailable not to inflict harm on patients.

The integration of the best research evidencewith clinical expertise and patients values

Our professional responsibility :

Research is the means by which we test thebeliefs that we are improving patients lives withour interventions.


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What is Evidence-Based Practice

Evidence-based medicine (EBM) is theconscientious, explicit and judicious use ofcurrent best evidence in making decisions about

the care of individual patients.

The practice of EBM means integrating individual

clinical expertise with the best available externalclinical evidence from systematic researchSackett et al. BMJ 312:71, 1996

Slide from Aliki Thomas, OCC1 545 notes, 2010


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Clinical decisionsabout clienttreatment

Pat ien t

i n p u t

Evidence

Cl in ic ian 'sj u dg m en t

Research ev id ence is on lyone e lem en t i n a com p lex set

o f r e lat i onsh ips

( Dav i do f f , 1999 )

ExperienceKnowledgeExpertise in a domain

Research studiesPublished work

ObjectivesInterestsExpectations

3 main components of EBP

Slide from Aliki Thomas, OCC1 545 notes, 2010


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A pr o fession a l r espon sib i l i t y

It is not good enough to simply report thatpatients are doing better or are satisfiedwith our services.

Demanded by patients and third-partypayers.

We must be willing to search, and in manyinstances, to create the evidence about thevalues of our practices and m o d if y o u rp rac t i ces in response to this evidence.


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Lear n ing abou t

r eh ab i l i t a t i on r esear ch i s

n o t an easy t ask

New sets of knowledge and skills that are

different to the typical set of skills commonlylearned in rehabilitation.

Leads to the re-examination of the status-quo.

Can lead to doubt about previous learning.


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Research in Rehab i l i t a t ion

Careful examination and systemicevaluation of the subject at hand.

A friendly, welcoming attituderegarding change.


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Research:

Challenges the status-quo:

Identifying gaps in knowledge

Collective wisdom has notalways been carefully

reviewed.

Novel treatments.

Creative

Systematic:

Much of our clinicalknowledge is anecdotal.


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What is research about?

Research is about answering importantand interesting questions (not aboutcollecting data)

Without bias

With precision

Bias is about how close you can get to thetruth related to design

Precision is about how much uncertaintyremains - related to sample size


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Bias vs. Precision


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Bias vs. Precision


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Get t i n g i t r i g h t

Research is about getting the right answer, not

just any answer

The right answer is hard to find


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Types of Research Questions

How does theworld work?

What does theworld look like?

How to make theworld better?

Populationhealth/healthservices

Mechanisms/determinants

Evaluativeresearch


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Most Com m on in Rehab i l i t a t i on

Mechanisms

Determinants

Evaluation

(Measurement)


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Bio log i ca l / Ph ysio log i ca l

Mechan isms Identified using a series of experiments

Highly controlled

Small studies in selected samples to reduceextraneous variables

Replication is important

Outcomes physiological in nature

Used to build a theory


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Det er m in an t s o f h e al t h

Factors that influence a disease or health state

Could be environmental, sociodemographic,psychosocial, etc.

Observational studies with larger samples

Used to build / test theory


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Ev alu at iv e Resear ch

How to make ______________ better?

cells, tissues, organs

individuals

groups


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Tar get s fo r Eva lu a t ive Research

Organ or tissue

Rehabilitation Strategy

Rehabilitation Intervention

Rehabilitation Program


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Medical Model


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Definition of RehabilitationStrategies

Single modalities(approaches ortechniques) thatseek to normalizebody structures orphysiologicalfunction at thetissue or organ

level such asmuscle, articularstructures, brain,heart, lung or skin


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Ex am ples o f Rehab i l i t a t i on

St ra teg ies

Dietary restrictions

Medications

Exercise

Biofeedback

Body-weight support

Application of an orthosis

Physical modalities


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Def in i t i on o fRehab i l i t a t i on

I n t e r v e n t i o n

A selection of

approaches ortechniques that seekto normalize anindividuals capacity

for activity


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Ex am p les o f I n t er v en t i on s

Physical activityBalance training

Healthy eating

Stress reduction


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Def in i t i on o f

Reh ab i l i t a t i on Pr og r amRehabilitation

programs comprise anumber ofinterventions thatseek to normalize(for individuals with a

particular healthcondition)participation in familyand community life

and quality of life


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Ex am p les of Pr og r am s

Stroke Rehabilitation (stroke unit,early supported discharge)

Spinal Cord Rehabilitation

TBI

Work hardening . Etc.

