Research Facilitation Group - Keele University · 2020-07-10 · Stoke PCT have a GRIP group-...

Musculoskeletal Research Facilitation Group – Welcome Pack January 2011- Kay Stevenson

Research Facilitation Group

Welcome to new

members

March 2011


Content Aims of the group and your commitment What‟s in it for you? Group membership and professional background Useful web sites Example of Critically Appraised Topic Example of minutes of a typical meting Testimonials from group members Generating CAT questions: a proforma to encourage questions Top Tips on how to lead a CAT question The Next Steps Reflection on the CAT process


Aims of the group and your commitment Our aim is to ensure that clinical practice is based on the best available evidence and encourage change in practice where necessary. The Research Facilitation Group is a group clinicians and clinical researchers that are interested in musculoskeletal disease. The professions represented are: Nursing Occupational Therapy Podiatry Physiotherapy Clinical Researchers Health Information Librarians Psychologists Therapy Managers The group is supported by Arthritis Research UK Primary Care Centre, University Hospital of North Staffordshire, Stoke PCT, North Staffs PCT and Central and Eastern Cheshire Primary Care Trust. Our aims are to:

Ensure clinical practice is evidence based and assist practice change where required

Increase the research awareness of staff involved in managing patients with musculoskeletal disease

Search the evidence for relevant up to date clinical recommendations and then feed this back to staff in clinical practice

Identify gaps in the evidence

Link with our academic partners to develop research proposals

Increase our research awareness skills

Publicise and communicate our results Your commitment The group meets four times a year at three monthly intervals. Meetings are held at Arthritis Research UK Primary Care Centre, Keele University and last 3 hours, normally 9-12. Coffee and refreshments are provided. You will be required to attend the meeting and commit to appraising articles in between the meetings. This would amount to no more than 2 hours per month. We would hope you would cascade useful information to your team within your own area of practice and highlight the work of the group. We would also ask that you canvas opinion on future questions that are important for us to answer


What’s in it for you Some of the benefits of being involved in such a group include:

Supportive environment to answer important clinical questions

Engage with a multi professional group who are interested in musculoskeletal disease

Opportunities to engage with an established research unit

Opportunity to learn about research methodology and research design from experienced researchers


Group membership and professional background

Caroline Amphlett Physiotherapist Kenneth Aaron Physiotherapist Hilary Bradbury Physiotherapist Robert Bradshaw-Hilditch Podiatrist Robert Bryan Clinical manager Linda Chesterton Physiotherapist and researcher Jemma Cowen Systematic reviewer Carol Doyle Physiotherapist and researcher Krysia Dziedzic Prof. of Musculoskeletal Therapies Sharron Edwards Podiatrist Carol Grahame Occupational Therapist Andrew Finney Nurse and researcher Deborah Fernyhough Occupational Therapist Nadine Foster Prof. of Musculoskeletal Health in Primary Care Noeleen Hellis Clinical manager and physiotherapist Jo Hill Occupational Therapist Mathew Hill Podiatrist Jonathan Hill Physiotherapist and researcher Sue Hill Psychologist and researcher Lucy Huckfield Physiotherapist and researcher Triana Larkin Physiotherapist and researcher Rachel Lewis Health technology Librarian Liz mason Physiotherapist and researcher Alison Morris Physiotherapist Sue Jackson Physiotherapist Jo Jordan Systematic Reviewer Kika Konstantinou Physiotherapist and researcher Mark Porcheret General Practitioner Panos Sarigiovannis Physiotherapist and clinical manager Julie Shufflebotham Physiotherapist and researcher Kay Stevenson Physiotherapist Gail Sowden Physiotherapist and researcher Cath Thwaites Nurse Amanda Walters Physiotherapist Elaine Wiltshire Physiotherapist


