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"Is the Research Sound?"
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"Is the Research Sound?" - May 24, 2005 5:16:00 PM
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jma
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Hello,
Here is the link in JOSPT (5/05) to an interesting article that talks about current research and how we should be looking at it. Worth reading. Here is the link:
http://jospt.org/members/fulltext/2005/may/May2005-Editorial.pdf
JMA
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Re: "Is the Research Sound?" - May 24, 2005 5:24:00 PM
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tamil
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The link is not working.
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Re: "Is the Research Sound?" - May 24, 2005 5:29:00 PM
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jma
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Hmmm,
One can try just clicking on http://www.jospt.org and then see if they can open the article link located in the editorial sections and see if that works.
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Re: "Is the Research Sound?" - May 25, 2005 12:45:00 AM
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KAK
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I read that yesterday. My background in stats is minimal and I never did quite get it- even in school. I’m not sure why I wasn’t highly motivated to understand then. Maybe because there was not a big push for EBM 22 years ago, and I have had a core belief those stats can be manipulated to prove a bias. I have always felt a bit inadequate as I skimmed (some times skipped) the more complicated data analysis while reading journals.
Having said that- my response to the editorial was one of motivation. I had already planned on starting the process of my t-DPT in the next year or two, but if I finish my current projects before then I’ll start some stat study on my own.
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Re: "Is the Research Sound?" - May 25, 2005 1:55:00 AM
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interstella
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The trouble with educating therapists to look at research is most methods use the heirechical view of evidence to explain the differences - where RCT's are reveeered and qualitative research is seen as less valid and near the bottom of the pile.
This view is out of date; qualitative research is just as important as 'experimental research' - it just looks at issues from a different perspective.
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Re: "Is the Research Sound?" - May 25, 2005 3:57:00 AM
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JLS_PT_OCS
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The issue, however, with qualitative research is that we have difficulty generalizing any findings or conclusions to other groups of patients.
Case studies/series are invaluable to help guide research directions, but the strength of their conclusions and their generalizability is the main issue. That's what makes a RCT or even better a validated RCT so important.
Healing people is a complex business, with lots of variables involved, not all of which can be measured in a study. But in order to get out of the absolutely bizarre variation in practice that is currently seen, RCTs provide some of the best guidance in treatment direction.
While qualitiative research is just as important in that we need it as well, it is not nearly as important/ persuasive due to it's inherent limitations I mentioned above.
I am no stats guru, but I have found even a little bit of education in this area has gone a long way towards my ability to peruse research.
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: "Is the Research Sound?" - May 25, 2005 4:30:00 AM
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jma
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I too hope to learn a lot from this as I look at the research. Not really emphasized in school except the numbers and the tests used to obtain those numbers. The references given are a great start to all this.
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Re: "Is the Research Sound?" - May 25, 2005 5:42:00 AM
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PTupdate.com
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I think getting PT's to learn how to critically review research is a lost cause. 99% of the PT's I know don't even bother to READ research and learn more, let along take the time to become proficient at understanding research methods and statistics, and then apply that to what they already are not reading.
Many others have even admitted to reading just the abstract, and basing conclusions and future treatments on what they read there!!!! Almost every medical and peer reviewed journal has the abstracts online for free, and some just read these abstracts in order to avoid paying for the journal....not always a good thing.
Plus, I think that the average PT "brain" (mine included) isn't geared towards math and stats, which is why most of us excel at PT, biology, chemistry, etc. Did you ever notice how people who are math whizzes usually suck at memorization sciences?
Much of the research I have seen has flaws that are visible in the product they give us, and it makes me wonder how many more flaws are tucked away. Spine journal recently did a critique of that particular journal, digging into fiding out how many studies did not even bother performing a power analysis to determine the prevalence of type II errors....it ended up being quite high.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: "Is the Research Sound?" - May 25, 2005 7:14:00 AM
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Dr.Wagner
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Mr. Duffy is absolutely correct, my ability to critically review research didn't truly develop until residency training. It takes time to develop...alot of time. Generally research in PT literature is of poor quality, generally poorly powered and with very little randomization. But those are simply the limitations that are accepted. Not everyone has the resources of GIANT cardiology research of THOUSANDS of patients.
I think if one reads the articles with critical eyes (actually READING the article not just the abstract), then that is a good start. Physical therapy is such a wonderful combination of art and science that to become too EBM would certainly exclude some fantastic aspects of PT (and likely lead to the developement of other specialties to fill in the gaps ie LMT's DC's etc).
One should certainly not throw the baby out with the bath water.
