To search literature related to anterior cruciate ligament reconstruction and about neuromuscular training and strength training for improving functional outcome after anterior cruciate ligament reconstruction ,which is the main intervention of my study.
Critically appraise the relevant literatures by using critically appraisal tool.
To state conclusion and recommendations which will lead to better understanding of neuromuscular training and strength training and its contribution in improving functional outcome after ACL reconstruction.
To provide the rational and research base for changing ingrained behavior within clinical practice.
THEORETICAL PERSPECTIVE: -
Research is defined as a rigorous, logical, systematic inquiry, utilising multiple disciplined methods. Its aim is to generate knowledge in relation to a specified question or problem, associated with human behaviour, human experience and human environment, as addressed by the researcher, with the ultimate goal of development, refinement and expansion of its body of knowledge (Hek et al 2004)
Almost all research studies require a rational or base for conducting research, this is often called theoretical framework (Radhakrishma et al 2007). The use of a theoretical framework refers to the application of a particular theory that is relevant to the research question and to which the eventual literature review is referred (Aveyard 2007). A theoretical framework is a conceptual model of how one theorises or makes logical sense of the relationship among several factors that have been identified as important to the problem (Sekaran 2000).
Kuhn (1970) used paradigms to describe how scientists work within accepted ways of defining, assigning categories, theorising and procedures within disciplines and during particular historical periods (cited Hart 2003).
Theoretical perspectives are a set of assumptions about the way we look at the world and on which research question is based. Theoretical perspectives are important because they provide a framework for interpreting observations.
As mentioned by Guba (1990) there are many paradigms but researcher's concern is with that paradigm which gives disciplined guidance for his research. When the question about paradigm arises the researcher should know how to define a paradigm and how to decide that his research question falls under which paradigm?
In attempt to answer this question Guba (1990) explains that researcher should ask himself three questions-
Ontology-
The ontology is that of critical realist, a tangible reality is strived for i.e. neuromuscular function is affected in anterior cruciate ligament injury and also it is a fact that neuromuscular training is effective in gaining functional outcomes.
Epistemology
What is the nature of relationship between the knower and the known?
My study is a modified objectivist as the results are going to be observed post intervention using various parameters.
Methodology
How should the researcher go about gathering knowledge to answer the research question?
As I m doing a secondary research, I will be gathering data from literature of previously done primary researches. And will be critically appraising, comparing and contrasting them to get the final conclusion of my research.
BACKGROUND-
The anterior cruciate ligament (ACL) is one of the most important of four strong ligaments connecting the bones of the knee joint. It is often injured.
The function of the ACL is to provide stability to the knee and minimize stress across the knee joint:
It restrains excessive forward movement of the lower leg bone (the tibia) in relation to the thigh bone (the femur).
It limits rotational movements of the knee.
A tear to the anterior cruciate ligament (ACL) results from overstretching of this ligament within the knee.
It's usually due to a sudden stop and twisting motion of the knee, or a force or "blow" to the front of the knee.
The extent of the tear can be a partial or a complete tear.
Individuals experiencing a tear to the ACL may feel a pop at the time of the injury.
It is often injured together with other structures inside the knee joint. After the initial injury, the knee may swell and become painful. Instability or a sensation the knee is "giving out" may be a major complaint following this injury.
ACL ruptures occur at a rate of 60 per 100,000 people per year. With society's increasing interest in physical fitness, primary care physicians are seeing more athletic injuries. Along with these injuries are the commonly experienced ACL ruptures in athletes and non-athletes.
ACL reconstruction is a highly successful operation. With good rehabilitation, 90% to 95% of individuals who undergo this surgery can expect to return to full sports participation within six months.
Rehabilitation after ACL reconstruction-
Following are the important things about rehabilitation after anterior cruciate ligament reconstruction, limb strength, patient-reported outcomes, functional knee stability, bilateral limb symmetry with functional tasks, postural control, power, endurance, agility, and technique with sport-specific tasks (. Myer et al 2006)
Anatomical studies have demonstrated the existence of mechanoreceptors in the human ACL (Schutte et al 1987 cited in Myer et al 2006). The ACL not only serves a mechanical role by limiting passive knee mobility but also serves a sensory role through the mechanoreceptors deep in its tissue, which communicate with the neuromuscular system to provide proprioceptive feedback during training and competition (Gray Cook et al 1999)
The decrease of proprioceptive sense in the ACL deficient knee has been well stated by Barrack et al 1989, Borsa et al 1997, Corrigan 1992, MacDonald 1996 cited in( Myer et al 2006).So neuromuscular training which comprises of proprioceptive training, balance training, perturbation training, agility task and sports specific training are crucial after ACL reconstruction surgery. For evaluating the effectiveness of this treatment various outcome measures are used. (Risberg and Holm 2009)
Standardized outcome measures can be described as measures with acceptable measurement properties that have been published with specific procedures for administration, scoring, and interpretation. For evaluating the effectiveness of knee stability and neuromuscular function after rehabilitation (strength and neuromuscular training) the outcome measures used are Cincinnate knee score, VAS, HOP test,SF-36,Joint laxity-T-1000 knee arthrometer test.
