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Putting research into practice

A year ago, Frontline profiled a novel method of translating research into practice. Colleen Shannon tracks progress since then

Researchers and scientists are often accused of sitting in ivory towers, ignorant of the world outside and its demands. Sadly this scenario is not uncommon, despite research being valueless if it is not applied to actual situations.

The trick to making research successful is three-fold. First, root your research in the real world. Second, find a way of translating research findings into practice. And third, shout about it. CATs groups (clinically appraised topics) offer a way of addressing parts two and three of the research conundrum above. In time, they're also likely to spark progress in the first.

The method is practical. It is focused on immediate clinical needs and aims to answer questions that crop up in daily practice. It is also a local effort, in which professionals work together to improve care for their own patients and to benefit the overall health economy.

Kay Stevenson is a consultant physiotherapist in musculoskeletal disease at the University Hospital of North Staffordshire in Stoke-on-Trent and honorary lecturer in the school of health and rehabilitation at Keele University. She set up the Keele CATs group in 2003.

'The idea was we would ask clinical and management staff if they had any particular questions they would like us to focus on. That could be around clinical interventions, it could be around service redesign issues, it could be about anything either clinicians or management had challenges with. And then as a group of clinicians we set ourselves a task of trying to find the latest and the most robust evidence to answer that question using the critical appraisal process.'

The group has grown to between 15 and 20 members, and is taking on a truly multidisciplinary face. In addition to physiotherapists, occupational therapists, researchers and an information specialist, members also include managers, GPs, and professionals from nursing and psychology with an interest in musculoskeletal medicine.  The group also draws on the expertise of academics at Keele University and benefits greatly from a specialist librarian's input.

Being on the lookout for ways to disseminate methods as well as findings is important. The group has presented to local GPs and at other professional meetings. The National electronic Library for Health is another potential outlet. In addition, the group has its first academic paper going through peer review. Publication will be a huge achievement for the group, Mrs Stevenson says. 

SELF-LED APPROACH

Success has brought growth, and led to the decision that the most productive way to work is to split off into smaller clusters so different topics can be tackled simultaneously. Maggie Bailey, director of postgraduate taught programmes at Keele University's school of health and rehabilitation, started a second CATs group at Keele in December, 2005, for professionals with an interest in neurophysiotherapy.

Work on the neuro group's first topic – the use of splints at the acute stage, to prevent soft tissue shortening on the affected arm of stroke patients – is underway, and the group plans to write its first report soon.

CATs members are proactive about their own training and development: identifying areas for further training and organising in-service sessions, covering topics like critical appraisal, statistics and study design. 'We teach ourselves,' Dr Bailey says. 'We don't invite an expert in to talk to us; we're all capable of self-teaching and self-learning. We take it in turns to find out about the topic of the moment and come back and discuss it.'

The hospital library offers staff training on searching databases and the literature, so group members take advantage of this. In addition to supporting the group's CATs work, the training makes a useful contribution to each individual's continuing professional development portfolio.

PROMISING FUTURE

Lack of time has probably been the most difficult issue for both of the Keele groups. 'It has been such a hard year in the NHS for staff shortages, for freezing posts, for people not knowing if their jobs are safe, and particularly for people getting time off for their CPD,' Dr Bailey says. 'Some people are really having difficulty getting that time off, to come and do something which is really quite worthwhile.'

She is keen to point out her group is integrated with the National Physiotherapy Research Network. The NPRN can be a useful source of support for people wishing to set up their own CATs group or to become involved in, or make use of, physiotherapy research.

Ann Moore, director of the clinical research centre for health professionals at the University of Brighton, is one of the four physiotherapy professors at the helm of the NPRN. She sees the CATs approach as a constructive way to draw more people towards research. 'Those who don't have well developed skills... can learn from those who do. CATs are also an excellent way of engaging new graduates who come out with great enthusiasm for evidence-based practice and research. It would be excellent if we could develop more of these groups in clinical practice.'

Now both musculoskeletal and neurophysiotherapy are represented, Dr Bailey says she would like to see a respiratory group set up. She sees the CATs group guiding the academic research agenda to answer practical clinical dilemmas, and perhaps undertaking some primary research of its own.

For the time being, though, the atmosphere is low key. There is enough pressure in daily clinical life, she says. 'The whole purpose and ethos of our meetings is for people to feel comfortable and supported.' FL

FURTHER INFO:

Stevenson et al. 'A new multidisciplinary approach to integrating best evidence into musculoskeletal practice', Journal of Evaluation in Clinical Practice: In pressFoster et al. 'Critically appraised topics (CATs): One method of facilitating evidence based practice in physiotherapy,' Physiotherapy (2001), 87 (4): 179Metcalfe et al. 'Barriers to implementing the evidence base in four NHS therapies: dietitians, occupational therapists, physiotherapists and speech and language therapists,' Physiotherapy (2001), 87 (8): 433National Physiotherapy Research Network contact details are available from the Society's website, see www.csp.org.uk/director/effectivepractice/research/nprn.cfm

Key features

The four basic elements of the CATs approach are:

  • work collaboratively as a group
  • formulate a precise question to answer
  • search the evidence base for robust studies that might answer the question
  • feed the answers back into local clinical practice, in a practical format

Questions & Answers

The Keele musculoskeletal group is working on its 10th clinical question. Kay Stevenson summarises their findings for some of the completed musculoskeletal topics below REHABILITATION IN FLEXOR TENDON REPAIRSClinical question: Examine the effectiveness of rehabilitation programmes in primary flexor tendon repairs following surgical reconstruction at 12 weeks and 12 months in terms of pain, disability, function, return to work.

Clinical bottom line:

Insufficient evidence to determine the best mobilisation strategy. An early mobilisation treatment regime within a protective back-slab is in line with the best available evidence and therefore no changes to clinical practice are required.

ONE-OFF V LONG-TERM MANAGEMENT FOR OSTEOARTHRITIS OF THE KNEE

Clinical question: Is one-off management versus a course of treatment more effective in terms of reducing pain and function for patients over 50 years with osteoarthritis of the knee joint?

Clinical bottom line: There is evidence to suggest there is short-term benefit (up to 24 weeks) in advising patients with OA knee to undertake active exercise. The benefits include reduced pain and improved function in relation to walking, sitting to standing, bending and reclining. 

APPOINTMENT DURATION AND OUTCOMES

Clinical question: Does appointment duration for musculoskeletal outpatient physiotherapy or occupational therapy in primary or secondary care settings have an effect on managerial, clinical or patient outcomes?

Clinical bottom line: Insufficient evidence to answer the question.

ECCENTRIC V CONCENTRIC EXERCISES IN ACHILLES TENDONOPATHIES

Clinical question: In the adult population, are eccentric or concentric exercises more effective in return to function, increasing muscle strength, reducing pain, improving range of movement and affecting reoccurrence rate in subacute chronic Achilles tendonopathies?

Clinical bottom line: Insufficient evidence to answer the question.

HAND THERAPY V USUAL CARE IN HAND ARTHRITIS

Clinical question: Is hand therapy more effective than usual care in improving coping and maintaining function in adults with hand arthritis?

Clinical bottom line: The group was unable to determine whether hand therapy is more effective than usual care in maintaining function and improving coping in adults with hand arthritis.

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