Welcome Pack

Research Facilitation 

Group 

Welcome to new 

members 

March 2011 

Musculoskeletal Research Facilitation Group – Welcome Pack January 2011- Kay Stevenson

Content 

Aims of the group and your commitment 

What‟s in it for you? 

Group membership and professional background 

Useful web sites 

Example of Critically Appraised Topic 

Example of minutes of a typical meting 

Testimonials from group members 

Generating CAT questions: a proforma to encourage questions 

Top Tips on how to lead a CAT question 

The Next Steps 

Reflection on the CAT process 


Aims of the group and your commitment 

Our aim is to ensure that clinical practice is based on the best available 

evidence and encourage change in practice where necessary. 

The Research Facilitation Group is a group clinicians and clinical researchers 

that are interested in musculoskeletal disease. The professions represented 

are: 

Nursing 

Occupational Therapy 

Podiatry 

Physiotherapy 

Clinical Researchers 

Health Information Librarians 

Psychologists 

Therapy Managers 

The group is supported by Arthritis Research UK Primary Care Centre, 

University Hospital of North Staffordshire, Stoke PCT, North Staffs PCT and 

Central and Eastern Cheshire Primary Care Trust. 

Our aims are to: 

Ensure clinical practice is evidence based and assist practice change 

where required 

Increase the research awareness of staff involved in managing patients 

with musculoskeletal disease 

Search the evidence for relevant up to date clinical recommendations 

and then feed this back to staff in clinical practice 

Identify gaps in the evidence 

Link with our academic partners to develop research proposals 

Increase our research awareness skills 

Publicise and communicate our results 

Your commitment 

The group meets four times a year at three monthly intervals. Meetings are 

held at Arthritis Research UK Primary Care Centre, Keele University and last 

3 hours, normally 9-12. Coffee and refreshments are provided. 

You will be required to attend the meeting and commit to appraising articles in 

between the meetings. This would amount to no more than 2 hours per 

month. We would hope you would cascade useful information to your team 

within your own area of practice and highlight the work of the group. We 

would also ask that you canvas opinion on future questions that are important 

for us to answer 


What’s in it for you 

Some of the benefits of being involved in such a group include: 

