Evidence Based Medicine Movement In Crisis: A Critical Appraisal Of Stroke Rehabilitation Essay.

Discuss About The Evidence Based Medicine Movement In Crisis.

The purpose of the essay is to critically appraise a mixed method research literature by Ekstam et al. (2017) to find out perception of stroke patient and their carers regarding rehabilitation needs 1 year after stroke. The critical appraisal is based on the research scenario of Aunt Sue-Anne, who had stroke six months ago who was an active and independent person prior to stroke. However, after stroke and a period of intensive rehabilitation, she reports of feeling low because of dependence on activities of daily living such as cleaning and showering. As a carer for post stroke patient like Aunt Sue, it is necessary to understand how carers may support post stroke patients with activities of daily living. Hence, critical appraisal gives an insight into authorship, use of appropriate research question, research deigns and results of the article. It also provides an insight into barriers to the application of the findings in evidence based practice.

The main aim of Ekstam et al. (2017) was to explore the link between dyad’s perception (people with stroke and dementia caregiver) on rehabilitation needs of person with stroke. To make judgment on quality of research paper, evaluation of authorship is necessary. There are six authors for this research and they are affiliated from the Department of Occupational Therapy, Department of Clnical Research, Department of Clinical Neuroscience, Division of physiotherapy and Department of Neuroscience and rehabilitation needs. From the affiliation of authors, it can be said that they have experience in an area related to the topic of rehabilitation needs. In terms of qualification, the author Lisa Ekstam has done Ph.D in occupational therapy and other authors also have qualification in similar field. Hence, this information gives the idea that the topic for research is in relevance with their qualification and area of expertise. The research was published in 2015 which means it is recently published paper that can give updated information on rehabilitation needs of participant. However, only one conflict of interest that has been seen in the paper was that ethical considerations during participant selection were not met.

The main research question for the study by Ekstam et al. (2017) was exploring and comparing perception of stroke patients and their informal caregivers on rehabilitation needs 1 year after stroke. The need for research in this area was stated by the author by stating current state of research and gap in research on the topic. For example, the author argued that sense of coherence (SOC) is needed to view world as manageable and meaningful. According to Ekstam et al. (2017), SOC should be linked with perceived rehabilitation needs to assess perception after stroke. The authors also mentioned about lack of studies that explore dyadic perspective on rehabilitation needs. However, there is lack of such studies. Hence, the rational for the research became evident from this explanation. The quality of reporting is also understood from author’s statement of significance of the research problem. The author emphasized on the importance of the topic by giving an overview about the prevalence of perceived unmet rehabilitation needs in patients 1 year after stroke. Ullberg, (2016) also proved that unfulfilled rehabilitation needs 1 year after stroke is common and it is associated with increased pain and dependency in stroke patient.

Research Question

Ekstam et al. (2017) used mixed method study design to gain answers to the research question. The use of mixed method is suitable as the research had multiple objectives. The primary objective was to find relation between dyads perception of person in relation to rehabilitation needs, severity of the condition and individual factors such as sense of coherence, age and gender. The secondary objective was to evaluate experience of daily life changes on person with stroke and their caregivers and the strategies they adapt to manage care. Hence, with such objective, use of both qualitative and quantitative research designs favored getting complete data related to the purpose of study (Palinkas et al., 2015).

The research is a primary research method and mixed method design has been used to completely understand the complex process involved in post stroke rehabilitation. The participants for the study include those who took part in LAS-1 (Life After Stroke Phase 1), a observation study on stroke. The data related to need for health service and satisfaction with service was taken from participants and it was evaluate on Liker scale to yield quantitative data. Quantitative analysis was also done for assessment of SOC at 12 months for participants. In Addition, qualitative data was collected regarding life after stroke and strategies to manage the change.