Geriatric Day program


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Rehabilitation Model


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Pr og r ession o f ResearchStages

MechanismRehabilitation

strategyRehabilitationintervention

Rehabilitationprogram


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Rehab i l i t a t ion Research Cy cle

Consequences ofdisease

Mechanism

Strategy

Intervention

Program

Implementation


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Cy cle o f Reh ab i l i t a t ion Resear ch

Consequences ofDisease

Bio-psycho-social

mechanisms

Strategy

Intervention

Program

Implementation

Population health

Basic science /

determinants of health

Evaluative Research

Health services

Research/

Knowledge

Translation


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Ex am ple o f r esear ch cy cle inac t ion

Mechanisms of gait and posture translate intostrategies

Strategies are tested for safety and efficacy

Strategies are incorporated into interventions

Interventions are evaluated for their ability toimprove the individual (without harm)

Interventions are bundled into programswhere they can do the most good, for thegreatest number of people at the least cost


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Resear ch Cy cle

Burden of disease

Mechanisms/Associations

Efficacy

Effectiveness

Efficiency

Implementation

After P Tugw ell, 1985


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Th e 3 Es

Eff icacy does more good than harm whendelivered exactly as directed, i.e. under

optimal conditions

Ef fec t iveness does more good than harmwhen delivered under usual conditions (e.g.fluctuating patient compliance)

Eff ic iency considers cost and resources


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Resear ch i s abou t Re lat ion sh ips

Links one variable or factor to another

One variable is thought (hypothesized) tobe associated with or cause the secondvariable

Note that association and causation aredifferent


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Va r i ab l e

A property or characteristic that can bemeasured and that varies across people,places, and time

Term used in research methods andstatistics

Examples ?


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Term s u sed t o descr ibe Re lat ion sh ips

Disc ip l ine Cause Ef fec t

Epidemiology Exposure* Outcome*

Medical/clinical Risk factor Disease

Psychology Independent Dependent

Statistical Stimulus Response

Mathematical X y


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Outcome

Characteristic of an individual that isexpected to change owing to an

intervention or exposure

Adapted from Dr. Nancy Mayo

www.clinepi.mcgill.ca/610/Lecture3Measures_Rehab_Mayo_Print.pdf, accessed 1/27/11
http://www.clinepi.mcgill.ca/610/Lecture3Measures_Rehab_Mayo_Print.pdfhttp://www.clinepi.mcgill.ca/610/Lecture3Measures_Rehab_Mayo_Print.pdfhttp://www.clinepi.mcgill.ca/610/Lecture3Measures_Rehab_Mayo_Print.pdf


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The Research Quest ion

(= Objective/Purpose/Goal)


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Why is the Research Question soimportant ?

Research is about answering important and interesting

questions

Research is not about collecting data

Good research questions are about what you WANT TOKNOW

Not about WHAT YOU WANT TO DO


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In order to get the right

answer at the endwemust ask the right

question at the beginning


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Nancy E. Mayo


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A Framework for Asking

QuestionsPopulation

I ntervention (Exposure level 1)

Comparison (Exposure level 2)

Outcome

T imePICOT (PECOT)


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PICOT Format

In people with ______________________ (P)

Does a new intervention ______________ (I)

In Comparison to usual care __ ________ (C)

Affect outcome characteristic __________ (O)

At Time __________________________ (T)


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PECOT Format

In people with ______________________ (P)

Does a higher level of an exposure _____ (Exposure level 1)

In Comparison to a lower level of exposure (Exposure level 2)

Affect outcome characteristic __________ (O)

At Time __________________________ (T)


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A Good Question is:

CLEAR

Population,Intervention/Exposure,Outcome

Time may notbe relevant insome studies

OPERATIONAL

A study could bedesigned

A results tablecould be drafted


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You be the judge ..

The aim of our study was to measurequality oflife (QOL) in a clinic-based sample of childrenwho had a diagnosis of attention deficit (ADHD),and to considerthe impact of symptom severity

on Quality of Life

Population:

Intervention or Exposure:

Comparator:

Outcome:


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Or ..

In children with AHDH, theobjectives of this study were: To determine the level of quality of life scores

To estimate the association of symptom severity withquality of life

Actually 2 separate objectives, as

each will have its own statisticalanalysis and results table


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Population:

Intervention orExposure:

Comparator:

Outcome:


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How do w e cond uc t Resear ch?

During this course, you will be learn how todistinguish between the different types of studies.

You should also be able to identify theappropriateness and the strengths and weakness ofeach design

You should be able to apply different study designs tothe same research question


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Ty pes o f Research Qu est ion s &Des igns

How does theworld work?

What does theworld look like?

How to make theworld better?

Observational design

e.g. estimating

relationships, associationsor mechanisms

Observational designe.g. estimating

relationships, associationsor mechanisms

Experimental designe.g. estimating the effect

of a treatment orintervention; also called

evaluative research


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Tw o b r oad Ca tego r ies of St ud y

Des igns

Observa t iona l

These types of designare those where youobserve but dontintervene

Exper imen ta l

These are designswhere you interveneand record what

happens


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Hier a rchy o f St ud y Typ es

Descriptive

Case report

Case seriesSurvey

Analytic

ObservationalCross sectional

Case-control

Cohort studies

ExperimentalRandomized

controlled trials

Quasi-

experimentalCross-over

Single subject

1. intro to research

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