first step to research

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My First Step to Research

1. Introduction

Evidence-based practice [EBP] has been increasingly promoted as a

model for physiotherapy practice (Ritchie, 1999).

“ Evidence-based practice is „conscientious, explicit and judicious use

of current best evidence in making decisions about the care of individual

patients”(Sackett et al., 1997).

The main aim of the EBP is to provide better result for the patient care

and the members of the family, to improve the attribute of the health care team

members and the systematic arrangement of the health care (Craig and Smyth,

2007).

The first step to research can be challenging to most researchers and

may seem an impossible task. According to Hicks (2004), the rise of EBP

encourages all health professionals to be research minded in developing and

assessing empirical evidence that corroborates their professional practice.

The aim of this essay is to outline a research journey to find the

effectiveness of mental practice [MP] in stroke patients. A review of the

available evidence base will guide the area of investigation and formulate a

research question.




2. Background

Stroke is a very limiting disease for the patient and a major health

problem in most parts of the world (AHA, 1997). The World Health

Organisation (1988) has defined stroke as a condition with “rapidly developing

clinical signs of focal loss of cerebral function, with symptoms lasting more

than 24 hours or leading to death, with no apparent cause other than that of

vascular origin”.

Stroke accounts for around 53,000 deaths each year and estimated

150,000 people have a stroke in the United Kingdom [UK] each year, at least

450,000 people are severely disabled as a result of stroke in England (Stroke

Association, 2011). The National Commission on Macroeconomics and

Health, India, estimates there will be 1.67 million stroke cases in India in 2015

(WHO, 2010).

Neurological conditions play a significant role in economic, social and

personal burden on the NHS and patient‟s families, as most of the neurological

conditions need long term rehabilitation (Neurological Alliance, 2003).

A research agenda should reflect the appropriate ways to answer the

questions. The acknowledgement of where the evidence falls short and how the

evidence falls short is essential to the development of important research

questions and in providing guidance in how to direct those questions.




3. L iterature Review As a process, EBP is about finding, appraising and applying scientific

evidence to the treatment and management of health care (Timmermans and

Mauck, 2005). It‟s ultimate goal is to support practitioners in their decision

making to eliminate the use of ineffective, inappropriate, too expensive and

potentially dangerous practices (Hamer and Collinson, 2005).

Heller et al. (2008) suggests that many clinicians are also cautious to

critically appraise published literature. However, a logical review of the

literature can identify clear research questions building on what is already

known and identifying areas to be addressed (Burns and Grove, 2002).

MP according to Richardson (1967) is “the symbolic rehearsal of a

physical activity in the absence of any gross muscular movements”.

MP has been proven to be useful in sports training and other skills

training (Athletic Insight, 2004). Still, much is yet to be determined if the same

assuring results may be derived when this training method is used in persons

with brain lesions, like stroke (Dizon and Calayan, 2009).

2001-2011 Eighteen studies, in which six Randomised Controlled

Trials (RCT‟s) (Page et al., 2001a, 2005; 2007;2011; Liu et al., 2004; Riccio et

al., 2010), two Controlled Clinical Trials (Dijkerman et al., 2004; Muller et al.,

2007), one is pre-post treatment study (Simmons et al., 2008) and remaining

are case studies and case series. All studies included both men and women as

participants. Study sizes were small, in 12 studies had 63 participants and 6




study had 180 participants (Dijkerman et al., 2004; Muller et al., 2007; page et

al., 2007; 2011; Liu et al., 2004; Riccio et al., 2010). Few studies had good

randomization procedures (Page et al., 2001a; 2005; 2011; Riccio et al., 2010;

Liu et al., 2004). In few studies, subjects in the chronic phase of recovery were

recruited (Page et al., 2005; 2011; Dijkerman et al., 2004). Liu et al., (2004)

included exclusively patients in the subacute phase of recovery (7 – 27days

poststroke). Page et al., (2001a) included patients in the chronic and acute

phase of recovery (4weeks to 4years poststroke).

MP intervention was given by using, audiotaped instructions (Hewett

et al., 2007; Page et al., 2001a; 2005; 2007), written instructions (Dijkerman et

al., 2004), self regulation (Liu et al., 2004), videotaped instructions (Crosbie et

al., 2004; Muller et al., 2007), computer-generated image (Gaggioli et al.,

2006), or visual displays of the less affected limb via a mirror box (Stevens and

Stoykov, 2003).

Additionally, the studies used various tasks such as functional reaching

and grasping tasks (Crosbie et al., 2004; Dijkerman et al., 2004; Page et al.,

2005), line tracing (Yoo et al., 2001), selective finger opposition sequences

(Muller et al., 2007), during the MP sessions. In several studies, the perspective

used was not clearly articulated (Crosbie et al., 2004; Dijkerman et al., 2004;

Yoo et al., 2001).




