Background and overview of the literature
The 'research-to-practice gap' describes the well-recognised struggle to put evidence into effective practice. Glasziou and Haynes (2005) use a 'pipeline' analogy and describe evidence 'leaking' at all stages along this pipeline. An estimated 85% of research is squandered (Chalmers and Glasziou 2009) making 'research waste' a priority problem (Chalmers et al 2014). Although the clinical encounter is complex and dynamic (Lau et al 2015) the pipeline model enables identification of 'leakage points' that may be targeted. Specifically, the student will target the following:
- the 'bottleneck' of summarising evidence (Tsafnat et al 2014)
- clinician awareness of evidence (Vogel et al 2013; daSilva et al 2015)
- the beliefs and attitudes of key influencers and their peers (Meats et al 2007; Aarons et al 2016).
The pace at which primary research is generated outstrips the capacity for reviewers to summarise it (Tsafnat et al 2014; Olah and Carter 2017). It is recognised that reviews need to be prioritised and streamlined if health-care professionals are to maintain an up-to-date evidence base (Bastian, Glasziou and Chalmers 2010). Despite this, reviews are often out of date due to the resources required to produce them and the high associated cost (Lau et al 2015). Innovation is required to overcome these issues (Bastian, Glasziou and Chalmers 2010).
The student will explore whether the time and resources required in reviewing literature can be significantly reduced. Computers can increase the efficiency of preparation for reviews (Chalmers et al 2014); specifically, machine learning may provide a means of accelerating initial stages by assisting reviewers in finding and categorising relevant research (Tsafnat et al 2014; O'Mara-Eaves et al 2015; Mo, Kontonatsios and Ananiadou 2015). Searching databases, "sifting" abstracts, organising papers into topics, and deduplicating papers may all be accelerated, thereby helping to address this bottleneck.
Clinician awareness: impact and implementation
"[A]ctionable, accessible, and trustworthy information" can help clinicians bring research into their decision making processes (NIHR Dissemination Centre 2016). However, passive dissemination alone has only minimal influence on professional behaviour (Feder et al 1999; Côté et al 2009). Instead, influencing leaders within a profession and professional organisations may be one key to impacting on practitioner beliefs (Aarons et al 2016; McCaughan et al 2002; Kasiri-Martino and Bright 2015; Dannapfel, Peolsson and Nilsen 2013). Identification and recruitment of advocates can increase the incorporation of evidence into clinical practise (Stevans et al 2015) through improved "social validation" i.e. acceptance of change within a peer group (Glasziou and Haynes 2005) and strong "social congruence" i.e. similarity of experiences and practices (Lockspeiser et al 2008). Recognition of clinician involvement in research activities encourages a positive attitude towards learning, and the development of a research culture (Royal College of Physicians 2017).
Any attempt to bridge the gap between evidence-based care and clinician practises should measure impact and reference appropriate theoretical justification (Vachon et al 2013).
Clinician beliefs and attitudes towards evidence
While primary care may be improved by clinicians' reading of evidence summaries (Schneider et al 2015), clinician attitudes are key to successful introduction (Côté et al 2009). Manual therapists may not follow advice in summaries or guidelines for various reasons, including:
- the size and complexity of research (Haynes and Haines 1998)
- practical issues including time (Bussières et al 2016)
- individual and cultural attitudes towards research (Dannapfel, Peolsson and Nilsen 2013)
- beliefs around professional identity (Evans 2007, 2013; Kasiri-Martino and Bright 2015)
- misalignment of research with clinician priorities and routines (Bauer et al 2015)
- reluctance or perceived inability to find and interpret research (Schneider et al 2015, Greenhalgh et al 2002)
Presentation of research in a format that clinicians find agreeable can help overcome these barriers (Wallace, Byrne and Clarke 2014, McCaughan et al 2002) and brief overviews may be more palatable than lengthier formats (Grimshaw et al 2012). There are numerous potential candidate formats, since summary formats and rapid methodologies are under development by many organisations (Tricco et al 2015). Consequently the student will conduct a systematic narrative review of the evidence to determine which methodology may address clinician-related barriers. Systematic narrative reviews combine a systematic search with a narrative critical analysis, aiming to mitigate bias in the selection of papers while permitting a narrative approach for producing insights and recommendations (Weed 2005, Snilstveit, Oliver and Vojtkova 2012).
Role of musculoskeletal therapists and the burden of musculoskeletal disease
People with musculoskeletal (MSK) conditions seek treatment from manual therapists including physiotherapists and osteopaths, who are state-regulated allied health professionals. MSK conditions are the largest contributor to the burden of disability in the UK (Arthritis Research UK 2016) costing the UK economy an annual 8.9 million lost work days (Health and Safety Executive 2016) estimated at £7.4 billion per year (Chartered Society of Physiotherapy 2012). MSK disease may be the second most common cause of GP visits, accounting for over 20% of their workload (Arthritis Research UK 2009).
This burden emphasises the importance of finding efficiencies in the evidence-to-practice pipeline, particularly regarding manual therapies.