The credibility and reliability of a research work is understood from the approach used to recruit research participants, collect research data and eliminate biases in research (Brownson, Colditz & Proctor, 2017). Ekstam et al. (2017) recruited participants who took part in LAS-1 study and data was collected by means of open-ended questionnaire as well as close ended questionnaires based on specific tools. For instance, SOC was measured by SOC scale and satisfaction with health care service was measured by using a questionnaire that has been used earlier. This consideration of using evidence based tool shows that author has considered using validated tools to enhance validity of the research work. While conducting research or implementing anything in practice, use of evidence based tools enhance decision making and improve quality of research evidence (Greenhalgh, Howick & Maskrey, 2014).  

During the sample recruitment stage, meeting ethical considerations in research also determined the quality of research evidence.  This aspect was not considered as the research was done with participants who took part in LAS-1 study. However, ethical considerations such as informed consent were made in the initial LAS study. This is a limitation because this study had different research objective compared to participants in LAS-1. Hence, informed consent requirement for participants recruited in this study was also necessary. The bias in research was avoided by informing participants to write their response instead of giving verbal response. Secondly, biases in interpretation of data was avoided by ensuring that three authors analyze the day and discuss the code together to prevent influence of individual judgment on study outcome. It point out to the strength of research.

Research Design

The main findings of the study was that more than 52% of the dyads perceived fulfillment of rehabilitation needs 12 months after stroke. However, the important finding was that dyad’s perceptive was dependent on severity of stroke, coping strategies and level of caregiver burden. For example, caregivers perceived fewer burdens when rehabilitations needs were met. This finding addressed the research question and shows that care giving burden and severity of condition is a factor that influence rehabilitation needs perspective of dyads. It also pointed out to limitation in research and the need to evaluate dyadic perceptive throughout rehabilitation. The finding is consistent with other research as Gbiri, Olawale & Isaac, (2015) also argues that stroke survivors put diverse type of burden on informal caregivers and the burden increases with duration, severity and length of daily care giving.

There are certain barriers to the application of evidence by Ekstam et al. (2017) to practice. This is because the research was done with participants from LAS-1 study and it did not have separate recruitment method. This kind of selection biases act as institutional barriers to application of evidence as such biases reduce the validity, credibility and trustworthiness of findings. Apart from this, the individual barrier to the application of evidence is that the study only established linked between caregivers and patient perspective; however it does not suggest strategies that informal caregivers can take to identify rehabilitation needs.

Conclusion:

The main purpose of the essay was to critically appraise a research article by Ekstam et al. (2017) to find out how caregivers can support family member with activities of daily living following a stroke. The evaluation of authorship, research design, study methods and results was done to find answer to the scenario question. The findings of the study established links between dyad’s perspective on rehabilitation needs based on severity and care giving burden. However, it did not suggested strategies that a caregiver can take to identity rehabilitation. Presence of several methodological limitations also reduces application of finding on patients with strokes and their caregivers.

Reference:

Brownson, R. C., Colditz, G. A., & Proctor, E. K. (Eds.). (2017). Dissemination and implementation research in health: translating science to practice. Oxford University Press.

Ekstam, L., Johansson, U., Guidetti, S., Eriksson, G., & Ytterberg, C. (2015). The combined perceptions of people with stroke and their carers regarding rehabilitation needs 1 year after stroke: A mixed methods study. British Medical Journal, 5(2), 1?7. Retrieved from:  https://bmjopen.bmj.com/content/5/2/e006784

Gbiri, C. A., Olawale, O. A., & Isaac, S. O. (2015). Stroke management: Informal caregivers’ burdens and strians of caring for stroke survivors. Annals of physical and rehabilitation medicine, 58(2), 98-103.

Greenhalgh, T., Howick, J., & Maskrey, N. (2014). Evidence based medicine: a movement in crisis?. Bmj, 348, g3725.

Palinkas, L. A., Horwitz, S. M., Green, C. A., Wisdom, J. P., Duan, N., & Hoagwood, K. (2015). Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Administration and Policy in Mental Health and Mental Health Services Research, 42(5), 533-544.

Ullberg, T., Zia, E., Petersson, J., & Norrving, B. (2016). Perceived unmet rehabilitation needs 1 year after stroke: an observational study from the Swedish stroke register. Stroke, 47(2), 539-541,