The intensity and duration of MP, in RCT studies varied substantially

regarding the number of trials or minutes engaged in practice, with participants

receiving around 4 – 5 hours of MP over a 3-weeks (Riccio et al., 2010) to 10

weeks period (Page et al., 2011). In each study, frequency with which the MP

was given varied, but a minimum of 2 times a week for 20-30 minutes was

reported.

Most studies used the Fugl-Meyer Motor Assessment (Gaggioli et al.,

2006; Page et al., 2001a; 2001b; 2009; 2011; Stevens and Stoykov, 2003), the

Jebsen Test of Hand Function ( Muller et al., 2007; Stevens and Stoykov,

2003), the Arm Function Test (Riccio et al., 2010), the Motricity Index

(Crosbie et al., 2004; Simmons et al., 2008; Riccio et al., 2010), or the Action

Research Arm Test (Gaggioli et al., 2006; Page et al., 2001a; 2005; 2007;

2011) as primary outcome measures. Hewitt et al. (2007) used a kinematic

analysis of functional reaching tasks, and Dijkerman et al. (2004) used

outcome measures aimed at complex task function.

Few studies showed statistically significant differences favouring MP

on at-least one outcome measure (Crosbie et al., 2004; Dijkerman et al., 2004;

Hewett et al., 2007; Muller et al., 2007; Page et al., 2005). MP alone did not

result in a clinically meaningful improvement in upper-limb impairment and

also the researchers described how these interventions may elicit “plastic”

changes in the brain (Butler and Page, 2006).




Moreover, from the studies, it appears that MP combined with physical

practice yields better outcomes than physical practice alone or conventional

therapy (Dijkerman et al., 2004; Muller et al., 2007; Page et al., 2005; 2007).

Interestingly, only three studies included a follow-up, after 1 month (Liu et al.,

2004), after 3 months(Page et al., 2009) and after six months(Page et al., 2011)

therefore little is known about possible long-term effects of MP.

Gentili, Papaxanthis and Porro (2006) compared the improvement in

arm motor performance in which the MP groups improved significantly in the

pointing task by decreasing their duration time that engaged in eye-movement

training. However, Gentili et al. (2006) study had participants with an intact

nervous system function. So, further studies employing quality research

designs are needed to strengthen the evidence.

The fact that intensive training on tasks, which have shown activate

motor regions in neuroimaging studies does not result in behavioural change,

may question the functional relevance of cortical activation in mental

simulation of action (Cinzia and Jean-Claude, 2003). Numerous neuroimaging

studies had demonstrated non-motor tasks (Rizzolatti and Craighero, 2004).

The consideration of existing evidence often highlights important areas

where deficiencies in information limit our ability to make decisions.

Encouraging outcomes were noted in some RCT‟s and much of the literature

suggests further studies are needed to evaluate the effects of MP in stroke

rehabilitation.




4. Research Question

By analysing the literatures thoroughly the research question will be

well-organised and formulated (LoBiondo and Haber, 2010). Reviewing of the

articles and literature has come into the conclusion of development of research

question by the identification of the gaps.

Possible methods of approach to the research journey will concentrate around

the question:

“I nvestigating evidence for the effectiveness of mental practice

in stroke rehabil itation to improve function ”

According to Sackett et al. (1997) a well structured research question

should answer PICO framework. The above research question answers the four

parts:

Population : Stroke patients

Intervention : Mental Practice

Comparison (If any) : Null or No Comparison

Outcome : Function Improvement

.




5. Methods of Approach

The kind of role adopted by a researcher determines what kinds of

methods can be utilised, means the extent to which the aims and methods of a

piece of research match and link to the way the researchers account for their

purpose (Ballinger; cited Finlay, 2006).

How researchers set about offering a convincing and relevant

interpretation may also vary according to the methodology employed. In

reference to discourse analysis, Potter and Wetherell (1994) suggest that

presenting work to a variety of different audiences helps researchers evaluate

how compelling their explanations are. When it comes to choosing criteria,

there is considerable divergence of opinion (Willig, 2001; cited Finlay, 2006).

5.1. Quanti tative Approach

The quantitative approach is called the “logical positivism”. Positivism

contends that there is a single reality and therefore seeks to identify causal

relationships through objective measurement and quantitative analysis

(Firestone, 1987; cited Doyle et al 2009). The only known way to avoid

selection and confounding bias is to use randomisation (Schulz and Grimes,

2006) as it heightens the internal validity of the study.