Supportive environment to answer important clinical questions 

Engage with a multi professional group who are interested in 

musculoskeletal disease 

Opportunities to engage with an established research unit 

Opportunity to learn about research methodology and research design 

from experienced researchers 


Group membership and professional background 

Caroline Amphlett Physiotherapist 

Kenneth Aaron 

Physiotherapist 

Hilary Bradbury 


Robert Bradshaw-Hilditch Podiatrist 

Robert Bryan 

Clinical manager 

Linda Chesterton Physiotherapist and researcher 

Jemma Cowen 

Systematic reviewer 

Carol Doyle 

Physiotherapist and researcher 

Krysia Dziedzic 

Prof. of Musculoskeletal Therapies 

Sharron Edwards Podiatrist 

Carol Grahame 

Occupational Therapist 

Andrew Finney 

Nurse and researcher 

Deborah Fernyhough Occupational Therapist 

Nadine Foster 

Prof. of Musculoskeletal Health in Primary Care 

Noeleen Hellis 

Clinical manager and physiotherapist 

Jo Hill 

Occupational Therapist 

Mathew Hill 

Podiatrist 

Jonathan Hill 


Sue Hill 

Psychologist and researcher 

Lucy Huckfield 


Triana Larkin 


Rachel Lewis 

Health technology Librarian 

Liz mason 


Alison Morris 


Sue Jackson 


Jo Jordan 

Systematic Reviewer 

Kika Konstantinou Physiotherapist and researcher 

Mark Porcheret 

General Practitioner 

Panos Sarigiovannis Physiotherapist and clinical manager 

Julie Shufflebotham Physiotherapist and researcher 

Kay Stevenson 


Gail Sowden 


Cath Thwaites 

Nurse 

Amanda Walters Physiotherapist 

Elaine Wiltshire 



Useful web sites 

Critical Skills Appraisal Programme 

http://www.phru.nhs.uk/Pages/PHD/CASP.htm 

CASP appraisal tools 

http://www.phru.nhs.uk/Pages/PHD/resources.htm 

McMaster University Evidence Based Practice Centre 

http://hiru.mcmaster.ca/epc/ 

National library for Health 

http://www.library.nhs.uk/Default.aspx 

Clinical Knowledge Summaries 

http://cks.library.nhs.uk/home 

Pub Med 

http://www.ncbi.nlm.nih.gov/pubmed/ 

University Hospital of North Staffordshire 

http://www.uhns.nhs.uk/home.aspx 

Haywood Hospital 

http://www.haywoodrheumatology.org.uk/ 


Example of a Critically Appraised topic 

In adults with shoulder joint impingement is the intervention of stabilization 

exercises and/or postural correction versus any treatment or no intervention 

effective in reducing pain and increasing function? 

Clinical bottom line 

There was no evidence specific to scapula stabilization exercises, but the general 

summary of the literature searched was that an exercise programme was beneficial 

with the addition of manual therapy being more effective than exercises alone 

Population: 

Male and female adults 

Intervention: 

Scapula stabilization exercises / postural correction 

Outcome: 

Reduced pain and increased function 

Excluded: 

Diagnoses other than shoulder impingement syndrome 

Databases Searched: Cochrane, Pedro, NHS Library for Health, medline, Cinahl, 

Embase, Psyclnfo, Clinical Evidence, Bandolier, NELH, Professional websites, 

Guidelines, NICE 

Search for the past 10 years i.e. 1996 – 2006 

Key words searched: 

Shoulder impingement, shoulder impingement syndrome, subacromial impingement, 

shoulder pain, tendonitis rehabilitation, exercises, exercise therapy, physical therapy, 

physiotherapy, conservative treatment, postural exercises, scapular stabilization 

Types of studies 

Systematic reviews, RCT‟s and guidelines 

Available Evidence 

Database ( Specific to our CAT) Number of abstracts Number of relevant 

abstracts 

Clinical evidence 

0 

PsychInfo 

158 2 

AMED/ CINAHL/ Embase 

3 1 

PEDRO 

27 2 

Medline 

4 3 

Cochrane 

Guidelines 1 1 

Total 193 9 


Results: 

There were no studies directly assessing scapular stabilization / postural correction 

exercises. The main systematic review (Faber et al 2006) looked at the treatment of 

impingement syndrome. They found 94 articles, 3 of which studied exercise 

interventions (Brox 1999, Bang 2000, Ludewig 2003). 

These articles were reviewed in more detail – generally small sample sizes (eg. n=40 

per group), and some issues relating to blinding and validity of outcome measures. 

All studies presented a positive outcome for patients undergoing an exercise 

programme. 

The summary from the CSP shoulder guidelines (2004) on impingement syndrome 

recommend 

A programme of exercises to restore range, strength, stability and 

scapulohumeral rhythm is beneficial – based on weak evidence from clinical 

trials 

Passive mobilization of the upper quadrant augments the beneficial effects of 

exercise, reducing pain and increasing range, strength and function – based 

on weak evidence from clinical trials 

Scapula stability when performing strengthening exercises is „paramount‟ 

based on clinical experience, opinion and committee reports 

Implications for practice: 

There is no evidence to suggest that inclusion of scapula stabilization exercises 

provide additional benefit to outcome for patients with shoulder impingement 

syndrome. However, an exercise programme that includes strengthening exercises 

+/- manual therapy is of benefit to patients with shoulder impingement syndrome. 

Further research question 

In adults with shoulder impingement syndrome, does the inclusion of scapular 

stabilisation/postural correction exercises provide additional benefit over a usual 

exercise programme in terms of pain relief and functional improvement? 