According to the definition of neuromuscular control, neuromuscular training could be defined as training enhancing unconscious motor responses by stimulating both afferent signals and central mechanisms responsible for dynamic joint control. The biomechanics of the knee are altered after anterior cruciate ligament (ACL) injury, but neuromuscular training may enhance control of abnormal joint translation during functional activities by inducing compensatory alterations in muscle activity patterns(Risberg et al 2001)
The objectives of neuromuscular training are to improve the nervous system's ability to generate a fast and optimal muscle firing pattern, to increase dynamic joint stability, to decrease joint forces, and to relearn movement patterns and skills. The exercises are designed to induce compensatory changes in muscle activation patterns and facilitate dynamic joint stability in patients with ACLinjury. The goal is to achieve a state of "readiness" of muscles to respond to joint forces resulting in enhanced motor control. ( Risberg et al 2001)
METHODOLOGY-
A critical literature review will be the method I am going to use for the research proposal. A literature review is a comprehensive study and interpretation of the literature that relates to a particular topic (Aveyard 2007).
The growing importance of evidence based practice within health care has lead to literature reviews becoming more relevant to current practice and an important research methodology in its own right. (Aveyard 2007). Evidence-based practice ensures operation, based on the most available, current, valid and reliable research (Hek et al 2004). Godling & Edwards (2002) explain how the research is used as evidence more now to guide clinical decision making and improving practice.
A literature review has its advantages and limitations: They are inexpensive to carry out, it doesn't need the time, space or man power that a primary research study would need. It does not need ethical committee approval, as it is analysing existing data. According to Hart (2003) the quality of the literature reviewed can vary considerably. Quality means appropriate breadth and depth, rigour and consistency, clarity and brevity, and effective analysis and synthesis within the research. Therefore the limitations of the literature review may be the literature reviewed itself. The researcher may miss relevant research due to disciplinary compartmentalisation (Hart 2003)
Lanoë (2002) elucidates how research can be descriptive, experimental or action research. The research question of 'what is / are' is characteristic of descriptive research; (Radhakrishma et al 2007). The role of descriptive correlation research is to explain / predict relationships. Experimental research answers the question of why a relationship exists, and when answering the question why, it incorporates the question of what, from descriptive research and the explanation from descriptive correlation research (Radhakrishma et al 2007). Therefore, it seems that all types of research designs are somewhat interlinked. All these types of research are important to be included within the literature review an order to fully answer to posed question.
METHOD-
Aveyard (2007) states that the researcher needs to develop a search strategy which will enable to identify and locate a wide range of published material on the research question. How the data will be collected needs to be indicated within the research proposal (Punch 2001).
I will be using a systematic approach to the data collection, to identify the key literature and texts related to the subject. Aveyard (2007) suggests that without a systematic search strategy the search may be random and disorganised and the reader may miss the relevant literature had been identified and reviewed.
To find out related articles to research question electronically, researcher will use Brooke's access on campus as well as off campus by using Athens account password.
The researcher will carry out systematic search of variety of electronic resources such as databases, books, e-books, websites etc.
Databases used were CINHAL, COCHRANE, EBSCO, EMERALD, PubMed, PEDro, AHMED, and SCIENCE DIRECT.
While searching through databases it is difficult find related journals, articles to particular type. Therefore it's necessary to set certain key terms which can directly lead researcher to related literature.
For the research question" How effective is neuromuscular training when combined with traditional strength training in improving functional outcome after anterior cruciate ligament reconstruction?" search terms are-
Anterior Cruciate Ligament
Anterior Cruciate Ligament reconstruction
Neuromuscular training
Neuromuscular exercises
Strength training
Strengthening exercises
Propripceptive training
Perturbation training
Balance training
Functional outcomes
Outcome measures
The mentioned above key terms alone are not enough to search the related literature. To connect them with each other it is necessary to use Boolean operator 'AND' and 'OR'. Following are the search strategy applied to collect the data using Boolean operators-
Neuromuscular training or proprioceptive training or pertubation training or balance training
Anterior cruciate ligament reconstruction and neuromuscular training or proprioceptive training or pertubation training or balance training
Anterior cruciate ligament reconstruction and strength training
Anterior cruciate ligament reconstruction and strength training and neuromuscular training or proprioceptive training or pertubation training or balance training.