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Dr. Wagner DO
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Re: "Is the Research Sound?" - May 25, 2005 8:08:00 AM
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JLS_PT_OCS
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Well said, Wags.
And Duff, don't despair. We PTs are not alone in our practice variation and poor global use of EBM. While your characterization of PTs may have some truth to it, let's not kid ourselves and think that every other profession out there is living by their professional journals, they're not.
I read a study recently on prescribing habits of family medicine practitioners... the gist was that the meds chosen were more dependent on what colleagues in the office were doing and what drug reps had come most recently.
Really.
Wags makes a good point, the money for physical medicine research (whether by PTs or MD/DOs) is not as large and forthcoming as it is for drug research. How complex is that? You're either the group taking the pill or in the group taking the placebo. It doesn't take much stats knowledge to figure that out.
It has been my personal experience that the primary care folks I interface with the most are just as ignorant of research methods and stats as are most of us.
But things are changing, always slowly, and that sort of change starts at the university/PT school level, where this training and EBM emphasis is already being embraced.
I think the t-DPT / DPT transition has been very important for that. Whether we needed the "D" to be good at research and EBM is, of course, another thread. :)
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: "Is the Research Sound?" - May 25, 2005 12:50:00 PM
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KAK
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Duffy’s comment about 99% of the PT’s not reading research perked my curiosity. I am polling my colleagues. I’ve gotten through half the staff therapists and 70% HAVE read a PT related research article in the past 2 months. I’ll let you know the results when I poll them all.
Of course it won’t be a large enough number to generalize to the whole population (we have 12 therapists). Jason, how many do we need?
Would any one else be willing to poll their co-workers and friends? It would be interesting to see how many out there are keeping up.
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Re: "Is the Research Sound?" - May 25, 2005 1:33:00 PM
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interstella
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The division of research into qualitative and quantitative is confusing. The best way to look at research it is to firstly determine how you view knowledge
Do you believe that there is only one answer or one reality?
Or do you believe that there are multiple realities?
If you believe that there is only one answer, then your questions can be only answered by experimental science.
If you believe that there are 'multiple realities' then your research approach will depend on the topic of your study or your research question. There is no need to say whether one research approach is better or worse than another - the research approach suits the need.
Incidentally, 'qualitative research' 'meta analysis' are being developed at the moment.
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Re: "Is the Research Sound?" - May 25, 2005 2:49:00 PM
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SJBird55
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I think that both kinds of research are necessary. As with anything, balance is important. If all the research was only quantitative, we'd be missing a lot of good information - and the same goes for if all the research were qualitative.
Examples of qualitative studies... what makes an expert therapist; does years of experience equate to expert; how are clinical decisions made; how are novice and experienced therapists different; who gets the best outcomes and how is that group of therapists different....
I think the problem in our professional field is that there is a small subset of therapists leading the research. Orthopaedically, I can probably easily come up with a couple dozen names at the top of my head. They are all basically tied to the educational world in some way, shape or form. I would assume that most of their studies are funded by grants. And, money talks... the pharm companies NEED the studies with a huge RCT in order to get their med on the market approved by the FDA - of course, they'll pay for that research to occur. Financially, the pharm companies have a huge initial upfront expense, but if the med is approved, they profit. We don't really have anything like that in our field. The clinicians in the trenches with the years of experience, in my opinion, would be the best candidates for doing something in the research area, but there is no incentive, there is no support and there is nothing in it for them. In my opinion, some of the most clinically applicable research has come from therapists actually working clinically - and the least useful in regard to being clinically applicable seems to come out of the ivory tower.
The EBM is a good push in the right direction... but there really isn't anything wrong with reading the abstract, Duffy. The first question I ask myself before even picking apart any article is more along the lines of clinical relevancy. If I read the abstract and I get the "well, duh" thought in my head, no, I don't read the article. If I read the abstract and I get the "who cares" thought in my head, no, I don't read the article. If I get the "whoa, that doesn't make sense" thought, I generally read the article. If I get the "hmmm, never thought of it that way" initial response, then I read the article.
When it comes to the stats, just because something is statistically significant doesn't always mean that it is clinically significant.
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Re: "Is the Research Sound?" - May 25, 2005 3:23:00 PM
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jma
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Good points. Makes a lot of sense. The minority of PTs are doing the majority of all the research being published out there.
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Re: "Is the Research Sound?" - May 25, 2005 5:13:00 PM
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PTupdate.com
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Jeeze KAK, are we supposed to be happy that 70% of your co-workers read an article in the past two months? I think that is a terrible rate of continued self education. There is no reason a PT cannot read quite a few articles each week...no reason what-so-ever.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: "Is the Research Sound?" - May 25, 2005 6:40:00 PM
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Andrew M. Ball PT PhD
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Wait, wait, wait,
There are quite a few incorrect statements and assumptions here that are being allowed unchallenged. With respect to qualitative methods, SJ is actually the closest to accurate.