References: 

Bang and Deyle 2000 Comparison of supervised exercise with and without manual physical therapy 

for patients with shoulder impingement syndrome (SIS) 

J Ortho Sports & Phys Ther 30:3 126-137 

Brox et al 1999 Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II SIS): A prospective 

randomized controlled study in 125 patients with a 2.5 year follow-up 

J Shoulder and Elbow Surgery 8: 2 102-111 

CSP 2004 evidence based clinical guidelines for the diagnosis, assessment and physiotherapy management for 

shoulder impingement syndrome 

Desmeules F et al 2003 Therapeutic exercise and orthopedic manual therapy for impingement syndrome: a 

systematic review 

Clinical Journal of Sport Medicine May; 13(3):176-182 

Faber et al 2006 Treatment of impingement syndrome: a systematic review of the effects on functional limitations and 

return to work Journal of Occupational Rehabilitation Mar; 16(1):7-25 

Ludewig and Borstad 2003 Effects of a home exercise programme on shoulder pain and functional 

status in construction workers 

Occup Environ Med 60 841-849 

Michener et al 2004Effectiveness of rehabilitation for patients with Subacromial impingement syndrome: a systematic 

review 

Journal of Hand Therapy Apr-Jun; 17(2):152-164 


Example of minutes of a typical meeting 

Present 

Musculoskeletal Research Facilitation Group- 13 th January 2010 

Minutes 

Alison Morris, Kay Stevenson, Jo-ann Hill, Rachel Lewis, Lucy Huckfield, Nadine Foster, 

Mathew Hill, Liz Mason, Mathew Hill, Jonathan Hill, Jo Jordan 

Apologies 

Carol Graham, Sue Jackson, Gail Sowden, Duncan Kett, Julie Shufflebotham, Panos 

Sarigiovannis, Caroline Amphlett, Sue Hill, Jemma Cowen 

Review actions from last meeting 

Update new members pack and send to all 

Comments taken from group, now to go on web site 

Update the proforma to generate Qs 

Comments taken on proforma, distribute to all 

Comments on web site 

Update Cats according to table included 

See below 

KS 

KS 

KS 

All 

All 

Welcome to Lucy Huckfield. Lucy had a split post between the centre and Stoke PCT. 

There are to be 5 similar posts in local PCTs. Trina Larkin appointed to South Staffs 

post. 

Update on new web site 

http://www.keele.ac.uk/research/pchs/pcmrc/EBP/index.htm 

Photographs to be added. 

We all discussed how accessible the web site is Lucy kindly investigated this for us. 

Results are: 

Access the CAT site by using different words through google search engine. I used the 

following words/ phrases and this is what I came up with...... 

1) CAT group Keele - This brought a link up that took you straight to the new MRF 

group website page on the CAT bank page (where the person is that you can click on to 

see the CAT for different areas). CAT group Keele was the top search link on google. 

2) Keele CAT group - was as number (1) 

3) CAT Keele - This was the third item on the google searched items list. The link 

took you to the Keele Primary Care Sciences website to the dissemination page with the 

list of the CATs 

4) Keele CAT - This was the second item on the google searched items list. This link 

took you to the dissemination page as in number (3). 


Training ideas/issues for next 4 meetings 

All 

13 th Jan- 

14 th April - Critical appraisal- homework to be sent to all 

14 th July - Statistics 

20 th Oct - Systematic reviews (Jo Jordan) 

Suggested future topics: observational studies, Cohort studies, Cost analysis 

Feedback from EBP group 

KD 

KD gave update on EBP group ( Krysia, Mark Porcheret, Jo Jordan and Kay Stevenson). 

Organised very successful event on NICE guidelines to promote debate. Next evening may 

well be on OA. 

Rhian and Kay met recently with local commissioners to outline the work of the centre and 

EBP groups. We discussed how we can integrate evidence into practice. 

Stoke PCT have a GRIP group- getting research into practice, KD involved with the group. 

Update on current CAT work- reviews 

CAT for review 

Is multidisciplinary management of chronic low 

back pain more effective in terms of reducing pain, 

improving function and increasing return to work 

compared with uni-disciplinary treatment. 

Is one off management versus a course of 

treatment more effective in terms of reducing pain 

and function for patients over 50 years old with 

osteoarthritis of the knee joint 

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 

In adult humans with peripheral musculoskeletal 

injury (who have not had previous repair) is the 

length of time of sustained active or passive 

stretching more effective than other aspects of 

stretching for increasing return to work function and 

activity. 

