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Expanding our perspectives on research in musculoskeletal science and practice

Article

Expanding our perspectives on research in musculoskeletal science and practice

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Introduction: The quantity and quality of scientific research within physiotherapy has unquestionably grown and matured over the last few decades, especially since the "formal" onset of evidence-based physiotherapy in the 1990s. The urgent need to evaluate our practice for effectiveness and efficiency has been responded to with thought and respect to both scientific integrity and shop-floor clinical needs. However, after thirty years or more of a professionally-governed and strategic approach to research activity, it is now timely to reflect, review, and consider the next chapter in the relationship between scientific research and clinical practice. Purpose: This masterclass aims to develop a research vision for the future of physiotherapy. It is proposed that a crisis is evident within evidence-based physiotherapy, particular so given the assumed complexity and context-sensitivity of our clinical practice. This crisis period has highlighted fundamental limitations within the way research and practice are currently related. These limitations are presented and framed within the problematisation of empirical and philosophical concerns. As research becomes increasingly aligned to traditional scientific principles, examination of the real world context in which its outcomes are intended expose critical challenges for both research and clinical practice. Implications: A reconceptualisation of fundamental elements of scientific research may allow more meaningful relationships between research and clinical practice. A proposed research vision encourages scientific activity to embrace real-world complexity in a way that it is presently unable to. An enhanced person-centered, scientifically-informed world of effective musculoskeletal practice is envisaged.

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... Cependant, plusieurs défis théoriques et pratiques ont également été identifiés (6)(7)(8)(9)(10) . L'un des défis potentiels de l'engagement dans la recherche est de lui donner un sens, de décider si elle est digne de confiance et si elle est applicable à la nature complexe et contextuelle de la pratique clinique et des soins aux personnes (11) . Les outils d'aide à l'analyse critique ne sont pas seulement nécessaires lors de la lecture de données issues de la recherche, mais aussi chaque fois que les ostéopathes rencontrent des informations qui pourraient avoir un impact sur les soins ou les informations fournies à leurs patients. ...
... However, several theoretical and practical challenges have also been identified (Miles and Loughlin 2011, Leboeuf-Yde, Lanlo et al. 2013, Tyreman 2018, Anjum, Copeland et al. 2020, Kamper 2020. One of the potential challenges when engaging with research is to make sense of it, to decide if it is trustworthy, and if it is applicable to the complex and context-sensitive nature of clinical practice and the care of individual people (Kerry 2017). Tools to support critical analysis are not only required when reading research, but whenever osteopaths encounter information that could impact on the care or information they provide to their patients. ...
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Osteopaths are expected to keep up to date with research evidence relevant to their clinical practice and to integrate this knowledge with their own experience and their patients' values and preferences. One of the potential challenges when engaging with research is to make sense of it, to decide if it is trustworthy, and if it is applicable to the complex and context-sensitive nature of clinical practice and the care of individual people. Clinicians are increasingly exposed to (deliberate and undeliberate) misinformation and overstatements which propagate easily, including via social media. This masterclass aims to facilitate critical thinking and engagement in research for clinicians to make better-informed decisions with their patients. It was developed to support osteopaths facing these questions with the aim of empowering them to judge research themselves, detect common fallacies in the conduct and reporting of different research designs, and to increase researchers' accountability. Ultimately, we hope that by reading and considering the guidance and examples in this paper, clinicians will be better equipped to optimise the use of their (and their patients’) time when facing potential sources of evidence. Mistakes, misinterpretation, misrepresentation and misinformation are discussed for each of these methods/methodologies: case reports, clinical trials, qualitative research, and reviews.
... design, environment) [5]. A range of qualitative and quantitative research methodologies from different perspectives are needed in order to have a rounded understanding of these domains, and their interaction with each other as it is this context-sensitivity which is often lost when trying to reduce and isolate them through quantitative methods alone [8]. ...
... Evidence from randomised clinical trials (RCTs) is considered to be the most reliable design for determining the most effective and appropriate therapy (Anjum, Kerry, and Mumford 2015). In order to ensure that the effects are likely to happen across individuals and contexts, personal and contextual factors are controlled for in the design (Kerry 2017). Thus, the assumption underpinning condition-specific knowledge is that people with the same diagnosis-regardless of who they are, the contexts in which they are living and who is delivering the programme-can successfully be treated by similar therapies. ...