Useful web sites Critical Skills Appraisal Programme http://www.phru.nhs.uk/Pages/PHD/CASP.htm CASP appraisal tools http://www.phru.nhs.uk/Pages/PHD/resources.htm McMaster University Evidence Based Practice Centre http://hiru.mcmaster.ca/epc/ National library for Health http://www.library.nhs.uk/Default.aspx Clinical Knowledge Summaries http://cks.library.nhs.uk/home Pub Med http://www.ncbi.nlm.nih.gov/pubmed/ University Hospital of North Staffordshire http://www.uhns.nhs.uk/home.aspx Haywood Hospital http://www.haywoodrheumatology.org.uk/

http://www.phru.nhs.uk/Pages/PHD/CASP.htm

http://www.phru.nhs.uk/Pages/PHD/resources.htm

http://hiru.mcmaster.ca/epc/

http://www.library.nhs.uk/Default.aspx

http://cks.library.nhs.uk/home

http://www.ncbi.nlm.nih.gov/pubmed/

http://www.uhns.nhs.uk/home.aspx

http://www.haywoodrheumatology.org.uk/


Example of a Critically Appraised topic

In adults with shoulder joint impingement is the intervention of stabilization exercises and/or postural correction versus any treatment or no intervention

effective in reducing pain and increasing function?

Clinical bottom line There was no evidence specific to scapula stabilization exercises, but the general summary of the literature searched was that an exercise programme was beneficial with the addition of manual therapy being more effective than exercises alone Population: Male and female adults Intervention: Scapula stabilization exercises / postural correction Outcome: Reduced pain and increased function Excluded: Diagnoses other than shoulder impingement syndrome Databases Searched: Cochrane, Pedro, NHS Library for Health, medline, Cinahl, Embase, Psyclnfo, Clinical Evidence, Bandolier, NELH, Professional websites, Guidelines, NICE Search for the past 10 years i.e. 1996 – 2006 Key words searched: Shoulder impingement, shoulder impingement syndrome, subacromial impingement, shoulder pain, tendonitis rehabilitation, exercises, exercise therapy, physical therapy, physiotherapy, conservative treatment, postural exercises, scapular stabilization Types of studies Systematic reviews, RCT‟s and guidelines Available Evidence Database ( Specific to our CAT)

Number of abstracts

Number of relevant abstracts

Clinical evidence

PsychInfo

0

AMED/ CINAHL/ Embase

158 2

PEDRO

3 1

Medline

27 2

Cochrane

4 3

Guidelines

1 1

Total 193 9


Results:

There were no studies directly assessing scapular stabilization / postural correction exercises. The main systematic review (Faber et al 2006) looked at the treatment of impingement syndrome. They found 94 articles, 3 of which studied exercise interventions (Brox 1999, Bang 2000, Ludewig 2003). These articles were reviewed in more detail – generally small sample sizes (eg. n=40 per group), and some issues relating to blinding and validity of outcome measures. All studies presented a positive outcome for patients undergoing an exercise programme. The summary from the CSP shoulder guidelines (2004) on impingement syndrome recommend

A programme of exercises to restore range, strength, stability and scapulohumeral rhythm is beneficial – based on weak evidence from clinical trials

Passive mobilization of the upper quadrant augments the beneficial effects of exercise, reducing pain and increasing range, strength and function – based on weak evidence from clinical trials

Scapula stability when performing strengthening exercises is „paramount‟ based on clinical experience, opinion and committee reports

Implications for practice: There is no evidence to suggest that inclusion of scapula stabilization exercises provide additional benefit to outcome for patients with shoulder impingement syndrome. However, an exercise programme that includes strengthening exercises +/- manual therapy is of benefit to patients with shoulder impingement syndrome. Further research question In adults with shoulder impingement syndrome, does the inclusion of scapular stabilisation/postural correction exercises provide additional benefit over a usual exercise programme in terms of pain relief and functional improvement? References: Bang and Deyle 2000 Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome (SIS) J Ortho Sports & Phys Ther 30:3 126-137 Brox et al 1999 Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II SIS): A prospective randomized controlled study in 125 patients with a 2.5 year follow-up J Shoulder and Elbow Surgery 8: 2 102-111 CSP 2004 evidence based clinical guidelines for the diagnosis, assessment and physiotherapy management for shoulder impingement syndrome Desmeules F et al 2003 Therapeutic exercise and orthopedic manual therapy for impingement syndrome: a systematic review Clinical Journal of Sport Medicine May; 13(3):176-182 Faber et al 2006 Treatment of impingement syndrome: a systematic review of the effects on functional limitations and return to work Journal of Occupational Rehabilitation Mar; 16(1):7-25 Ludewig and Borstad 2003 Effects of a home exercise programme on shoulder pain and functional status in construction workers Occup Environ Med 60 841-849 Michener et al 2004Effectiveness of rehabilitation for patients with Subacromial impingement syndrome: a systematic review Journal of Hand Therapy Apr-Jun; 17(2):152-164