There are numerous ways of designs in the quantitative; they are

descriptive to represent the variables, correlation to exam relationship between

the variables, quasi-experimental and the experimental to figure out the cause




and effect among variables, which includes the range from uncontrolled

method to controlled methods (Burns and Grove, 2010).

Historically the approach in health care research was nearly exclusively

of the quantitative or positivist tradition for the researcher to be objective and

unbiased, (Firestone, 1987; cited Doyle et al 2009) and for many, it is

considered to be the „gold standard‟ (Bowling, 2005) of research strategies in

healthcare where the results of objective testing on samples of patients are

applied to wider populations. In corresponding to the question, RCT appears be

the most appropriate and well controlled approach method to conduct a

research.

5.1.1. Randomised Control Tr ial Approach

According to Bolyai and Bova (2010) when the intervention is more

efficient it presents the identical outcomes even when it is trialled more number

of times. To answer the question with RCT, the samples are enrolled into two

groups with an experimental group receiving the MP intervention and the other

control groups receiving the normal and usual guidelines. So, that whatever

may be variance in outcome is the effect of intervention.

Gray (2001, pp. 133) suggests that for RCT‟s to be ethical there needs

to be equipoise, that is, genuine doubt prior that one option is better than

another. Alternative quantitative strategies that may need to be considered

include cohort studies, which may have limited internal cogency due to

confounders as a result of neglecting the essential element of randomisation

(Schulz and Grimes, 2006). However, the RCT is determined not to be the




suitable method of approach for the research question owing to shortage of

perceptibility and the training of techniques, though it contributes the desired

result in the clinical effectiveness (Evans and Pearson, 2001), then the clinical

experimental method using the design of controlled pre-test and post-test or

can be done only with the design of controlled post-test group can be

considered.

5.1.2. Quasi Experimental Approach

The research question can also be approached by the quasi experimental

research. The non-equivalent control group design is effective, because the

researcher can collect the data in the pre-test and the independent variable can

be introduced by relating the sameness of two groups (Bolyai and Bova, 2010).

Although, there are advantages of using the design, but it cannot be approached

as it has threats to selection, maturation, testing and morality are probable

within this design (LoBiondo and Haber, 2010).

5.1.3. Non Experimental Approach

The other method to approach the question is by using the non-

experimental research to investigate the relationships and the dissimilarity

among the variables (LoBiondo and Haber, 2010). However, the results

produced by the non-experimental are not stronger than the experimental study,

since the independent variables are not manipulated, the randomisation of

participants are not considered and there is an absence of a control group

(LoBiondo and Haber, 2010).




Meanwhile the qualitative research method also considered although

most of the methods of quantitative approaches are applicable to the research

question.

5.2. Quali tative Approach

Qualitative researchers study things in their natural settings, attempting

to make sense of or interpret Phenomena in terms of the meanings that people

bring to them (Denzin and Lincoln, 1994 pp.2). Mason (2002) described the

qualitative research as “encom passes modes of inquiry oriented towards how

the social world is interpreted, understood, experienced, produced or

constituted”.

5.2.1. Grounded Theory Approach

Grounded Theory [GT] is a method of qualitative approach; the

development of a systematic understanding, the data can be obtained from

variety of sources, is clearly recognisable and understandable to the members

of the setting and is done as much as possible in their own terms (Holloway

and Todres, 2010) such as uses their words, ideas and methods of expression,

but cautiously goes beyond these‟ (Glaser and Strauss, 1967).

GT can also be approached for the research question. Though, this

method is very good at constructing theories and lead to future research in

testing theories, it has drawbacks like measuring the effectiveness of MP is

unwieldy; consumes more time for collecting and analysing data; due to

subjective nature it may even be difficult to ascertain validity, reliability and

prevent bias (Chenitz and Swanson, 2010, pp.14).




Qualitative investigators are concerned with the beliefs, motivations,

and experiences, as well as the actions and interactions of people, organisations

and institutions (Gibson and Martin, 2003). Qualitative research is concerned

with describing and explaining complex social phenomena that occur in natural

settings (Pope and Mays, 1995).

5.3. Mixed Method Approach

Both the qualitative and quantitative methods are equivalent in nature.

No method is considered to be the comprehensive design because they vary

a lot, in which each and every method has its own strengths and limitations.

Burns and Grove (2002) described that RCT‟s are good for all the studies,

but it needs much time and effort.

Giddings (2006) describes that mixed method is widely used in the

health care settings which answers in positive way for the difficult questions

which can be done only with the approach of different methods. Wooley

(2009) suggested that mixed methods can be used to contribute an efficient

methodology in “multiple studies”. Therefore, mixed methods can be used for

the research question. Brannen (cited Finlay 2006) claims that it is quite rare

that the mixed method research or indeed the individual researcher, is likely to

put equal emphasis on qualitative and quantitative methods (Bowling, 2005).

