Making meaning from research; developing ways to best apply research to practice.
Hub Coordinators: A/Profs Jean Hay-Smith and William Levack
- Developing methods for evidence synthesis in rehabilitation
- Addressing challenges in evidence-based practice in rehabilitation for traumatic brain injury
- Evidence reviews on rehabilitation for problems with incontinence
- Past publications on methods for evidence syntheses in rehabilitation
Approximately 2.5 million new scientific papers are published every year. These can vary in scientific quality, accessibility, and usefulness. It is increasingly difficult to remain up to date with all the science in one area of clinical practice, or even in just one specialty topic within that clinical area. Systematic reviews and other forms of evidence synthesis are required in order to help people make sense of this research, and even then tools and techniques may be needed to help apply this knowledge to clinical practice. Staff at RTRU specialise in the implementation of methods for evidence synthesis and knowledge translation, and have strong links to international groups in this area, including Cochrane (formerlly the Cochrane Collaboration).
In partnership with a new international network, Cochrane Rehabilitation, RTRU was recently successful in securing a $39,300 seeding grant from the Royal Society of New Zealand to support the development of work on better methods for evidence synthesis in rehabilitation. The project, led by Associate Professor William Levack, will center on a series of smaller 6-month projects contributing to a 2-day meeting just prior to the International Society of Physical & Rehabilitation Medicine (ISPRM) Conference in Paris, July 2018.
The project will bring together researchers from around the world to share and discuss innovative thinking to support the objectives of Cochrane Rehabilitation. The specific goals of this meeting are:
- To develop a preliminary guideline for review authors who conduct systematic reviews on rehabilitation topics, to be published on the Cochrane Rehabilitation website
- To develop a series of papers to contribute to a Special Issue of the European Journal of Physical & Rehabilitation Medicine to address the challenges in evidence synthesis (particularly evidence syntheses of RCTs) in rehabilitation.
- To explore opportunities for future international research collaborations to further this work, and ideally the establishment of some kind of a permanent working group.
Projects will focus on challenges in the production of evidence synthesis on rehabilitation topics. Rehabilitation is a complex intervention, which makes it more challenging to study empirically than many pharmaceutical or surgical interventions. For instance, rehabilitation interventions often require active involvement of both patients and the health professional in their delivery, making it impossible to blind study participants to group allocation. These interventions also frequently involve a number of interacting components. For instance, a return to work intervention might involve physical reconditioning, changes to work tasks, communication between injured workers, case managers and employers and so on. These complexities introduce challenges such as ensuring fidelity to an intervention protocol – both in terms of observing it happening and describing what constitutes the intervention. These issues (and more) mean that rehabilitation research is not well served by scientific methods designed for synthesis and translation of evidence from drug trials. New, innovative methods are therefore urgently required. Internationally there has been a significant growth of activity around the design of better ways to undertake rehabilitation research and evidence synthesis – including past work of our collaborating partners. The proposed project will be on the cutting edge of these methodological developments, focusing on novel perspectives and novel methods in evidence synthesis and knowledge translation in rehabilitation research.
In comparison to other conditions such as stroke and spinal cord injury, there appears to be a lack of research-based evidence to guide clinical practice in rehabilitation for traumatic brain injury (TBI). There are far fewer systematic reviews published on TBI compared to stroke and spinal cord injury, and the vast majority of Cochrane reviews on TBI rehabilitation conclude that there is insufficient research to draw any strong recommendations for practice. Recently, the overall quality of reporting of clinical trials involving interventions for TBI has been criticised, with the observation that many of these clinical trials are simply too small (Lu et al., 2015). However, knowledge about how to conduct good studies has been around for TBI as long as it has for stroke or spinal cord injury, so it seems overly simplistic to assume that this problem can be simply addressed by working harder. If it were easy to do good clinical research on TBI rehabilitation, wouldn't these studies have already been done? It is possible that TBI rehabilitation is more difficult to study than rehabilitation for other populations. Speculatively, some of these problems might arise from a higher degree of heterogeneity (variation in presentation and responses to interventions) in populations of people with TBI, greater difficulties with recruitment and retention of people with TBI in clinical trials, and more of a focus in TBI rehabilitation on outcomes that are hard to measure objectively and in a blinded fashion (such as community reintegration, emotional well-being, and quality of personal relationships).
RTRU PhD student, Kadri Englas, is studying the underlying causes of problems with developing a strong evidence base to guide clinical practice in TBI rehabilitation. Beginning in 2018, her PhD will involve analysis of problems in the development of systematic reviews for TBI rehabilitation, including exploration of the experience and knowledge of TBI researchers and authors of TBI reviews regarding the challenges inherent in development this evidence base. This PhD aims to identify the root cause of problems with current approaches to developing evidence-based TBI rehabilitation, and thus provide clear guidance regarding the direction of future research efforts in this area of practice. Are more sophisticated approaches to randomised controlled trails in TBI needed or is a new approach to research in this area required?
Kadri Englas is a physiotherapist from Estonia. Her PhD supervisors are Associate Professors William Levack & Jean Hay-Smith, with advisory input from Dr Alex Pollock, a Cochrane expert and systematic review specialist from Glasgow Caledonian University in Scotland. Kadri's PhD is supported by a grant from Haapsalu Neurological Rehabilitation Centre in Estonia.
Associate Professor Jean Hay-Smith has been a Cochrane reviewer since the 1990s. Five of her nine current Cochrane reviews investigate the effectiveness of pelvic floor muscle training for prevention and treatment urinary incontinence in women.
- Comparisons of approaches to pelvic floor muscle training for urinary incontinence in women
- Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women
- Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women
- Pelvic floor muscle training added to another active treatment versus the same active treatment alone for urinary incontinence in women
- Feedback or biofeedback to augment pelvic floor muscle training for urinary incontinence in women
Jean has also published other types of research syntheses – metasynthesis and critical interpretative synthesis – addressing questions about women’s experiences of pelvic floor muscle training and the challenges and opportunities for implementing pelvic floor muscle training in antenatal and postnatal care. Jean's work in this area of research is ongoing, and currently feeding into RTRU's work on development of guidelines for evidence-synthesis in rehabilitation.
RTRU's past publication on systematic review methods has also included articles on:
- Problems with validity of numeric quality scores (A/Prof Jean Hay-Smith & Emertius Prof Peter Herbison)
- Whether meta-analysis of several small trials can give an accurate estimate of the true effect on an intervention (A/Prof Jean Hay-Smith & Emertius Prof Peter Herbison)
- Whether different types of random allocation concealment lead to different levels of bias (A/Prof Jean Hay-Smith & Emertius Prof Peter Herbison)
- The role of qualitative evidence synthesis in evidence-based physical therapy (A/Prof William Levack)