The first malassumption is that a case report is the best, or even only, form of qualitative research. Technically, it's not qualitative research at all. Sometimes single subject designs are confused with case studies, which are quantitative --- just extremely low power.
The second malconception is the common complaint of quantitative researchers is that qualitative results cannot be generalized to larger populations. Not only is this assumption not entirely true, it misses the point . . . the essence . . . of qualitative research. Qualitative research is not as concerned with generalization to larger populations as it is to different samples, settings, and situations.
I know a bit about this, as my PhD, in large part, focused upon economic analysis and qualitative research methodology.
Qualitative research represents the other side of the “coin of research” by aiming not to establish cause and effect relationships, but to, “describe the experiences of people in particular settings and to understand their perspectives. Its purpose is also to develop hypothesis, concepts and theory.” It is guided by three underlying assumptions. First, human behaviors extend beyond the observable and incorporate subjective meanings, values, and perceptions that are difficult, (if not impossible), to quantify. Second, actions and ideas can only truly be understood from within the physical, economic, and socio-cultural contexts in which they exist. Third, people (including researchers using any methodology) interpret realities differently due to past experiences. There are therefore no objective truths. Just as quantitative research has its roots in Newtonian physics, qualitative research is actually rooted from the relativistic philosophies of quantum mechanics. Zukav contrasted these philosophical assumptions as follows:
"The old physics [Newtonian/quantitative research] assumes that there is an external world which exists apart from us. It further assumes that we can observe, measure, and speculate about the external world without changing it . . . . the new physics, quantum mechanics [qualitative research], tells us clearly that it is not possible to observe reality without changing it. If we observe a certain particle collision experiment, not only do we have no way of proving that the result would have been the same if we had not been watching it, all we know indicates that it would not have been the same, because the results that we got were affected by the fact that we were looking for it."
In fact, the most popular physicist of our time, Albert Einstein, noted the inadequacies of Newtonian physics in explaining the universe. It was only following his drift toward quantum mechanics that the world was graced with the Theory of Relativity (E=mc2), the Theory of Everything (TOE), and atomic energy. If quantitative methods proved inadequate for some of the most important developments in a “hard science” such as physics, it’s hard to argue that qualitative methods wouldn’t have as profound effects upon the understanding of human behavior and movement pathology. Perhaps qualitative methods would enjoy greater acceptability among quantitative researchers if they were more accurately referred to as quantum methods, thereby reclaiming Einstein as the father of the discipline. Qualitative/Quantum methods are guided by five underlying assumptions that stand in direct contrast to those of quantitative researchers, as articulated by Lincoln and Guba:
·There are multiple constructed realities. The truth of which is illustrated by the notion that, “Beauty is in the eye of the beholder.”
·Investigators and subjects are interdependent. The process of questioning and/or observation will add to, and forever change, the sum experience of both participant and researcher. This interdependence is not only acceptable --- it is often desirable.
·Results are time and context specific. It is considered idiographic, though insights gained through specific research may generate generalized curiosities regarding the possible observation of similar patterns and themes in other times, settings, and samples.
·Cause and effect cannot truly be determined. Everything is relative. It’s therefore more productive to describe and interpret events than to attempt to control them in the ultimate generation of oversimplified cause and effect relationships that are not truly ever generalizable to real life.
·Research is never free of values and subjectivity.
Rather than deducing fact, qualitative methods begin with concepts and constructs deemed important to understand (recognizing that participants may re-define other realities that may be of greater importance in the understanding of a particular phenomenon). Investigators therefore seek to describe and understand subjective behaviors and phenomena, thereby inducing hypotheses. It’s a valuable process that compliments quantitative methods by examining the meanings and motives of behaviors that cannot be accurately (or at least easily) measured by more traditional quantitative methods.
In contrast to quantitative research, where samples are randomized in an effort to exert maximum control and minimize the influence of factors external to the cause and effect relationship under investigation; qualitative researchers identify purposeful samples of individuals whom the investigator believes will enlighten understanding of a particular phenomenon. Whereas small sample sizes are considered a fundamental limitation of quantitative research due to difficulties in both statistical analysis and generalization of results to larger populations, qualitative/quantum research is not bound by these rules because statistical analysis and generalization to larger populations were never the goals of the investigation in the first place.