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Researchers and a multidisciplinary clinical team collaborated on the development of a rehabilitation programme for patients with fibromyalgia (FM). In this chapter, we describe the process of developing the programme, which involved reflecting across evidence, patient-centeredness, and clinical experiences. Pulling the different knowledges together, we applied condition-oriented evidence and a biopsychosocial model to demonstrate the complexity of FM and determine the target of the programme. The programme's patient-centred approach was supported by patient-oriented evidence, theories of suffering and personal recovery, and clinical experiences, which fit together into a personal resource-oriented recovery model. Our experience was that applying a qualitative explorative approach and incorporating evidence from qualitative studies enhanced our reflexivity. Moreover, a 'bottom-up' working process resulted in a broad understanding about FM, what FM is like to live with and what a personal recovery process implies for a patient. List of keywords Fibromyalgia-development of rehabilitation programme-working process-qualitative inquiry-life stress 3
... Wallden and Chek's (2018a) position also contrasts the contemporary reframing of EBP as relationshipbased, context-specific, judicious and individualised (Loughlin 2009;Greenhalgh et al., 2014;Tyreman 2018). Recent discussions of EBP (Greenhalgh et al., 2014), and indeed, musculoskeletal practice (Kerry 2017) emphasise the incorporation of evidence from a range of research methodologies, methods and theoretical perspectives far beyond only "epidemiological evidence". Similarly, simple characterisation of research methods as "linear" and all research as equating to positivism, denies the rich variety of methods and paradigms available for inquiry (Creswell and Creswell 2017). ...
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To estimate the global burden of low back pain (LBP). LBP was defined as pain in the area on the posterior aspect of the body from the lower margin of the twelfth ribs to the lower glutaeal folds with or without pain referred into one or both lower limbs that lasts for at least one day. Systematic reviews were performed of the prevalence, incidence, remission, duration, and mortality risk of LBP. Four levels of severity were identified for LBP with and without leg pain, each with their own disability weights. The disability weights were applied to prevalence values to derive the overall disability of LBP expressed as years lived with disability (YLDs). As there is no mortality from LBP, YLDs are the same as disability-adjusted life years (DALYs). Out of all 291 conditions studied in the Global Burden of Disease 2010 Study, LBP ranked highest in terms of disability (YLDs), and sixth in terms of overall burden (DALYs). The global point prevalence of LBP was 9.4% (95% CI 9.0 to 9.8). DALYs increased from 58.2 million (M) (95% CI 39.9M to 78.1M) in 1990 to 83.0M (95% CI 56.6M to 111.9M) in 2010. Prevalence and burden increased with age. LBP causes more global disability than any other condition. With the ageing population, there is an urgent need for further research to better understand LBP across different settings.
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Background Despite clear benefits of the Evidence-Based Practice (EBP) approach to ensuring quality and consistency of care, its uptake within physiotherapy has been inconsistent. Objectives Synthesise the findings of research into EBP barriers, facilitators and interventions in physiotherapy and identify methods of enhancing adoption and implementation. Data sources Literature concerning physiotherapists’ practice between 2000-2012 was systematically searched using: Academic Search Complete, Cumulative Index of Nursing and Allied Health Literature Plus, American Psychological association databases, Medline, Journal Storage, and Science Direct. Reference lists were searched to identify additional studies. Study selection Thirty-two studies, focusing either on physiotherapists’ EBP knowledge, attitudes or implementation, or EBP interventions in physiotherapy were included. Data extraction and synthesis One author undertook all data extraction and a second author reviewed to ensure consistency and rigour. Synthesis was organised around the themes of EBP barriers/enablers, attitudes, knowledge/skills, use and interventions. Results Many physiotherapists hold positive attitudes towards EBP. However, this does not necessarily translate into consistent, high-quality EBP. Many barriers to EBP implementation are apparent, including: lack of time and skills, and misperceptions of EBP. Limitations Only studies published in the English language, in peer-reviewed journals were included, thereby introducing possible publication bias. Furthermore, narrative synthesis may be subject to greater confirmation bias. Conclusion and implications There is no “one-size fits all” approach to enhancing EBP implementation; assessing organisational culture prior to designing interventions is crucial. Although some interventions appear promising, further research is required to explore the most effective methods of supporting physiotherapists’ adoption of EBP.
Article
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Medically unexplained symptoms (MUS) remain recalcitrant to the medical profession, proving less suitable for homogenic treatment with respect to their aetiology, taxonomy and diagnosis. While the majority of existing medical research methods are designed for large scale population data and sufficiently homogenous groups, MUS are characterised by their heterogenic and complex nature. As a result, MUS seem to resist medical scrutiny in a way that other conditions do not. This paper approaches the problem of MUS from a philosophical point of view. The aim is to first consider the epistemological problem of MUS in a wider ontological and phenomenological context, particularly in relation to causation. Second, the paper links current medical practice to certain ontological assumptions. Finally, the outlines of an alternative ontology of causation are offered which place characteristic features of MUS, such as genuine complexity, context-sensitivity, holism and medical uniqueness at the centre of any causal set-up, and not only for MUS. This alternative ontology provides a framework in which to better understand complex medical conditions in relation to both their nature and their associated research activity.