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 

Group 

Noeleen, Nadine, Jonathan 

Present at next meeting 

Krysia Kay Andrew 

No new evidence to add to 

existing CAT, updated Cat on web 

site 

Carol, Debbie and Jo 


Linda and Richard 


Carol and Kay 

No new evidence to add to existing 

CAT, updated Cat on web site 


Update on current CAT work 


Access to healthcare practitioners 

Carol Jonathan, Panos, Carol, Krysia, Duncan, 

Carol, Andre, Sue 

GH joint capsulitis 

Caroline Nadine, Kay, Jemma 

Comment 

Completed, now on web site 

Completed now on website 

May be taken forward to the centre for 

funding application 

CAT and quick and dirty process came 

up with same answer.?? Should we 

write this up for publication? 

Therapists involved in requesting investigations 

Amanda, Kay Sue, Matt 

Is an exercise regime in addition to routine 

mobilisation / gait re-ed of improved benefit to 

function / QOL in post operative adult THR's? 

Jo Hill, Alison, KD and KS 

Whether a urinalysis that is positive with Nitrites 

and Leucocytes is sufficient evidence to not give a 

soft tissue/intra articular injection. 

Andrew Finney and the nursing group, Kyrsia, 

Jo 

TNS and the management of post op pain 

Alison and Linda 

Completed, now on website 

To be presented at next meeting 



Web site of interest identified by Nadine re self referal pilot projects 

> http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publica 

Feedback on quick and dirty searches 

o Shoulder capsulitis- as above 

o Multidisciplinary referral- not undertaken 

New questions from Clinicians 


Use of Splint in neurologically compromised patient with 

ankle fractures ( Vick Terry) 

Weight bearing/ mobilisation on day 0 for patient with 

total hip or knee replacement ( Alison Morris) 

Group 

Lucy, Kay Caroline 

Alison, Jo Liz 


Does lack of sleep cause reduction in serotonin and can lack of serotonin have physical manifestations 

Corinna Dennison, Physiotherapist band 7,Burslem HC 425702 – Need clarification – Lucy to do this 

Feedback on shoulder and hand trial 

Shoulder trial at final protocol stage, hoping to go for ethics in March, recruiting in June. Will 

be undertaken at 2 main sites. 

Hand trial in last 6 months of the study. 85% follow up at 6 months, analysis to begin in the 

summer. 

Update on nursing link 

Andrew providing a clear lead for the nursing group, decided on question concerning joint 

injections and the value of urinalysis. 

AOB 

o 

o 

o 

o 

o 

Present work of the group to local ARMA group 

Discussed the need to provide patient friendly information, our information 

aimed primarily at clinical staff. Could ask the Research user group (RUG) 

group to look at existing Cats 

WCPT pre event training session- do we want to develop one? 

Gail and Jonathan leading local Outcome measures group. Have put together 

a proforma for those considering undertaking audit 

DUETS- data base of uncertainty of treatments, hosted by the James Lind 

alliance. WE could send out unanswered questions to this site. Funding 

bodies look at the site to inform call for research. Jo Jordan involved through 

the work of the arc. Could this be a link on our web site 

http://www.lindalliance.org/ 

Actions for next meeting 

New members pack on web site 

KS 

Critical appraisal training sent info to all: 

BMJ article KS ( Sent 10/1/10) 

Ask Sue Hill re stats training on 14 th july KS 

Ask Jo Jordan re training on systematic 

reviews 20 th Oct 

KS 

e mail all local PCT staff re web site 

KS 

WCPT pre training event 

KS 

Ask RUG group to look at existing Cats KD 


Testimonials from group members 

“Being involved in the group has been a very positive experience. Initially I felt 

daunted at being the only OT and felt that I had very little knowledge in this 

area and had nothing to offer the group. The group environment is extremely 

supportive and my research knowledge and skills have grown, and I am still 

learning! I would recommend this type of group to colleagues and advise them 

to attend even if they are the only representative of their profession” 

“I used to think of evidence based practice as rather daunting. However 

membership on the group has helped me develop a systematic approach 

when reading research articles allowing me to appraise the methodology used 

and therefore the evidence for the conclusions drawn from said research” 

“Joining the CAT group was a career changing event. It made me sit up and 

take note of what was going on around me, outside of my day-to-day work. It 

made me question my routine practice. It has demystified research for me. 

Research was something that I had always thought was for those more 

intelligent than me. But appraising the evidence to inform practice should not 

just take place in the Universities it should be part of the routine day-to-day 

work of a physiotherapist. It makes work more interesting trying out new ideas 

and challenging old ones, rather than just repeating what I was taught 10 

years earlier.” 

