Persistent Back Pain Why Do Physical Therapy Clinicians Continue Treatment - Outline Example

BSc (Hons) Physiotherapy Module EEB Critical appraisal of a research paper: Persistent back pain – why do physical therapy clinicians continuetreatment? A mixed methods study of chiropractors, osteopaths and physiotherapists Candidate number: Word count: 1976 Submission date: XXXXXXX There is evidence that some clinicians continue to treat individuals suffering from long-term back pain, despite the patient showing no significant improvement (Frost et al, 1995). The study investigated here looks into the reasoning behind this, covering the reasons why these clinicians continue treatment, looking into the opinions and morals of chiropractors, osteopaths and physiotherapists. The study also investigates how wide-spread the practice of treating this type of patient is, sending questionnaires to 354 participants from the relevant fields and interviewing a further fourteen. These responses meant that the study used both qualitative and quantitative data, making it a mixed-method study, the benefits and negatives to this being discussed below. The purpose of this essay is to fully explore and critically examine the work by Pincus et al (2006) and the way that they have approached the topic of persistent back pain and treatment. In doing so, it will become clear how this type of research functions within the wider scope of physiotherapy, and how the practical nature of the field influences research literature, as well as how the literature can be used in practical applications. Methodology The methodology of the Pincus et al (2006) study is fairly simple, and comprises of two major elements. The first element is the questionnaire response which gives quantitative data. 354 participants responded to the questionnaire, which was delivered to a total of 600 people; 200 from each field of chiropractic, osteopathy and physiotherapy. Evidently, this is quite a large group of participants which means that there is less likely to be any participant bias, which can so often be found amongst smaller groupings. Another major strength here is that the study approached equal amounts of individuals from each relevant field, again meaning that the responses are less likely to hold any bias. In total 122 chiropractors, 120 osteopaths and 105 physiotherapists responded, all similar in number, again reducing the likelihood of bias (Ellis, 2010). However, there are issues. One of the major issues with allowing respondents to participate at their leisure is that there may be a certain type of person that is more likely to respond, therefore skewing the responses to this type of individual. The use of a questionnaire to garner quantitative information is common, and has some positives and negatives. The first positive benefit is that a questionnaire is cheap to distribute and fairly simple to analyze (Munn et al, 1999), particularly with the development of online questionnaires (Wright, 2005). This means that researchers gain include more participants at a very low effort and economic rate, which means sample sizes are larger and therefore less like to be biased (Ellis, 2010). Questionnaires also give data which is very easily manipulated, with statistical interpretations being applied very easily (Balnaves & Caputi, 2001). However, questionnaires come with negatives too. One of the major ones is that participants could be coerced into answering with a response that is not theirs because the option they would choose is not available (Balnaves & Caputi, 2001). The second is that, if a questionnaire is too long, a participant may become bored or otherwise disenchanted with the study and answer superficially (Dillman, 1978). There is no attached copy of the questionnaire to ascertain whether this is the case. The second element of the Pincus et al (2006) study is the interview. These were those who ‘indicated that they did not continue treating low back pain patients who failed to recover (Pincus et al, 2006, p2). Fourteen participants were interviewed, although data was only used from twelve. The research does not indicate why these two interviews were disregarded, which could be confusing for the reader and beg questions. The sample size is small, which is typical of interviews, which means that there may be some bias. There are indications that this qualitative data was collected more for information purposes, and therefore the small sample size may not be problematic. Although the interview was conducted by only one researcher, the interviews were taped and transcribed, meaning that they could be analyzed by a number of researchers rather than being victim of bias. Interestingly, the study highlights that the transcribed interviews were returned to the individuals to allow them to ensure that the responses were a clear representation of their ideas. This is good because it could help to minimize the Hawthorne effect, but could allow respondents to change their answers from something true to something false. Another interesting aspect of the methods used here is that Pincus et al (2006) used a grounded theory method. This method of doing scientific research relies on the principle of collecting the data and then using coding to draw inferences from this (Charmaz, 2006). This seems contradictory