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This paper explores the nature of causation within the framework of evidence-based practice (EBP) for health care. The aims of the paper were first to define and evaluate how causation is presently accounted for in EBP; second, to present an alternative causal account by which health care can develop in both its clinical application and its scientific research activity. The paper was premised on the idea that causation underlies medical and health care practices and impacts on the way we understand health science research and daily clinical practice. The question of what causation is should therefore be of utmost relevance for all concerned with the science, philosophy and progress of EBP. We propose that the way causation is thought of in contemporaneous health care is exposed by evidential frameworks, which categorize research methods on their epistemological strengths. It is then suggested that the current account of causation is limited in respect of both the functionality of EBP, and its inherent scientific processes. An alternative ontology of causation is provided, which has its roots in dispositionalism. Here, causes are not seen as regular events necessitating an effect, but rather phenomena that are highly complex, context-sensitive and that tend towards an effect. We see this as a better account of causation for evidence-based health care.
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This volume offers an exploration of major changes in the way knowledge is produced in science, technology, social science, & humanities, arguing that a new mode of knowledge production promises to replace or radically reform established institutions, disciplines, practices, & policies. A range of features - reflexivity, transdisciplinarity, heterogeneity - associated with the new mode of knowledge production are identified to illustrate the connections between them & the changing role of knowledge in social relations. Methodological difficulties inherent in attempts to describe a new mode of knowledge production are discussed, & implications of this mode for science policy & international economic competitiveness, collaboration, & globalization are treated. The book is particularly relevant for those concerned with educational systems, the changing nature of knowledge, the social study of science, & the connections between research & development, & social, economic, & technological development. The book is presented in 7 Chpts with a Preface & an Introduction. (1) Evolution of Knowledge Production. (2) The Marketability and Commercialisation of Knowledge. (3) Massification of Research and Education. (4) The Case of the Humanities. (5) Competitiveness, Collaboration and Globalisation. (6) Reconfiguring Institutions. (7) Towards Managing Socially Distributed Knowledge. References accompany each Chpt. 2 Tables. W. Howard (Copyright 1995, Sociological Abstracts, Inc., all rights reserved.)
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A distinction in trial design is made between explanatory (or efficacy) and pragmatic (or effectiveness) trials.1 These terms, originally coined by Schwartz and Lellouch in 1967, are used to describe trials that either test causal research hypotheses to determine whether an intervention works in tightly controlled conditions to achieve optimal efficacy and/or to understand the key mechanism of action (explanatory); or that help choose between options for care under the usual conditions in which those options may be offered (pragmatic). The pragmatic–explanatory distinction really comprises a continuous spectrum1 with many elements, from the breadth of eligibility criteria, the flexibility in intervention delivery, expertise of those delivering treatment, degree of standardisation of intervention protocol, the efforts to ensure compliance, through to specific approaches to analysis. Pragmatic trials are increasingly adopted to test the effectiveness of complex interventions for patients in primary care, but may have explanatory elements. The Medical Research Council Framework for the development and evaluation of complex interventions provides helpful guidance, as complex interventions involve a number of separate but interacting components which are likely to be important to the success of the intervention, although the ‘active ingredients’ are often difficult to specify.2,3 In developing a novel, complex intervention comprising separate elements — for example, an education package with exercises for back pain — a rigorous …
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The claims of RCTs to be the gold standard rest on the fact that the ideal RCT is a deductive method: if the assumptions of the test are met, a positive result implies the appropriate causal conclusion. This is a feature that RCTs share with a variety of other methods, which thus have equal claim to being a gold standard. This paper describes some of these other deductive methods and also some useful non-deductive methods, including the hypothetico-deductive method. It argues that with all deductive methods, the benefit that the conclusions follow deductively in the ideal case comes with a great cost: narrowness of scope. This is an instance of the familiar trade-off between internal and external validity. RCTs have high internal validity but the formal methodology puts severe constraints on the assumptions a target population must meet to justify exporting a conclusion from the test population to the target. The paper reviews one such set of assumptions to show the kind of knowledge required. The overall conclusion is that to draw causal inferences about a target population, which method is best depends case-by-case on what background knowledge we have or can come to obtain. There is no gold standard.
