Critically appraising research in pain management by Ee1Ux5


									Critically appraising research
     in pain management

Making sense of the evidence

M.Sc. The nature of pain and its’ management,
• Why do we need to appraise the
  literature on pain ?

• What is the current state of the art ?

• How do we go about it ?

• What are good sources of information ?
           Critical Appraisal

The process of “weighing
up” the evidence to assess
how useful it is in making
decisions about clinical
Some “drivers” promoting critical review of
           research literature

• Evidence based practice
  Clinical effectiveness > guidelines, standards
  and pathways
• Continuing Professional Development (CPD)

• Modernisation Agenda eg. patient choice

• Research – asking the right questions
         Types of Evidence
• Primary
 Generated from first hand experience
 eg. diaries, letters, research reports

• Secondary (synthesis of others work)
 eg. narrative and systematic literature
  reviews, scholarly papers
         Information explosion
c. 20.000 journals, 2 million papers p.a.
Pain Management – The Evidence

• Meta-analyses, RCT’s
• Systematic reviews
• Cohort studies
• Case studies
• Narrative reviews
• Updates
• Reports, editorials, working papers, product
• Conference proceedings, abstracts
• Dissertations etc.
    Traditional Hierarchy of Evidence
          Quantitative Research
       Which research has most “weight” ?

•   Meta-analysis, systematic review
•   High quality RCT
•   Controlled study without randomisation
•   Observational study eg. case control study
•   Descriptive study
•   Expert consensus
•   Clinicians and clients/patients views
                Systematic review
- The “sharp end” of critical appraisal
- Used for development of clinical guidelines

Many stages including:

•   Development of a protocol
•   Systematic selection of studies
•   Data Extraction
•   Quality assessment
•   Statistical or other synthesis of findings
•   Rating of the overall body of evidence
• Cox II selective inhibitors are not recommended
  for routine (regular) use in patients with
  rheumatoid arthritis or osteoarthritis (2001,
  Guidance 27)

• Current evidence on the safety and efficacy of
  percutaneous disc decompression using
  coblation for lower back pain does not appear
  adequate to support the use of this procedure
  without special arrangements for consent and
  for audit or research (Consultation Document,
  25 May 2004)

• Adalimumab, etanercept and infliximab for the
  treatment of ankylosing spondylitis (in progress,
  due Feb. 2007)
              Assessing the quality
               “critical appraisal”
a) Quality of individual publications

•   Checklists
•   Guidelines/reading guides
•   Questionnaires
•   Frameworks,
•   Criterion based scoring tools

b) Quality of bodies of evidence

• Grading schemes
• hierarchies
 Quality Evaluation Tools

• Many “off-the-shelf” tools available for
  different types of studies
  eg. Jadad, Delphi, Maastricht, SIGN

• Debate on scales v scores v weighting

• Few have been properly validated and
  the criteria for validation are unknown

• Move towards customised checklists
• Critical Appraisal Skills Programme

• Scottish Intercollegiate Guidelines Network

• Jadad et. al. (1996) Control Clin Trials 17:1–12

• Newcastle Ottawa Observational Study checklist
  Quality in quantitative research
                   eg. RCT’s
Emphasis on issues such as:

Random allocation of subjects, “blinding”
Allocation concealment
Similarity at baseline
Standard, reliable and valid outcome assessment
Intention to treat analysis (ITT)

     Quality in qualitative research
• Dependability (reliability) eg.
  - justification of methods
  - audit trail
  - providing information about the researcher
     - member checking, inter-researcher comparisons, triangulation
• Credibility eg.
  - providing raw quotes
 - reference to accepted procedures for analysis
 - discussion of how researcher may have effected outcomes
 -    clear distinction between data and interpretation
• Transferability eg.
   - detail about participants and context
  - identifying differences between individual participants and
     participants and researcher
     CASP – Qualitative Studies
Rigour: has a thorough and appropriate
 approach been applied to key research
 methods in the study?

Credibility: are the findings well
 presented and meaningful?

Relevance: how useful are the findings to
 you and your organisation?
    Structure of a research paper

• Title, author
• Abstract: summary of what the paper is about
• Introduction: Background including previous
  research, aims, research question/hypothesis,
• Methods: patients, methods, equipment, data
• Results
• Discussion (may include results in qualitative
• Conclusion, recommendations for clinical
  practice and further research
    General questions for any study
•   Are the aims clearly stated ?
•   Was it ethical ?
•   Does the design match the aims ?
•   Was the sample size justified ?
•   Sufficient methodological detail eg. drop outs ?
    Missing data ?
•   Are the measurements/outcomes valid and
    reliable ? (NB. study population)
•   Are statistical methods/data analysis described ?
•   Are the main findings explicit ?
•   Are important effects considered ?
•   Are results/findings compared with previous
•   Are implications for practice discussed ?
              Papers for review:
    Effects of pool-based and land-based
aerobic exercise on women with fibromyalgia/
        chronic widespread muscle pain
Jentoft et al
Arthritis Care and Research, 2001, 45:42-47

 In the system: the lived experience of chronic
     back pain from the perspectives of those
          seeking help from pain clinics
Walker et al
Pain, 1999, 621-628

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