to the scientific method which suggests that research should be proving or disproving a hypothesis. Pincus et al (2006) do not give their reasoning for using a grounded theory approach, merely giving a citation to (Smith, 1995) for further explanation of the method. This is confusing and may mislead the audience about their approaches to research. In this case, the study could benefit from being clearer about their aims. The grounded theory in itself is not a bad method and can give strong results in the field, but there should be some explanation of the reasoning behind it and perhaps even a short explanation of how the method applies to this research and why it was used (Charmaz, 2006). It could be suggested that completing a stronger, lengthier literature review and formatting a hypothesis from this would lead the research to be considered stronger and standardized. Results Overall, the results section of the research is very clear and gives the reader a full understanding. The main problem seems to be that the section seems to give more space to the qualitative data. Although some of this may be from the fact that qualitative data takes longer to express (Auerbach & Silverstein, 2003), it seems problematic that the quantitative data is merely expressed in a single table with a short restatement of the participant group. The results section then leads onto a brief introduction to the meta-themes. This section was again mostly dedicated to the qualitative interview results. This is perhaps most problematic because the research seems to involve a large participant group but then largely ignores the result in the results and analysis section, which could be confusing and means that the positive aspects of using a large sample can be disregarded as they are not actually being used here. It should be noted that the results were collected from the participants own responses and not during their practice. This means that their memories could have been altered and therefore the results inaccurate (Loftus et al, 1985). The practical nature of physiotherapy means that it may be difficult to remember the precise course of action (Simons et al, 2003), even with detailed case notes. The results are interesting but will perhaps not influence physiotherapy very strongly as they suggest that the clinicians are doing their best concerning low back pain patients (Airaksinen et al, 2006). There are no suggestions made about what these practitioners should do to resolve the issues that their patient has, and therefore the results are likely to simply contribute to the information available about practice style rather than being used in any practical way. Validity & Publishing The internal validity of the study is threatened in a number of ways. The Hawthorne effect has already been mentioned, but is always likely to be present in this type of test. Many participants are likely to act differently or alter their responses because they know they are being watched and examined (Adair, 1984). In this case, the practitioners may be acting differently on the belief that their answers will be judged as a measure of how capable they are at their job, although the study is anonymous. There may also be a selection bias because of the way that the participants were recruited, as previously mentioned. This comes as part of a more general problem of confounding, which means that the results may be impacted by a variable that the researchers had not accounted for (MacKinnon et al, 2000). There are a number of positive factors, too. The nature of the study means that it is unlikely that there is any experimenter bias. This is because, although the interviews were conducted by one individual, they were recorded and anonymised before being analyzed. A number of people examined the results, including the participants. Additionally, the questionnaire was only completed once by each individual, which means that there is no repeated testing or testing affects which also often confound the results. The external validity of the results is also interesting. Although the number of participants for the testing is fairly large, these were all registered on a directory for their relevant practice. They were also all from the London area, which may mean that the results are not applicable to those in other areas who may continue treatment on these individuals more often. Being able to generalize results is always an issue when using samples of this nature (Ellis, 2010). The research does discuss the nature of NHS vs. private care, which means that the results cannot be generalized abroad where these systems are not in place (Anderson et al, 2003). One of the simplest ways of judging the appropriateness and validity of the study is by a short investigation into the authors and the publishers. In this case, all five of the contributors have a clearly labeled association with a reputable British university or research center. These institutions have published a wide range of literature on a variety of subjects, and therefore it can be assumed that the academics involved will provide relevant and truthful information. The publisher is also reputable, with a European impact factor of 3.819, meaning that it has published a significant amount of reputable academic work from trustworthy sources. These two factors