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Transdisciplinary approaches are becoming increasingly adopted as a way to research complex socio-environmental problems. Conceptually, transdisciplinarity aims to foster meaningful knowledge co-production through integrative and participatory processes that bring together diverse actors, disciplines, and knowledge bases. In practice, transdisciplinarity is more ambiguous. While there is a growing body of literature on such approaches, there remains no widely-accepted definition, concrete framework, or empirical strategy for how to carry out a transdisciplinary project. We propose that this lack of explicit structure and entrenched meaning leaves space for transdisciplinary approaches to be shaped by the evolving network of participating scientists and stakeholders, according to their perspectives of the approach and what it embodies. Here, we examine the perspectives of a diverse group of actors (n = 42) embarking on a 10-year transdisciplinary research project focused on building resilience to natural hazards and disasters in New Zealand. We present the findings of qualitative surveys and group interviews that investigate stakeholders’ and scientists’ early perspectives of transdisciplinary, or co-created, research. The study represents the first stage of longitudinal research that will continue over the course of the project. Results show that early actors in the project share an overall consistent understanding of co-created research. Participants described a process that integrated diverse people and knowledge; created benefits on both a social and personal level; fostered clear, two-way dialogue; and overcame pragmatic and intrinsic challenges. Collectively, participants agreed with adopting transdisciplinary approaches to natural hazard, risk, and resilience research, with stakeholders showing a stronger degree of agreement than scientists. While attitudes towards transdisciplinarity were overall positive, a number of underlying conflicts emerged in regards to carrying out new modes of knowledge production within traditional social and institutional structures. These conflicts result in a tension that is felt by actors involved in transdisciplinary projects early on, and in some cases, influences perception of their ability to fully participate in such an approach. Evaluating actor perspectives and expectations early in the transdisciplinary process can give insight into how attitudes, expectations, and conflicts might shape transdisciplinary efforts, and can provide relevant parameters for assessing change over time.
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This paper explores a novel clinical framework that is underpinned by a specific philosophical perspective of causation and its utility in clinical practice. A dispositional theory of causation may overcome challenges that clinicians face in complex clinical presentations including those that are medically unexplained. Dispositionalism identifies causes not as regular events necessitating an effect but rather phenomena, which are highly complex, context-sensitive, and which tend toward an effect. Diagnostic uncertainty and causal explanation are significant challenges in terms of clinical reasoning, communication, and the overall therapeutic outcome. This novel framework aims to facilitate improved collaborative clinical reasoning, enhanced patient-practitioner interaction, and supported treatment planning. The paper uses a real case study of a patient with nonspecific spinal pain to demonstrate the clinical framework as used in clinical practice.
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In response to limitations in the understanding and use of published evidence, evidence-based medicine (EBM) began as a movement in the early 1990s. EBM's initial focus was on educating clinicians in the understanding and use of published literature to optimise clinical care, including the science of systematic reviews. EBM progressed to recognise limitations of evidence alone, and has increasingly stressed the need to combine critical appraisal of the evidence with patient's values and preferences through shared decision making. In another progress, EBM incorporated and further developed the science of producing trustworthy clinical practice guidelines pioneered by investigators in the 1980s. EBM's enduring contributions to clinical medicine include placing the practice of medicine on a solid scientific basis, the development of more sophisticated hierarchies of evidence, the recognition of the crucial role of patient values and preferences in clinical decision making, and the development of the methodology for generating trustworthy recommendations.