Example of minutes of a typical meeting

Musculoskeletal Research Facilitation Group- 13th January 2010 Minutes

Present Alison Morris, Kay Stevenson, Jo-ann Hill, Rachel Lewis, Lucy Huckfield, Nadine Foster, Mathew Hill, Liz Mason, Mathew Hill, Jonathan Hill, Jo Jordan Apologies Carol Graham, Sue Jackson, Gail Sowden, Duncan Kett, Julie Shufflebotham, Panos Sarigiovannis, Caroline Amphlett, Sue Hill, Jemma Cowen

Review actions from last meeting

Update new members pack and send to all KS Comments taken from group, now to go on web site Update the proforma to generate Qs KS Comments taken on proforma, distribute to all KS Comments on web site All Update Cats according to table included All See below

Welcome to Lucy Huckfield. Lucy had a split post between the centre and Stoke PCT. There are to be 5 similar posts in local PCTs. Trina Larkin appointed to South Staffs post.

Update on new web site http://www.keele.ac.uk/research/pchs/pcmrc/EBP/index.htm Photographs to be added.

We all discussed how accessible the web site is Lucy kindly investigated this for us. Results are:

Access the CAT site by using different words through google search engine. I used the

following words/ phrases and this is what I came up with......

1) CAT group Keele - This brought a link up that took you straight to the new MRF

group website page on the CAT bank page (where the person is that you can click on to

see the CAT for different areas). CAT group Keele was the top search link on google.

2) Keele CAT group - was as number (1)

3) CAT Keele - This was the third item on the google searched items list. The link

took you to the Keele Primary Care Sciences website to the dissemination page with the

list of the CATs

4) Keele CAT - This was the second item on the google searched items list. This link

took you to the dissemination page as in number (3).

http://www.keele.ac.uk/research/pchs/pcmrc/EBP/index.htm


Training ideas/issues for next 4 meetings All

13th Jan-

14th April - Critical appraisal- homework to be sent to all

14th July - Statistics

20th Oct - Systematic reviews (Jo Jordan)

Suggested future topics: observational studies, Cohort studies, Cost analysis

Feedback from EBP group KD

KD gave update on EBP group ( Krysia, Mark Porcheret, Jo Jordan and Kay Stevenson). Organised very successful event on NICE guidelines to promote debate. Next evening may well be on OA. Rhian and Kay met recently with local commissioners to outline the work of the centre and EBP groups. We discussed how we can integrate evidence into practice. Stoke PCT have a GRIP group- getting research into practice, KD involved with the group.

Update on current CAT work- reviews

CAT for review

Group

Is multidisciplinary management of chronic low back pain more effective in terms of reducing pain, improving function and increasing return to work compared with uni-disciplinary treatment.

Noeleen, Nadine, Jonathan Present at next meeting

Is one off management versus a course of treatment more effective in terms of reducing pain and function for patients over 50 years old with osteoarthritis of the knee joint

Krysia Kay Andrew No new evidence to add to existing CAT, updated Cat on web site

Examine the effectiveness of rehabilitation programmes in primary flexor tendon repairs following surgical reconstruction at 12 weeks and 12 months in terms of pain, disability, function, return to work

Carol, Debbie and Jo Present at next meeting

In adult humans with peripheral musculoskeletal injury (who have not had previous repair) is the length of time of sustained active or passive stretching more effective than other aspects of stretching for increasing return to work function and activity.