The most striking methodological difference between qualitative and qualitative methods is a direct result of their emergence from Newtonian and Quantum physics respectively. In order to investigate the possible presence or absence of a cause and effect relationship, it is necessary to choose a cause (independent variable) to manipulate, and observe its effect upon a specific outcome (dependent variable). The extent to which other independent variables can be controlled will affect the confidence with which the researcher can proclaim the existence and influence of a cause and effect relationship. Because the goal of both qualitative research and quantum physics is to not artificially manipulate, but to rather describe and understand the unpredictable interaction of known and unknown variables, there is no need (nor desire) to control and manipulate. In the words of physical therapy researcher and educator Elizabeth Domholdt, PT, Ed.D., “The mere fact that the researcher is present or asks certain questions is bound to influence the subjects and their perception of the situation.” Given this philosophical difference, it is clearly understandable why both qualitative and quantum researchers alike believe there is very little to be gained, and much to be lost, from creating and artificial research situation or environment.
For example, Susan McGinty's research suggested that “cost” accounts for roughly 80% of the reason that physical therapists choose not to join the American Physical Therapy Association (APTA). Upon realizing that APTA membership fees are different from state-to-state, for identical (or at least similar) products, and knowing both membership fees and market saturation for each state, for my MBA I created a demand curve (receiver operating curve) and calculated a coefficient of determination (R2). In a completely objective manner, the R2 suggested that cost had a far less significant influence upon decisions not to join the APTA . . . not 80%, but rather somewhere around 9%. Given this discrepancy between what non-members report on surveys, and no appreciable increase in market saturation rates in states with lower chapter dues, the question posed by my upcoming Ph.D. dissertation, “What motivates a person to choose not to be involved in their professional organization?,” is clearly better explored through qualitative means. In other words, because physical therapists apparently don’t feel comfortable with answering survey questions on this issue truthfully, (e.g. choosing to respond with the ego protecting, “It’s too expensive,” than what may be a more accurate answer of, “I’m an apathetic therapist.”), qualitative methods may more accurately uncover the motives behind these decisions.
Similarly, and more commonly, qualitative methods are used to describe the experiences of patients and families. The qualitative approach arguably offers enhanced researcher access to the study of patient experiences at the disability and functional limitation levels of Disability Models Considering the increased focus of allied health professions upon the upper levels of the disability model with respect to both treatment and outcome measures in recent years, it is no surprise that qualitative methods are being used with increasing frequency to explore the patient condition. Questions posed at the disability and functional levels simply cannot be answered by quantitative methods alone.
There are several ways that qualitative designs tend to be classified. Boundaries between them are flexible and fluid. Some studies may seem to fall into more than one category, while others may not seem to fall into any. Though quantitative researchers may feel a need to precisely define qualitative research designs, strict classification is of little concern to the qualitative researcher. To do otherwise actually violates one of the basic philosophies of qualitative research. In the words of physical therapy researcher and author Elizabeth Domholdt, Ed.D., PT, “arguments about which definition is the ‘one true definition’ tend to be counterproductive in that they violate one of the basic tenets of qualitative research --- the acceptance of multiple realities. Thus, readers should use this classification of qualitative research as one way to organize information and recognize that other may use equally useful alternative classification systems.”
·Ethnography
The goal of the ethnographic approach is, as an outsider, to describe the feelings and meanings of a culture from the perspective of the insider, through study of emotions and meanings of the people within that culture. The culture can be defined broadly (e.g. people with disabilities), or narrowly (e.g. directors of physical therapy education program). The terms macroethnograry and microethnography are sometimes used to describe the characteristics of the sample group. It’s not so much studying participants, as it is learning from participants.
·Phenomenology
The goal of the phenomenologic approach is a bit narrower than the ethnographic. Researchers seek to describe not life and culture in total, but some specific aspect of life as lived by the participants. The difference between ethonographic interview and phenomenologic methods may be illustrated by examining the question of why some physical therapists choose not to be members of the APTA. Phenomenologic study may be narrowed in focus to physical therapy non-members alone, while ethnographic study may expand to question APTA members, and perhaps members and non-member groups of other disciplines.
·Grounded Theory
The goal of grounded theory approach is to develop initial theories, initial concepts, and initial frameworks about the nature of a specific topic or interest --- that are grounded in data. In grounded theory, the researcher does not enter into investigation with, “hypothesis in hand,” but rather tries to identify variables, and/or generate ideas and models to be subsequently tested through ethnographic, phenomenologic, or even quantitative methods.