Article
John Ioannidis and colleagues explain how clinical trial outcomes are less fixed than we think and advocate transparency in documenting why they change Selective reporting of outcomes can bias clinical trials.1 This happens when investigators publish some prespecified outcomes but not others, depending on the nature and direction of the results. They may also add outcomes that were not prespecified or modify some of the prespecified outcomes in subtle or major ways. These selective reporting practices tend to make trial results more attractive but also spurious. The proposed solution has been trial registration, including the explicit listing of prespecified outcomes before launch, and the transparent description of all changes that occur afterwards. The BMJ asks the guarantor of research to sign a declaration of transparency at submission, stating that the manuscript is an “honest, accurate, and transparent account” of the methods and results, including explanations of “any discrepancies from the study as planned” (http://www.bmj.com/about-bmj/resources-authors/). We discuss efforts to identify discrepancies between trial protocols and published papers and outline possible quality control measures for the future. From October 2015 to January 2016 the Centre for Evidence Based Medicine Outcome Monitoring Project (COMPare) team checked articles published in the top five general medicine journals based on impact factor— New England Journal of Medicine , Lancet , JAMA , The BMJ , and Annals of Internal Medicine —against protocols and registries pre-dating trial launch.2 Only nine of the 67 clinical trials published (13%) were “perfectly reported,” that is all primary and secondary outcomes were the same in the protocols or registries and the articles. COMPare found that investigators didn’t report the results of 354 outcomes that were prespecified in protocols or registries and that they added—without flagging it to the editor and reviewers—357 outcomes that were not prespecified. COMPare …
Article
Importance: Many published randomized clinical trials (RCTs) make claims for subgroup differences. Objective: To evaluate how often subgroup claims reported in the abstracts of RCTs are actually supported by statistical evidence (P < .05 from an interaction test) and corroborated by subsequent RCTs and meta-analyses. Data sources: This meta-epidemiological survey examines data sets of trials with at least 1 subgroup claim, including Subgroup Analysis of Trials Is Rarely Easy (SATIRE) articles and Discontinuation of Randomized Trials (DISCO) articles. We used Scopus (updated July 2016) to search for English-language articles citing each of the eligible index articles with at least 1 subgroup finding in the abstract. Study selection: Articles with a subgroup claim in the abstract with or without evidence of statistical heterogeneity (P < .05 from an interaction test) in the text and articles attempting to corroborate the subgroup findings. Data extraction and synthesis: Study characteristics of trials with at least 1 subgroup claim in the abstract were recorded. Two reviewers extracted the data necessary to calculate subgroup-level effect sizes, standard errors, and the P values for interaction. For individual RCTs and meta-analyses that attempted to corroborate the subgroup findings from the index articles, trial characteristics were extracted. Cochran Q test was used to reevaluate heterogeneity with the data from all available trials. Main outcomes and measures: The number of subgroup claims in the abstracts of RCTs, the number of subgroup claims in the abstracts of RCTs with statistical support (subgroup findings), and the number of subgroup findings corroborated by subsequent RCTs and meta-analyses. Results: Sixty-four eligible RCTs made a total of 117 subgroup claims in their abstracts. Of these 117 claims, only 46 (39.3%) in 33 articles had evidence of statistically significant heterogeneity from a test for interaction. In addition, out of these 46 subgroup findings, only 16 (34.8%) ensured balance between randomization groups within the subgroups (eg, through stratified randomization), 13 (28.3%) entailed a prespecified subgroup analysis, and 1 (2.2%) was adjusted for multiple testing. Only 5 (10.9%) of the 46 subgroup findings had at least 1 subsequent pure corroboration attempt by a meta-analysis or an RCT. In all 5 cases, the corroboration attempts found no evidence of a statistically significant subgroup effect. In addition, all effect sizes from meta-analyses were attenuated toward the null. Conclusions and relevance: A minority of subgroup claims made in the abstracts of RCTs are supported by their own data (ie, a significant interaction effect). For those that have statistical support (P < .05 from an interaction test), most fail to meet other best practices for subgroup tests, including prespecification, stratified randomization, and adjustment for multiple testing. Attempts to corroborate statistically significant subgroup differences are rare; when done, the initially observed subgroup differences are not reproduced.
Article
The central purpose of this study is to document how a sharper focus upon statistical power may reduce the impact of selective reporting bias in meta-analyses. We introduce the weighted average of the adequately powered (WAAP) as an alternative to the conventional random-effects (RE) estimator. When the results of some of the studies have been selected to be positive and statistically significant (i.e. selective reporting), our simulations show that WAAP will have smaller bias than RE at no loss to its other statistical properties. When there is no selective reporting, the difference between RE's and WAAP's statistical properties is practically negligible. Nonetheless, when selective reporting is especially severe or heterogeneity is very large, notable bias can remain in all weighted averages. The main limitation of this approach is that the majority of meta-analyses of medical research do not contain any studies with adequate power (i.e. >80%). For such areas of medical research, it remains important to document their low power, and, as we demonstrate, an alternative unrestricted weighted least squares weighted average can be used instead of WAAP. Copyright
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In Reply Drs Miller and Sittig challenge our claim that the big ideas that have long dominated biomedical research have underperformed. Interestingly, they admit that morbidity and mortality can be reduced by “getting the general population to eat less and exercise more; reducing the incidence of drunk driving; increasing the use of seat belts, child restraints, and bicycle helmets; and reducing cardiovascular disease risk through aspirin, blood pressure control, cholesterol reduction, and smoking cessation.” Indeed, these interventions constitute a terrific research agenda! Why not devote more research funds to finding out how to make these interventions more efficient?