combined, as well as the previous discussion, mean that the work is of a high standard and the results trustworthy. Mixed-method studies have the huge benefit of providing the researchers with extremely large amounts of data in different formats. This can be used to answer all the research questions, and triangulation means that the data is complete and the issues with using only qualitative or only quantitative data do not apply. There are issues, however, as having this much data in so many formats can mean that the results and final message can become complicated and lost. Overall, the method seems strong although the section is very short and reads as being incomplete, and therefore it may be difficult to recreate this experiment in a different environment; the reproducibility may be low. Conclusions Pincus et al (2006) have used some interesting methods to gather results for this research. The two most surprising and unusual aspects of this are the mixed-method and grounded theory approaches. The mixed-method theory is a strong one and allows for the collection of a lot of data. The use of the grounded theory is less common in science, and the research lacks an explanation for the use. The methods in general are quite strong, although the participant group is misleading in that it seems large but many of the results are drawn from the smaller group of twelve semi-structured interviews. The internal validity has some problems but is generally good overall, particularly as clear efforts have gone into preventing experimenter bias. The study may not generalize well, which could be problematic for the utility of the results. The results were also gathered after the cases had been seen so the memories of the participants may not reflect reality. Overall, the study was strong and reliable, although the information contained within may not have a strong effect on the practice of physiotherapy. References Appraised Article Pincus, T., Vogel, S., Breen, A., Foster, N., Underwood, M., 2006. Persistent back pain—why do physical therapy clinicians continue treatment? A mixed methods study of chiropractors, osteopaths and physiotherapists. European Journal of Pain 10, 67–67. Secondary Literature Adair, J.G., 1984. The Hawthorne effect: A reconsideration of the methodological artifact. Journal of applied psychology 69, 334. Airaksinen, O., Brox, J.I., Cedraschi, C., Hildebrandt, J., Klaber-Moffett, J., Kovacs, F., Mannion, A.F., Reis, S., Staal, J.B., Ursin, H., others, 2006. Chapter 4 European guidelines for the management of chronic nonspecific low back pain. European spine journal 15, 192–300. Anderson, L.M., Scrimshaw, S.C., Fullilove, M.T., Fielding, J.E., Normand, J., 2003. Culturally competent healthcare systems: A systematic review. American journal of preventive medicine 24, 68–79. Auerbach, C., PH.D, L.B.S., 2003. Qualitative Data. NYU Press. Balnaves, M., Caputi, P., 2001. Introduction to quantitative research methods: an investigative approach. SAGE. Charmaz, K., 2006. Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis. SAGE. Dillman, D.A., 1978. Mail and telephone surveys. Wiley New York. Ellis, P.D., 2010. The Essential Guide to Effect Sizes: Statistical Power, Meta-Analysis, and the Interpretation of Research Results. Cambridge University Press. Frost, H., Moffett, J.A.., Moser, J.S., Fairbank, J.C.T., 1995. Randomised controlled trial for evaluation of fitness programme for patients with chronic low back pain. Bmj 310, 151–154. Loftus, E.F., Schooler, J.W., Wagenaar, W.A., 1985. The fate of memory: Comment on McCloskey and Zaragoza. MacKinnon, D.P., Krull, J.L., Lockwood, C.M., 2000. Equivalence of the mediation, confounding and suppression effect. Prevention Science 1, 173–181. Munn, P., Drever, E., 1999. Using questionnaires in small-scale research: a teacher’s guide. Scottish Council for research in Education. Simons, M., King, S., Edgar, D., 2003. Occupational therapy and physiotherapy for the patient with burns: principles and management guidelines. Journal of Burn Care & Research 24, 323. Wright, K.B., 2005. Researching Internet-based populations: Advantages and disadvantages of online survey research, online questionnaire authoring software packages, and web survey services. 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Glossary Bias – Refers to the way in which participant responses can lean towards certain perspectives External Validity – The validity of the results in their surroundings, usually referring to how the results can be generalized to the population Hawthorne Effect – A type of reactivity making the participants change their behavior because they know they are being studied Hypothesis – A statement which research is usually aiming to prove or disprove Impact Factor – A measurement of the number of citations to recent articles within a journal, often used as the primary measure of importance Internal Validity – Showing a causal link between the variables examined within a study Methodology – The way in which an experiment is carried out Qualitative Data – Data which is descriptive and usually verbal Quantitative Data – Data which can be numerically manipulated Reproducibility – The easiness to recreate the experiment in question Skewing – When the results of a study tend to lean more towards one perspective Read More