“The CAT group has proved to be an excellent resource over the last few 

years. On occasion we have asked questions that have changed our practice 

within the UHNS. This process has been reassuring and rewarding. The vast 

scope of experience and professions within the group ensures a broad 

approach within the MSK field.” 


Generating Cat Questions - Proforma to encourage questions 

Musculoskeletal Research Facilitation Group 

Proforma to facilitate questions asked 

The aim of our Musculoskeletal Research Facilitation Group is to facilitate that our practice is 

based on the best quality evidence available. Questions arising in our practice need answers 

and if you want help finding out what the evidence says, this group exists to assist you. 

This document has been designed to help clinicians formulate detailed questions that will help 

our Musculoskeletal Research Facilitation group in their search for the evidence, using a tried 

and tested process. We anticipate the process will be used: 

by individual clinicians or groups to generate clinical questions 

to facilitative discussions in groups of staff at training or staff meetings 

to facilitate discussion between managers and clinicians on evidence based 

practice 

The aim of the process is to produce a clinical bottom line with a summary of the evidence for 

each question identified. We have produced 31 to date and our results to date can be found 

online at: http://www.keele.ac.uk/research/pchs/pcmrc/EBP/MRF/search/bank_full.htm 

Example of the types of questions that have been put to the group: 

Question examples 

Are shoulder exercises effective for treating 

shoulder pain? 

Does being overweight increase the risk of knee 

arthritis? 

How reliable is an MRI scan at detecting a 

lumbar disc herniation? 

How likely is that people over 50 will develop 

neck pain? 

How common is plantar fascitis? 

What are the barriers to lifestyle change such as 

increase activity levels 

Question types 

Intervention 

Aetiology and risk factors 

Diagnosis 

Prognosis and prediction 

Frequency and rate 

Phenomena and thoughts 

(Glasziou P, Mar C, Salisbury J 2007 Evidence Based Practice Workbook 2 nd Edition BMY Books Blackwell Publishing) 

We would welcome questions in any of the above categories. Please use the table 

below to help formulate any questions you have and send to any member of the 

Research Facilitation Group (or Chairperson Kay.stevenson@uhns.nhs.uk). 

We are happy to receive broad questions, but prefer it if you are able to give us slightly 

more detail if possible, by producing a „refined question‟. 

For example a general question might be: 

“Are stability exercises effective at treating patients with shoulder pain?” 


To help you further refine your question and to assist group members undertaking the 

search we recommend the use of an evidence-based model for formulating a clinical 

question known as the PICO model (Richardson, 1995). By dividing your concepts into 

a few specific categories, you will provide the groundwork for developing the search 

strategy. The PICO model is particularly appropriate for intervention topics, but there are 

alternatives such as ECLIPSE model (Wildridge, 2002), which is expanded below. You 

may also prefer to adapt the PICO headings to fit the type of research question you are 

interested in. 

Patient/Population and/or Problem 

- any characteristics that define your patient or population, e.g. target clinical condition, coexisting 

condition, ethnicity, age group etc…. 

Intervention/Investigation 

- what you want to do with the patient/population or problem e.g. form of treatment, diagnostic 

test, education programme, type of service delivery. This can also include any exposures 

(e.g. asbestos) or factors influencing prognosis. 

Comparison/Control Intervention 

- alternatives to the main intervention e.g. placebo, usual care etc…. 

Outcomes or effects 

- any outcomes or effects relating to the intervention e.g. prevention, side effects, morbidity, 

quality of life, cost-effectiveness 

PICO Table (example question): 

Question type 

Population 

Intervention 

Comparison 

Outcome 

Provide details about the exact population, 

any comparison/ control groups & 

the outcomes you are interested in 

Adults with shoulder impingement tendonitis 

Shoulder stability exercises, scapular stabilization 

exercises, postural correction 

Normal care, routine physiotherapy 

Reduced shoulder pain, function 

An example of a “refined question” that would emerge from completing this PICO is: 

“In adults with shoulder joint impingement is the intervention of stabilization exercises 

and/or postural correction versus any treatment or no intervention effective in reducing 

pain and increasing function?” 