Article
Over the past seven decades, randomised controlled trials (RCTs) have revolutionised clinical research and achieved a gold standard status. However, extending their use to evaluate complex interventions is problematic. In this paper we will demonstrate that complex intervention RCTs violate the necessary premises that govern the RCTs logic and underpin their rigour. The lack of blinding, heterogeneity of participants, as well as poor treatment standardisation and difficulty of controlling for confounders, which characterise complex intervention RCTs, can potentially be profoundly detrimental to their integrity. Proponents of this approach argue that matching "real world" circumstances, while maintaining the randomised design, enhances external validity. We counter this argument by pointing out that an inverted U relation exists between internal and external validity, and thus relaxing the experimental conditions beyond a certain threshold can potentially paradoxically render the RCT externally invalid, i.e. its results cannot be used anywhere. We shall illustrate the inappropriate use of RCTs to evaluate community treatment orders and propose an alternative epistemic model that is based on mechanistic reasoning and Cartwright's capacity concept.
Article
Low back pain (LBP) is the leading cause of disability worldwide. Various approaches to diagnose and manage LBP have arisen, leading to an exponential increase in health care costs. Paradoxically, this trend has been associated with a concurrent increase in disability and chronicity. The health care system faces enormous challenges, with both the disability burden and financial impact relating to LBP escalating. Growing evidence suggests that current practice is discordant with contemporary evidence, and is in fact often exacerbating the problem. Change will demand a cultural shift in LBP beliefs and practice. J Orthop Sports Phys Ther 2016;46(11):932–937. doi:10.2519/jospt.2016.0609
Article
No abstract is available for this article.
Article
I first propose to distinguish between two kinds of external validity inferences, predictive and explanatory. I then argue that we have a satisfactory answer to the question of the conditions under which predictive external validity inferences are good. If this claim is correct, then it has two immediate consequences: First, some external validity inferences are deductive, contrary to what is commonly assumed. Second, Steel’s requirement that an account of external validity inference break what he calls the ‘Extrapolator’s Circle’ is misplaced, at least when it comes to predictive external validity inferences.
Article
This article presents elements to better understand health systems from the complexity approach, a position that moves away from the linearity, rigidity, and directional. It is characterised by the study of the emergence of unexpected behaviours, oriented to explain and understand more completely what happens in health systems. The current systems are becoming overwhelmed. The complexity paradigm represents a conceptualisation different to the prevalent epistemol-ogy, non-isolated, non-reductionist, or fixed. It does not solve the problems, but presents other bases to fully understand the physical, biological and social systems. It is a perspective that has its basis in the systems theory, informatics and cybernetics beyond traditional knowledge, the positive logics, Newtonian physics and symmetric mathematics, in which everything is centred and balanced. It is the link between the "soft" and "hard sciences, and takes into account the determining factors of social health and organisation culture. Under the complexity paradigm the health systems are identified with the following concepts: entropy, negentropy, the second law of thermodynamics, attractors, chaos theory, fractals, self-management and self-organization, emerging behaviours, percolation, uncertainty, networks, and robustness. These expressions open new possibilities to improve the management and better understanding of the health systems, giving rise to consider health systems as complex adaptive systems. © 2015 Academia Mexicana de Cirugía A.C. Publicado por Masson Doyma México S.A.
Article
Background: Evidence-based practice (EBP) is promoted to ensure quality of care. However, analysis of the skill of physiotherapists in undertaking the steps of EBP, or the impact of EBP on the work of physiotherapists is limited. Objectives: To conduct a scoping review into physiotherapists performing the steps of EBP. Data source: Literature concerning the skill of physiotherapists in EBP between 1990 and June 2013 was searched using AMED, Academic Search Complete, CINAHL, PubMed, ERIC, PEDRO and EMBASE databases. Study selection: Twenty-five studies (six qualitative, one mixed methods and 18 quantitative) were selected. Data extraction and synthesis: Quantitative and qualitative data were extracted using two appraisal tools to analyse each of the five steps of EBP. Results: Limited evidence exists to show that physiotherapists undertake the full EBP process. Despite formulating clinical questions and acquiring literature-based evidence, the drivers for conducting literature or evidence searches have not been clarified. The critical appraisal step was mainly assessed in the form of recognition of statistical terms. Only examples of guideline usage support the reflective final assessment step. Physiotherapists report using their peers and other trusted sources in preference to literature, primarily due to time but also due to divergence between the literature-based evidence and other evidence that they use and value (tacit knowledge). A positive impact of EBP on patient outcomes is lacking. Conclusions: Understanding the information needs of physiotherapists may be necessary before adoption of the EBP process. The use of professional networks may offer a better means to identify knowledge gaps and translate acquired knowledge into practice, rather than focusing on individual skills in EBP.