Linda and Richard Present at next meeting

Does appointment duration for musculoskeletal outpatient physiotherapy or occupational therapy in primary or secondary care settings, have an effect on managerial, clinical or patient outcomes

Carol and Kay No new evidence to add to existing CAT, updated Cat on web site


Update on current CAT work CAT for review

Comment

Access to healthcare practitioners Carol Jonathan, Panos, Carol, Krysia, Duncan, Carol, Andre, Sue

Completed, now on web site

GH joint capsulitis Caroline Nadine, Kay, Jemma

Completed now on website May be taken forward to the centre for funding application CAT and quick and dirty process came up with same answer.?? Should we write this up for publication?

Therapists involved in requesting investigations Amanda, Kay Sue, Matt

Completed, now on website

Is an exercise regime in addition to routine mobilisation / gait re-ed of improved benefit to function / QOL in post operative adult THR's? Jo Hill, Alison, KD and KS

To be presented at next meeting

Whether a urinalysis that is positive with Nitrites and Leucocytes is sufficient evidence to not give a soft tissue/intra articular injection. Andrew Finney and the nursing group, Kyrsia, Jo


TNS and the management of post op pain Alison and Linda


Web site of interest identified by Nadine re self referal pilot projects

> http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publica

Feedback on quick and dirty searches

o Shoulder capsulitis- as above o Multidisciplinary referral- not undertaken

New questions from Clinicians

CAT for review

Group

Use of Splint in neurologically compromised patient with ankle fractures ( Vick Terry)

Lucy, Kay Caroline

Weight bearing/ mobilisation on day 0 for patient with total hip or knee replacement ( Alison Morris)

Alison, Jo Liz

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publica


Does lack of sleep cause reduction in serotonin and can lack of serotonin have physical manifestations Corinna Dennison, Physiotherapist band 7,Burslem HC 425702 – Need clarification – Lucy to do this

Feedback on shoulder and hand trial

Shoulder trial at final protocol stage, hoping to go for ethics in March, recruiting in June. Will be undertaken at 2 main sites. Hand trial in last 6 months of the study. 85% follow up at 6 months, analysis to begin in the summer.

Update on nursing link Andrew providing a clear lead for the nursing group, decided on question concerning joint injections and the value of urinalysis.

AOB

o Present work of the group to local ARMA group o Discussed the need to provide patient friendly information, our information

aimed primarily at clinical staff. Could ask the Research user group (RUG) group to look at existing Cats

o WCPT pre event training session- do we want to develop one? o Gail and Jonathan leading local Outcome measures group. Have put together

a proforma for those considering undertaking audit o DUETS- data base of uncertainty of treatments, hosted by the James Lind

alliance. WE could send out unanswered questions to this site. Funding bodies look at the site to inform call for research. Jo Jordan involved through the work of the arc. Could this be a link on our web site

http://www.lindalliance.org/

Actions for next meeting New members pack on web site KS Critical appraisal training sent info to all: BMJ article KS ( Sent 10/1/10) Ask Sue Hill re stats training on 14

th july KS

Ask Jo Jordan re training on systematic reviews 20

th Oct KS

e mail all local PCT staff re web site KS WCPT pre training event KS Ask RUG group to look at existing Cats KD


Testimonials from group members

“Being involved in the group has been a very positive experience. Initially I felt daunted at being the only OT and felt that I had very little knowledge in this area and had nothing to offer the group. The group environment is extremely supportive and my research knowledge and skills have grown, and I am still learning! I would recommend this type of group to colleagues and advise them to attend even if they are the only representative of their profession” “I used to think of evidence based practice as rather daunting. However membership on the group has helped me develop a systematic approach when reading research articles allowing me to appraise the methodology used and therefore the evidence for the conclusions drawn from said research” “Joining the CAT group was a career changing event. It made me sit up and take note of what was going on around me, outside of my day-to-day work. It made me question my routine practice. It has demystified research for me. Research was something that I had always thought was for those more intelligent than me. But appraising the evidence to inform practice should not just take place in the Universities it should be part of the routine day-to-day work of a physiotherapist. It makes work more interesting trying out new ideas and challenging old ones, rather than just repeating what I was taught 10 years earlier.”