For questions that are not about treatments, you may wish to use the ECLIPSE model 

(Wildridge, 2002): 

Expectation – what does the search requester want the information for? 

Client group. 

Location. 

Impact – what is the change in the service, if any, which is being looked for? What 

would constitute success? How is this being measured? 

Professionals. 

Service – for which service are you looking for information? For example, outpatient 

services, nurse-led clinics, intermediate care. 


Some tips to help you ask a refined clinical question include: 

Define the type of question you think you are asking 

Determine who the relevant people are in relation to your clinical problem 

Agree which intervention or treatment you are wanting to find out about 

Decide if there is a particular diagnostic test you are interested in 

Detail what you‟d like to compare your intervention to; e.g. „usual care‟ or an 

alternative treatment or a control group 

Determine what outcomes you are most concerned about…. e.g., pain reduction, 

increased function or return to work 

Please bear in mind that this process will take a number of months to complete. 

Thanks again for your contribution. 


Proforma to complete (return to kay.stevenson@uhns.nhs.uk): 

Your name: 

Date: 

Contact details (email): 

Question type 

Patient/population/problem 

Provide details about the exact population, 

any comparison/ control groups & 

the outcomes you are interested in 

Intervention or 

Investigation or 

Procedure 

Comparison (if appropriate) 

Outcomes of interest 

Your refined question: 


Top Tips on how to lead a CAT Question 

If you are leading a CAT question, here are some key points that may 

help you: 

Ensure your group has formulated an answerable question that 

considers the population, intervention, comparison and outcome. 

Ensure that every member of the group has a clear role, one person 

may complete the proforma for the library search, one person may be 

responsible for organising e-mail contact and meetings 

Liaise with our librarian in order for the search to be done. This will 

require you to complete a form which gives the librarian more detail 

about the topic area you are interested in. 

Give yourself enough time to read through the abstracts, ask members 

of the group to assist. Don‟t get distracted by articles which interest 

you, the focus needs to be your question and does this research 

answer your specific question 

Look for the very best evidence, for interventions, this will be a 

systematic review. 

Decide on the key articles and then divide them between the group 

members, give everyone enough time to complete this task. 

Ask for assistance when you are formulating the CAT, other members 

of the group will be happy to help 


The next steps 

A CAT is completed with a „clinical bottom line‟ and „recommendations for 

practice‟. There are many different ways of integrating this into practice. Some 

services used map of medicine Pathways, while others use clinical algorithms. 

It is advisable to have the information in as many different formats as 

possible, such as electronic versions, hard copy and available on web sites. 

The information that is produced by the CAT process can be disseminated as 

staff meetings, personal development reviews, e mails. 

Where there is no clear evidence to answer the clinical question, the group 

feeds this to the arc national Primary Care Centre, Keele Universality. The 

centre then decides if a full research protocol can be developed to answer the 

question. Two funded research projects have started in this way, they are: 

Interventions for hand arthritis 

Intervention for treating shoulder impingement 

Unanswered questions can also be forwarded to the James Lind alliance. 

“The James Lind Alliance aims to identify the most important gaps in 

knowledge about the effects of treatments, and has been established to bring 

patients and clinicians together in 'Priority Setting Partnerships' to identify and 

prioritize the unanswered questions that they agree are most important. This 

information will help ensure that those who fund health research are aware of 

what matters to patients and clinicians.” 

http://www.lindalliance.org/ 


Reflection on the CAT process 

This section encourages you to reflect on the CAT process 

Describe your recent involvement in the CAT process 

What was the experience? 

What did you do? 

And why did you do this? 

What went well? 

What do you think could have been 

improved? 

What would you do differently next 

time? 

What did you learn from the experience? 

Any learning objectives generated? 

Reflection on incident and learning objectives 


Reference List 

Foster N Barlas P Chesterton L Wong J 2001 Critically Appraised Topics 

(CATS): One method of facilitating evidenced based practice in physiotherapy 

Physiotherapy 87 4 179-190 

Stevenson K, Bird L Sarigiovannis P Dziedzic K Foster NE Grahame C (2007) 

A new multidisciplinary Approach to integrating best evidence into 

musculoskeletal practice. Journal of Evaluation in Clinical Practice (online 

early articles)

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