Book
Commit it then to the flames: for it can contain nothing but sophistry and illusion.' Thus ends David Hume's Enquiry concerning Human Understanding, the definitive statement of the greatest philosopher in the English language. His arguments in support of reasoning from experience, and against the 'sophistry and illusion' of religiously inspired philosophical fantasies, caused controversy in the eighteenth century and are strikingly relevant today, when faith and science continue to clash. The Enquiry considers the origin and processes of human thought, reaching the stark conclusion that we can have no ultimate understanding of the physical world, or indeed our own minds. In either sphere we must depend on instinctive learning from experience, recognizing our animal nature and the limits of reason. Hume's calm and open-minded scepticism thus aims to provide a new basis for science, liberating us from the 'superstition' of false metaphysics and religion. His Enquiry remains one of the best introductions to the study of philosophy, and this edition places it in its historical and philosophical context.
Article
To estimate disability from the remainder of musculoskeletal (MSK) disorders (categorised as other MSK) not covered by the estimates made specifically for osteoarthritis (OA), rheumatoid arthritis (RA), gout, low back pain and neck pain, as part of the Global Burden of Disease (GBD) 2010 study. Systematic reviews were conducted to gather the age-sex-specific epidemiological data for other MSK. The focus was on finding health surveys and published studies that measured the overall amount of MSK disorders and complaints, and classified the remainder of MSK disorders that was not RA, OA, gout, low back or neck pain. Six levels of severity were defined to derive disability weights (DWs) and severity distribution. The data, DWs and severity distribution were used to calculate years of life lived with disability (YLDs). Mortality was estimated for MSK-related deaths classified under other MSK. YLDs were added to years of life lost (YLLs) from the mortality estimates to derive overall burden in disability-adjusted life years (DALYs). Global prevalence of other MSK was 8.4% (95% uncertainty interval (UI) 8.1% to 8.6%). DALYs increased from 20.6 million (95% UI 17.0 to 23.3 million) in 1990 to 30.9 million (95% UI 25.8 to 34.6 million) in 2010. The burden of other MSK increased with age. Globally, other MSK disability burden (YLD) ranked sixth. Ageing of the global population will further increase the burden of other MSK. Specific MSK conditions within this large category should be considered separately to enable more explicit estimates of their burden in future iterations of GBD.
Article
Evidenced-based medicine (EBM) is a philosophic approach to clinical problems introduced in the 1980s by a group of clinicians at McMaster University in Canada with an interest in clinical epidemiology. The concepts associated with EBM have been widely disseminated. While many feel EBM represents a paradigm shift,1,2 others have debated the usefulness of this approach.3
Article
A NEW paradigm for medical practice is emerging. Evidence-based medicine de-emphasizes intuition, unsystematic clinical experience, and pathophysiologic rationale as sufficient grounds for clinical decision making and stresses the examination of evidence from clinical research. Evidence-based medicine requires new skills of the physician, including efficient literature searching and the application of formal rules of evidence evaluating the clinical literature.An important goal of our medical residency program is to educate physicians in the practice of evidence-based medicine. Strategies include a weekly, formal academic half-day for residents, devoted to learning the necessary skills; recruitment into teaching roles of physicians who practice evidence-based medicine; sharing among faculty of approaches to teaching evidence-based medicine; and providing faculty with feedback on their performance as role models and teachers of evidence-based medicine. The influence of evidencebased medicine on clinical practice and medical education is increasing.CLINICAL SCENARIO A junior medical resident working in a teaching hospital
Article
Evidence is mounting that research is riddled with systematic errors. Left unchecked, this could erode public trust, warns Daniel Sarewitz.
Article
Rationale, aims and objectives: Systematic reviews, meta-analyses and clinical guidelines (reviews) are intended to inform clinical practice, and in this sense can be thought of as scientific truthmakers. High-quality controlled trials should align to this truth, and method quality markers should predict truth status. We sought to determine in what way controlled trial quality relates to scientific truth, and to determine predictive utility of trial quality and bibliographic markers. Method: A sample of reviews in rehabilitation medicine was examined. Two scientific truth dimensions were established based on review outcomes. Quality and bibliographic markers were extracted from associated trials for use in a regression analysis of their predictive utility for trial truth status. Probability analysis was undertaken to examine judgments of future trial truth status. Results: Of the 93 trials included in contemporaneous reviews, overall, n = 45 (48%) were true. Randomization was found more in true trials than false trials in one truth dimension (P = 0.03). Intention-to-treat analysis was close to significant in one truth dimension (P = 0.058), being more commonly used in false trials. There were no other significant differences in quality or bibliographic variables between true and false trials. Regression analysis revealed no significant predictors of trial truth status. Probability analysis reported that the reasonable chance of future trials being true was between 2 and 5%, based on a uniform prior. Conclusions: The findings are at odds with what is considered gold-standard research methods, but in line with previous reports. Further work should focus on scientific dynamics within healthcare research and evidence-based practice constructs.
