The goal of this assignment is to critically appraise the scientific research paper "The role of physiotherapy in the treatement of subacromial impingement symptoms" by Dickens, Williams & Bhamra (2005) while describing the goals of the paper, research methods used and the outcomes of the research findings.
What is the methodical paper is about?
The aims of the research paper corresponding to Dickens Williams & Bhamara (2005:1) was to investiagte the potency of a physiotherapy programme in patients with subacromial impingement syndrome.
This paper did not summarize specific modalities and was reliant on convincing the audience that physiotherapy should be looked at as a first line management for subacromial impingement syndrome against today's orthepedic view which would swing towards operative treatment as the corrective action.
The paper was published by Elsevier for the Chartered Culture of Physiotherapy by way of a combined band of physiotherapists and Orthepedic surgeons and was funded by the Physiotherapy Research Basis. When put together these communities may lead the paper to be viewed as home servicing and lead the audience to pinpoint a lack of impartiality.
Patients for the research where taken from a longing list for surgery for subacromial impingement syndrome. Each of these patients was separately reviewed by doctor Adam L Williams, a coauthor of the newspaper, and had "underwent three steroid shots in to the subacromial space, given at 6-each week intervals as part of an exisiting process" (Dickens et al, 2005:160).
The research was conducted in a randomised fashion in that the eighty five clients were chosen by giving a client on a operative waiting around list an envelope that acquired within it either control or physiotherapy, 45 signed up with the physiotherapy group while 40 joined the control group. There have been 100 envelopes divided 50:50 between the groups which leads the reader to trust this might have been quasi-randomised.
In order to examine physiotherapy without bias clients who possessed previous physiotherpay treatement were excluded from the analysis corresponding to Dickens et al. Also clients with signs of "cervical radiculopathy, adhesive capsulitis or medically evident rotator cuff tears. . . or a grade III subacromial spur on their shoulder suprasinatus wall socket radiograph" (Dickens et al, 2005:160). The randomised fashion was implemented by human being administrators rather than via a computerised system.
A control group was used and this group acquired no choice but to keep on towards surgical intervention, this created a bias because of this group since the probability for having operative treatment was P-1.
Intitially the group of patients numbered eighty five patients from a short set of 100 envelopes. 9 of the initial 40 patients in the control group refused to wait the repeat assessmemt at the end of the program, 3 of the physiotherapy group fell out for communal reasons departing 42 partcipating within group. Due to the substantial volume of dropouts weight must be given to the emergence of unfairness to any comparsion portrayed in the paper.
Follow up occurred following a 6 month period and performed by James L Williams, a coauthor of the newspaper, and might not exactly have been blind since he might have easily reviewed whether "they felt they still needed surgery" (Dickens et al, 2005:161).
How the study was designed?
The seeks of the research paper relating to Dickens Williams & Bhamara (2005:1) was to research the effectiveness of a physiotherapy program in patients with subacromial impingement syndrome. According to the Webster dictionary the word performance means "to make a desired impact", the desired impact is not proven in the aim. This ambiguity around the purpose of the paper leaves any summary available to interpretation by the audience. When the paper is read in its entirety you could potentially interpret desire to as conveying the concept that physiotherapy should be first range management for subacromial impingement therefore moving interventive surgery to second lines.
There is not a shared pilot data therefore we cannot correctly build if the sample size for the clinical newspaper is justified. We do know that the randomisation process catered for 100 patients, 100 envelopes, of which only 85 were taken up, 72 patients effectively rendering it to the reassessement level.
The age ranges within the teams have relevance to the results of the clinical research. We have only a mean era of every group without an mention of outliers who could have an effect on the statistical data. It is clear that a lot more junior males act in response better under all conditions. This contradicts the assertion "both categories were well matched up for age, sex and initial regular credit score" (Dickens et al, 2005:161).
The probability values (p-values) have been averaged (p<0. 05) which converys a less correct degree of information. Ideally the exact probability value should have been given. Similarly though talked about not data was provided for the Chi-squared value therefore negating the validity of any imperical data.
This insufficient depth in the data provided does not allow the audience to establish if a null hypothesis was demonstrated and may lead them to believe this was 100 % pure coincidence. Scientific research should always start from the null hypothesis point of view to ensure impartiality.
The selection process for patients, holding out list for surgery, post steroid shot, exclusion of specific pathologies, scientific history and evaluation intended the group might have been skewed to fulfill the authors is designed. Steriod injections can provide a noticable difference in subacromial impingement anticipated to it's anti-inflammatory result. The selection process didn't seem to take into account the period nor the severe nature of the impingement symptoms on the individual nor if they were getting treatment from other practitioners not outlined.
There is not any detailed information regarding the treatment programme dispensed to the physiotherapy patients. If a specific treatment programme had been documented and put on all patients in this group more quantative data and allowed the research to be replicated and possibly validated by other authors. This would have also allowed the treatments to be cross referenced with socio demographic data from each patient and build sub units within the grasp data.
We are uncertain the way the null results are interpreted since the authors do not details this. Nor have they given any data surrounding the chi-squared test. Probability values are give in a round format (p<0. 05) and exact (p=0. 0008), mixing both techniques ensures ambiguity and imprecise effects.