“The CAT group has proved to be an excellent resource over the last few years. On occasion we have asked questions that have changed our practice within the UHNS. This process has been reassuring and rewarding. The vast scope of experience and professions within the group ensures a broad approach within the MSK field.”


Generating Cat Questions - Proforma to encourage questions

Musculoskeletal Research Facilitation Group Proforma to facilitate questions asked

This document has been designed to help clinicians formulate detailed questions that will help our Musculoskeletal Research Facilitation group in their search for the evidence, using a tried and tested process. We anticipate the process will be used:

by individual clinicians or groups to generate clinical questions

to facilitative discussions in groups of staff at training or staff meetings

to facilitate discussion between managers and clinicians on evidence based practice

The aim of the process is to produce a clinical bottom line with a summary of the evidence for each question identified. We have produced 31 to date and our results to date can be found online at: http://www.keele.ac.uk/research/pchs/pcmrc/EBP/MRF/search/bank_full.htm Example of the types of questions that have been put to the group:

Question examples Question types

Are shoulder exercises effective for treating shoulder pain?

Intervention

Does being overweight increase the risk of knee arthritis?

Aetiology and risk factors

How reliable is an MRI scan at detecting a lumbar disc herniation?

Diagnosis

How likely is that people over 50 will develop neck pain?

Prognosis and prediction

How common is plantar fascitis? Frequency and rate

What are the barriers to lifestyle change such as increase activity levels

Phenomena and thoughts

(Glasziou P, Mar C, Salisbury J 2007 Evidence Based Practice Workbook 2

nd Edition BMY Books Blackwell Publishing)

We would welcome questions in any of the above categories. Please use the table below to help formulate any questions you have and send to any member of the Research Facilitation Group (or Chairperson [email protected]). We are happy to receive broad questions, but prefer it if you are able to give us slightly more detail if possible, by producing a „refined question‟. For example a general question might be: “Are stability exercises effective at treating patients with shoulder pain?”

The aim of our Musculoskeletal Research Facilitation Group is to facilitate that our practice is based on the best quality evidence available. Questions arising in our practice need answers and if you want help finding out what the evidence says, this group exists to assist you.

http://www.keele.ac.uk/research/pchs/pcmrc/EBP/MRF/search/bank_full.htm

mailto:[email protected]


To help you further refine your question and to assist group members undertaking the search we recommend the use of an evidence-based model for formulating a clinical question known as the PICO model (Richardson, 1995). By dividing your concepts into a few specific categories, you will provide the groundwork for developing the search strategy. The PICO model is particularly appropriate for intervention topics, but there are alternatives such as ECLIPSE model (Wildridge, 2002), which is expanded below. You may also prefer to adapt the PICO headings to fit the type of research question you are interested in.

Patient/Population and/or Problem

- any characteristics that define your patient or population, e.g. target clinical condition, co-existing condition, ethnicity, age group etc….

Intervention/Investigation - what you want to do with the patient/population or problem e.g. form of treatment, diagnostic test, education programme, type of service delivery. This can also include any exposures (e.g. asbestos) or factors influencing prognosis.

Comparison/Control Intervention - alternatives to the main intervention e.g. placebo, usual care etc….