Article
This paper offers a systematic reflection on the Gibbons–Nowotny notion of ‘Mode 2 knowledge production’. We review its reception in scientific literature and compare it with seven alternative diagnoses of changing science systems. The ‘Mode 2’ diagnosis identifies a number of important trends that require further empirical efforts, but it suffers from severe conceptual problems. It is time to untie its five major constitutive claims and investigate each separately.
Article
Manual therapy is frequently used to treat low back pain (LBP), but evidence of its effectiveness is limited. One explanation may be sample heterogeneity and inadequate sub-grouping of participants in randomized controlled trials (RCTs) where manual therapy has not been targeted toward those likely to respond. To determine the effectiveness of specific manual therapy provided to sub-groups of participants identified as likely to respond to manual therapy. A systematic search of electronic databases of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled trials (CENTRAL). TRIAL ELIGIBILITY CRITERIA: RCTs on manual therapy for participants identified as belonging to a sub-group of LBP likely to respond to manual therapy were included. TRIAL APPRAISAL AND SYNTHESIS METHODS: Identified trials were assessed for eligibility. Data from included trials were extracted by two authors independently. Risk of bias in each trial was assessed using the PEDro scale and the overall quality of evidence rated according to the GRADE domains. Treatment effect sizes and 95% confidence intervals were calculated for pain and activity. Seven RCTs were included in the review. Clinical and statistical heterogeneity precluded meta-analysis. Significant treatment effects were found favouring sub-group specific manual therapy over a number of comparison treatments for pain and activity at short and intermediate follow-up. However, the overall GRADE quality of evidence was very low. This review found preliminary evidence supporting the effectiveness of sub-group specific manual therapy. Further high quality research on LBP sub-groups is required.
Article
To what extent do the results of randomized controlled trials inform our predictions about the effectiveness of potential policy interventions? This crucial question is often overlooked in discussions about evidence-based policy. The view I defend is that the arguments that lead from the claim that a program works somewhere to a prediction about the effectiveness of this program as it will be implemented here rests on many premises, most of which cannot be justified by the results of randomized controlled trials. Randomized controlled trials only provide indirect evidence for effectiveness, and we need much more than just randomized- controlled-trial results to make reliable predictions.
Article
For evidence-based practice and policy, randomised controlled trials (RCTs) are the current gold standard. But exactly why? We know that RCTs do not, without a series of strong assumptions, warrant predictions about what happens in practice. But just what are these assumptions? I maintain that, from a philosophical stance, answers to both questions are obscured because we don't attend to what causal claims say. Causal claims entering evidence-based medicine at different points say different things and, I would suggest, failure to attend to these differences makes much current guidance about evidence for medical and social policy misleading.
Article
Evidence based practice has been defined as "the explicit, conscientious and judicious attempt to find the best possible available research evidence to assist the health professionals to make the best decision for their individual clients." (Sackett et al., 1996). In clinical manual therapy practice, this involves integrating research evidence with clinical experience and patient values. Currently randomised controlled trials are considered the highest level of research design in terms of strength of the evidence provided, due to the methodological control of potential sources of bias. However, the mechanisms that ensure internal validity of an RCT, i.e. randomisation, and intervention standardisation, threaten the generalisibility, and therefore relevance of the evidence to manual therapy. Manual therapy represents a complex intervention and therapists need to review the notion of 'research evidence', in the context of the clinical practice of manual therapy. Reviewing the construct of what constitutes an intervention, increasing post-hoc analysis of subject sub groupings and revisiting 'lower levels' of research design are all suggested as possible approaches.
Article
This article is the first of a series providing guidance for use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of rating quality of evidence and grading strength of recommendations in systematic reviews, health technology assessments (HTAs), and clinical practice guidelines addressing alternative management options. The GRADE process begins with asking an explicit question, including specification of all important outcomes. After the evidence is collected and summarized, GRADE provides explicit criteria for rating the quality of evidence that include study design, risk of bias, imprecision, inconsistency, indirectness, and magnitude of effect. Recommendations are characterized as strong or weak (alternative terms conditional or discretionary) according to the quality of the supporting evidence and the balance between desirable and undesirable consequences of the alternative management options. GRADE suggests summarizing evidence in succinct, transparent, and informative summary of findings tables that show the quality of evidence and the magnitude of relative and absolute effects for each important outcome and/or as evidence profiles that provide, in addition, detailed information about the reason for the quality of evidence rating. Subsequent articles in this series will address GRADE's approach to formulating questions, assessing quality of evidence, and developing recommendations.