The constant rating has a low systematic error but is not reliable for professional medical follow-up in patients. The continuous scores taken in the beginning of the research were predicated on 85 patients not on a single 72 patients whom allowed themselves to be reassessed by the end of the programme. This lead to too little confidence in the method employed by the writers to compare pre and post program data, they might not have itemised which data belonged to each patient and for that reason cannot remove this anomoly.
The engagement of Adam L Williams in the reassessment process made certain a lack of blinding and a bias, although authors clearly didn't see this position "the follow up assessments were performed by JLW in a blinded situation" (Dickens et al, 2005:162). All assessments must have been performed by the validated alternative party reusing the initial assessment conditions.
Since we have no in depth information about the modalities utilised, treatment cycles matched with socio demographic information there is no medical relevance to the final results. To have professional medical relevance the process must be reproducable which is highly improbable based on the info offered in the methodical paper.
How was the study conducted?
A quasi-randomised real human administer method of 100 envelopes divide evenly between the control and physiotherapy categories were passed out to 85 patients. All 85patients were informed that contribution on the programme would not have an impact on there sitting on a hanging around list for surgery. This promise may have influenced participation since they would have already been convinced of the necessity for surgery by an orthepedic plastic surgeon.
The dropping out of patients in both groupings weakened the statistical data which the paper relies after and imbalanced any findings. Interpreting clinical programmes requires greater participants reducing any prospect of the play of chance.
How was the analysis analysed and have there been limitation and mistakes in the analysis?
Each treatment group must have been similar predicated on age, sex, duration of syndrome, decrease in range of motion and similar capacities to perform the home care plan. Based on the information conveyed in the paper we must assume none of the points were established and therefore does not allowed for every single group to truly have a similar baseline. The quasi-randomised allocation of each patient to a group ensured that the treatment groups weren't comparable.
Since all members stayed within their allocated categories we can set up that the objective was for the results to be analysed by purpose to treat. However there were patient withdrawals from the programme which allows to construe that the comparision of treatments would no longer be reasonable. Also the procedure received within the physiotherapy group as a whole may have differed from person to person but no patient transferred between groupings.
Not enough importance was placed on statistical information like the control group having members who improved, yet weren't involved in the physiotherapy programme. Also confounding may have occured because of the pre program steroid treatment. Steroid shots are interrelated to anti inflammatory improvements in a range of impingement syndromes. The article had no reference to any confidence intervals which would have ensured removing the chance effect and imporved the significance of any reports.
The insufficient statistical data in desk format and the reliance on prose within the paper show the paper to be more a marketing document when compared to a reliable way to obtain data. Quantative data desks would have allowed the reader to see and validate the authors outcomes. This insufficient independence in data lead the reader to wonder does indeed the data actually support the results. The way of only conveying 'results' considered by the authors, could create suspicion in your brain of the audience, undermines the reliability of the paper.
Side effects are an important factor in all scientific research papers. Imagine if the side effect of the treatment modalities outwayed the choice approach considered by the control group. Success of treatment and a smaller set of side effects would need to be established from the control group to ensure there is no bias. Since there is no mention of side effects for either groupings we can only just assume that the authors wished to purposefully withhold these details. This factor only would ensure it clinical relevant is negated.
How would you interpret the analysis and what if any will be the implications of the analysis for your practice?
The main finding "confirms that a physiotherapy programme is of benefit" (Dickens et al, 2005:163) does not confirm the aim of the scientific paper. All the newspaper conveys is that there are successful alternatives to surgery for a subset of the populace. There are too many pervasive factors to count on the statistical significance of the data put forward by the writers. No true finding can be extracted from the paper and it portrays a note established by the writers who went out to establish it.
Therefore I cannot see any try out by the authors to perform a null hypothesis test that ought to have been their strategy. The only assumption to an attempt at a null hypothesis is the assumption that first of the programme no difference existed between all patients in each group. Other alternatives could account for the 11 physiotherapy group patients increasing, steriod injection, age, change in lifestyle etc.
This overlooking of the steroid shot pre programme contribution has a significant impact on the validity of the results. The severe nature and duration of the syndrome on the individual could potentially have an impact of any 'positive' results. The research funder being truly a physiotherapy organisation has may experienced an impact on the interpretation of data. The distance of gap between the post surgery and last step in the physiotherapy program and final evaluation may have had an effect on the results. Rehabilitation programmes may well not have been honored during this period. You will want to take periodical assessements every fortnight over the final 6 month period? We also do not know how the drop outs from the program affect the info use to aid the outcome. We are able to only presume if this data was removed the outcome may never have supported the target and therefore shown the physiotherapy is not or forget about effective than surgery.
Alarmingly this clinical research paper recommendations 26 papers published prior to 2000, the oldest being from 1973, while only 5 paperwork are structured between 200 and enough time of release of the newspaper. This tips to the lack of curiosity about this field or a selective extraction of papers to support the authors objective. Normally assisting information referencing in other records should be relatively up to date and from journals of quality.
Ideally a study paper should turn to changing your specialized medical practice. This newspaper will not provide me with any rational to improve nor if it had a credible circumstance would I understand what I will be changing. Since I cannot replicate the treatment modalities used within the study I cannot change practise nor would I recommend another practioner to execute the same.