Outcomes or effects - any outcomes or effects relating to the intervention e.g. prevention, side effects, morbidity, quality of life, cost-effectiveness

PICO Table (example question):

Question type Provide details about the exact population, any comparison/ control groups & the outcomes you are interested in

Population Adults with shoulder impingement tendonitis

Intervention Shoulder stability exercises, scapular stabilization exercises, postural correction

Comparison Normal care, routine physiotherapy

Outcome Reduced shoulder pain, function

An example of a “refined question” that would emerge from completing this PICO is: “In adults with shoulder joint impingement is the intervention of stabilization exercises and/or postural correction versus any treatment or no intervention effective in reducing pain and increasing function?” For questions that are not about treatments, you may wish to use the ECLIPSE model (Wildridge, 2002): Expectation – what does the search requester want the information for? Client group. Location. Impact – what is the change in the service, if any, which is being looked for? What would constitute success? How is this being measured? Professionals. Service – for which service are you looking for information? For example, outpatient services, nurse-led clinics, intermediate care.


Some tips to help you ask a refined clinical question include:

Define the type of question you think you are asking

Determine who the relevant people are in relation to your clinical problem

Agree which intervention or treatment you are wanting to find out about

Decide if there is a particular diagnostic test you are interested in

Detail what you‟d like to compare your intervention to; e.g. „usual care‟ or an alternative treatment or a control group

Determine what outcomes you are most concerned about…. e.g., pain reduction, increased function or return to work

Please bear in mind that this process will take a number of months to complete. Thanks again for your contribution.


Proforma to complete (return to [email protected]): Your name: Date: Contact details (email):

Question type Provide details about the exact population, any comparison/ control groups & the outcomes you are interested in

Patient/population/problem

Intervention or Investigation or Procedure

Comparison (if appropriate)

Outcomes of interest

Your refined question:


Top Tips on how to lead a CAT Question

If you are leading a CAT question, here are some key points that may help you:

Ensure your group has formulated an answerable question that considers the population, intervention, comparison and outcome.

Ensure that every member of the group has a clear role, one person may complete the proforma for the library search, one person may be responsible for organising e-mail contact and meetings

Liaise with our librarian in order for the search to be done. This will require you to complete a form which gives the librarian more detail about the topic area you are interested in.

Give yourself enough time to read through the abstracts, ask members of the group to assist. Don‟t get distracted by articles which interest you, the focus needs to be your question and does this research answer your specific question

Look for the very best evidence, for interventions, this will be a systematic review.

Decide on the key articles and then divide them between the group members, give everyone enough time to complete this task.

Ask for assistance when you are formulating the CAT, other members of the group will be happy to help


The next steps

A CAT is completed with a „clinical bottom line‟ and „recommendations for practice‟. There are many different ways of integrating this into practice. Some services used map of medicine Pathways, while others use clinical algorithms. It is advisable to have the information in as many different formats as possible, such as electronic versions, hard copy and available on web sites. The information that is produced by the CAT process can be disseminated as staff meetings, personal development reviews, e mails. Where there is no clear evidence to answer the clinical question, the group feeds this to the arc national Primary Care Centre, Keele Universality. The centre then decides if a full research protocol can be developed to answer the question. Two funded research projects have started in this way, they are:

Interventions for hand arthritis

Intervention for treating shoulder impingement Unanswered questions can also be forwarded to the James Lind alliance. “The James Lind Alliance aims to identify the most important gaps in knowledge about the effects of treatments, and has been established to bring patients and clinicians together in 'Priority Setting Partnerships' to identify and prioritize the unanswered questions that they agree are most important. This information will help ensure that those who fund health research are aware of what matters to patients and clinicians.” http://www.lindalliance.org/

http://www.lindalliance.org/


Reflection on the CAT process This section encourages you to reflect on the CAT process

Describe your recent involvement in the CAT process

What was the experience?

What did you do?

And why did you do this?

What went well?

What do you think could have been improved?

What would you do differently next time?

What did you learn from the experience?

Any learning objectives generated?

Reflection on incident and learning objectives


Reference List Foster N Barlas P Chesterton L Wong J 2001 Critically Appraised Topics (CATS): One method of facilitating evidenced based practice in physiotherapy Physiotherapy 87 4 179-190 Stevenson K, Bird L Sarigiovannis P Dziedzic K Foster NE Grahame C (2007) A new multidisciplinary Approach to integrating best evidence into musculoskeletal practice. Journal of Evaluation in Clinical Practice (online early articles)

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