It was only with the rapid development of statistical methods that these

two strands diverged and the field of health research does seem particularly

keen on combining qualitative and quantitative research methods, given the




pragmatic nature of the discipline, coupled with the complexity of the many

factors that influence health and health care (Bowling, 2005).

5.4. Acti on Research

Action research is a form of self-reflective enquiry attempted by

participants in social situations in order to improve the rationality and justice of

their own practices, their understanding of these practices, and the situations in

which the practices are carried out (Carr and Kemmis, 1986). Positivism, used

in scientific and applied research, has been reckoned by many to be the

antithesis of the principles of action research (Winter, 1989; cited O‟Brien,

2001) and it is useful method to answer the question.

Though, sharing a number of perspectives with the interpretive

paradigm, and making considerable use of its related qualitative

methodologies, there are researchers who feel that neither it nor the positivist

paradigms are sufficient epistemological structures under which to place action

research (Morley, 1991; cited O‟Brine, 2001). Because action research is

carried out in real-world circumstances, and involves close and open

communication among the people involved, the researchers must pay close

attention to ethical considerations in the conduct of the work (Ahmed, 2009).

Although, I felt this approach as appropriate initially because of direct

involvement of researcher to understand people needs, values and beliefs

regarding the effectiveness of MP which is required for the study. On the other

side, it makes me really think of its applicability because of its nature of data




overload leading to misinterpretation of information and even sometimes

resulting omitting the information.

6. Evaluation Morris and Williams (2009) recommends that further research is

needed to explore new ways of working and delivering focused interventions in

stroke, and that physiotherapists can play a key role in achieving this.

Delivering MP interventions that meet the needs of people with stroke

will require thorough research, careful planning and good communication

networks in order to understand the perceptions of those affected, and to ensure

adequate funding and training (Physiotherapy, 2010).

Processes of functional redistribution have been presented in early post-

stroke, if the neural principle of „firing is rewiring‟ applies to MP in stroke,

expect to find a clinical benefit in patients (Nelles et al., 2001).

The rationale for the efficacy of MP in stroke, which is subscribed by

researchers and clinicians, generates a feeling that this is a useful rehabilitation

method, that activation of motor brain areas through imagery will enhance

brain plasticity (Nelles et al., 2001).

The evidence is limited to suggest MP to be beneficial in improving

function, when compared to other treatments in stroke rehabilitation (Barclay




et al., 2011). Evidence of MP regarding, improvement in motor recovery;

quality of movement; effectiveness; ideal dosage required to improve function

is less clear.

7. Systematic Review ‘ A systematic review is an overview of primary studies which contains

an explicit statement of objectives, materials, and methods and has

been conducted according to explicit and reproducible methodology‟

(Trisha, 1997)

In clinical care for many interventions the evidence base is relatively

weak (Bowling, 2005 pp. 47) because comprising studies with small group of

participants and poor methodological back up with evidence. Grootens et al.,

(2003) claims that systematic reviews and meta-analyses have assumed an

increasing role in healthcare literature reviews during the past decade because

it provides the best evidence from the numerous literatures for the EBP.

Systematic reviews of all relevant research about the efficacy of a

treatment are progressively seen by clinicians and healthcare suppliers as

providing the most reliable basis for conclusions about treatment effects (Gray,

2001). In order to achieve reliable and valid systematic reviews and meta-

analysis the studies being compared must be directing the same hypothesis in

the same direction (Bowling, 2005).




A systematic review carried to investigate MP describes quality of

movement is less clear (Barclay et al., 2011) which shows lack of in-depth

empirical evidence regarding the MP.

A systematic review is suggested at this stage as the treasure and

influence they posses for clinical deciding (Gray, 2001) makes thoughtfulness

of this approach worthy for further enquiry of the research question as it offers

a problem solving and practice development strategy that can evaluate (Walsh

and Wigen, 2003).

8. Conclusion The emergency of EBP has thrown many involved in clinical care into

the daunting research world (Burns and Grove, 2002). Many approaches are

very near to address the research question but there are disadvantages in the

models to investigate and find the effectiveness of MP. In a Cochrane review

Barclay et al., (2011) also suggested that further studies are required to

evaluate the effectiveness of MP; to affect the outcomes on the post stroke as

numerous ongoing studies might improve the evidence base of MP. So, the best

way to find the effectiveness of MP can be answered by a systematic review of

quantitative studies. (Appendix 1)




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Appendix 1:

As illustrated in the JBI model evidence generation that includes

discourse, experience and research (of any methodology) precedes evidence

synthesis (systematic review). It follows then that JBI reviews address

questions by systematically examining evidence that may include discourse,

experience or research.

first step to research

Documents