Qualitative methods can confuse the qualitative researcher who’s used to evaluating research in terms of (among other things) factors such as control of external variables, and number of subjects in the study. Quantitative researchers believe that, “people are inseparable from their contexts or environments,” and as such, analyze not only the subject, but the way that the subject interacts with the world on social, cultural, physical, economic, political, legal, and historical grounds. While qualitative researchers give the highest respect to research where both subjects and researchers are unaware of who is in the experimental group and who is in the control group (e.g. randomized controlled trials), qualitative researchers make no attempt to do so, recognizing that the presence of the researcher is simply another context of the environment in which the subject is operating. In addition, qualitative researchers are not particularly concerned with the number of subjects in their study, rather ceasing to recruit new subjects for study at the point where the data becomes saturated and no new themes are emerging, whatever the “n” may be. Finally, qualitative researchers recognize the cooperative relationship that occurs between the researcher and subject in generating data. Out of that respect, the term subject is replaced by the more accurate participant or sometimes even, co-researcher.
Again, a common complaint of quantitative researchers is that qualitative results cannot be generalized to larger populations. Not only is this assumption not entirely true, it misses the point . . . the essence . . . of qualitative research. Qualitative research is not as concerned with generalization to larger populations as it is to different samples, settings, and situations. In other words, the qualitatively identified sentiment of a small sample of APTA non-members (e.g. that APTA membership is a poor dollar value) may not be generalizable to the larger population of all non-member physical therapists though it may suggest areas for further quantitative research. The results of the qualitative study may however be generalizable in terms of suggesting that similar sentiments may exist among groups of professional association non-members of other disciplines.
Hope that helps clarify some thing, and give pause for personal self-review regarding the value of qualitative research.
Drew
Qualitative Researcher
_____________________________
Dr. Andrew M. Ball, PT, DPT, Ph.D.
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Re: "Is the Research Sound?" - May 25, 2005 11:43:00 PM
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interstella
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Another point is that qualitative or intepretive research aims to develop theory whilst quantitative research is concerned with testing theory.
Without interpretive research we would have a very narrow view of practice.
It is such a shame that interpretive reserarch is considered the ugly little sister.
Drew you are so right about understanding the concept of 'value.' To me, that is fundamental and what is so exciting about qualitative research. I have just finished my MSc, and found that releasing the chains of objectivity and immersing myself within the project has changed me completely. I look at everything from a different perspective now, and cant believe what Ive been missing all these years!
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Re: "Is the Research Sound?" - May 26, 2005 4:38:00 AM
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Yogi
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Drew, thanks for the excellent overview, esp. the case study point that it is actually quantitative of low power. I had always thought case studies were qualitative, due to being descriptive. I really liked the point that qulitaive research purpose is to "descibe and develop hypotheses, concepts, and theory.
I'm not too certain about multiple realities, the way I think about it is that there are things in the one reality we are not aware of, but when we do become aware of them, we can disseminate that awareness via publishing of case studies and qualitative research, which might indicate need for quantitative studies.
Points were made about funding quantitative research. We all know about the, what's it called? The orphan diseases that are too rare to sink research money into. I doubt if there's been any RCTs done for Stiff Person Syndrome, my guess is it was identified as an entity via case studies.
I've always seen case studies as descriptive, often bringing attention to the rare and unusual, and they have often led to outcome studies, esp. in the ortho/surg literature, necessary to judge results of procedures, often times resulting in the procedures being abandoned. That is power, maybe not statistical, at least initially, but over time.
The first research item I found searching for info on low intensity long duration stretching almost twenty years ago, was a single descriptive case study using a turnbuckle in a split cast, from sometime around 1940, I think. Now we have, with better technology, Dynasplints and the rest.
I think everyone here has leanings, but everyone sees the need for both types, so everyone accept kudoes for very excellent input on this topic.
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Re: "Is the Research Sound?" - May 26, 2005 4:44:00 AM
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Yogi
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One last thought on the soundness. Descriptively that's not much of an issue, but there sure used to be alot of soundness issues quantitatively, I could identify poor soundness in design quite easily, but stat wise I had to take them at their word, even if it seemed not quite right. I do know that some universities have staff statisticians that do or assist in the analysis. I'm sure this is all improving alot now that it's getting so much attention, as this thread is indicative of. In all research, I have to make the assumption no one is lying.
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Re: "Is the Research Sound?" - May 26, 2005 5:48:00 AM
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Yogi
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Here's a research report from another field. I knew a Psychology Doc that worked for the FAA back in the eighties. They were researching effects of alcohol and sleep deprivation and the mandatory pilot retirement age. They happened to have a cou;le of orangutans so they thought they since they had some non-human subjects they would research majariana effects also. I started laughing and said I could tell him what happened without him telling me. He said I was right. Can anyone guess what I predicted to him? Answer will be provided if no one gets it correct, and/or if someone asks.
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