Snowball Sampling:
According to Greenhalgh and Peacock (2005) 'snowball sampling' will also be useful effective approach to literature searching in their systematic review. Snowball sampling effect appears as a multiplication of referral at each step. In such practices researcher can search reference list of references whenever there are limited options to find out relevant literature.
Searching the reference list:
According to Greehalfh and Peacock(2005) reference list which not only gives a judgement to decide whether this aricle should be pursued further but also gives a good source of articles. Searching a relevant article for the research question is quite time consuming and complex process. After doing systematic search for the literature sorting them according to their relevancy is crucial. According to Barraso et al (2003) and Evans (2002) the use of title alone to determine the relevancy of a study to their particular research is not efficient. Reading abstracts of the literature will be helpful to determine its relevancy with the researcher's question.
The sequence of reliability is as follows
Journals> Articles> Books> Conference paper> Dissertation abstract> web search.
Sample- By using previously described search strategy the sample will be obtained. The key issue for using this available sample is its relevancy. To ensure the selection of right evidence there should be a inclusion and exclusion criteria. Select studies that meet the inclusion and exclusion criteria. This will help to reduce the number to good number of useful and related literature.
The criteria will be as follows:
Inclusion criteria
Exclusion criteria
1.Researches related neuromuscular and strength training after anterior cruciate ligament reconstruction.
2.Age group below 50 yrs
3. Those articles which are in English language are included
4. The studies after 2000 were emphasized more.
5. Published articles
6.Only RCT's were included
1. Those articles which are in other than English language are excluded
2. Age above 50 yrs old
3. Studies before 2000.
4. Unpublished articles
5. Other than RCT's
DATA ANALYSIS-
Once the relevant research articles have been identified, a critical review of the research will be carried out. Not all research are good quality and many studies are biased and results are untrue (Burls 2009). Greenhalgh (2006) highlights the need for critical appraisal of medical papers, and she suggests that if a researcher is going to decide to read a paper they should do so on the design of the methods section and not on the interest value of the hypothesis or speculation in the discussion (Greenhalgh 2006).
Burls (2009) states that "critical appraisal is the process of carefully and systematically examining research, to judge its trustworthiness, and its value and relevance in a particular context".
Many tools have been developed to aid critical appraisal, for example; those developed by the Critical Appraisal Skills Programme (CASP) found via the Public Health Resource Unit (2007). With the wide choice of tools available, the reviewer does need to assess the quality and appropriate application of the critical appraisal tool (Aveyard 2006). There could be an argument that an appraisal tool is not necessary to critique research papers, however, Aveyard (2006) states that the review process is complex and the use of an appraisal tool will assist in the development of a systematic and equitable approach to the critique process.
I will be using the CASP tools, specific to the research designs of each of the papers read. This critical appraisal process will be a time consuming aspect to the study, especially, initially as a novice using the tools and the limited knowledge of the research designs. However as the process develops, the researcher will become more proficient at this process.
The prime important thing after critically appraising the literature is to summarise and synthesize all the results together so as to determine the results of the research. According to Fingeld (2003) the aim of synthesis is bring together the different studies and to find new meaning from the sum of papers as a whole than that could be achieved by reading each separately.Being a novice researcher it is easy to follow simplified approach proposed by Aveyard (2007) and adapted from Paterson et al. (2001) which says,
Summarise the content of all papers
Compare and contrast the described studies
Interpretation of Results
Thorne et al. (2004) describe this process as a Meta-summary. To present the findings of reviewed literature and summerise them all together, tabulated format will result in better view.
ETHICAL ISSUES-
As I am doing secondary research with the help of literature review of primary research and there is no interaction with the participants so there is no need of ethical approval. But when using different articles, journals and books of different authors and even literature from different institutes there should be legal authority and permission from authors to use the data without changing authors view or concept. I will ensure that the research I will review articles that are been carried out in ethical manner.According to cresswell(2009),ethical issue applies to writing and dissemination as well.Therefore ill make sure that the information I provide is accurate,it is written in unbiased language that do not suppress other authors findings,is not discriminative for people based on age,gender,background,race or religion.also the information will be transparent and honest in releasing the study design so that the readers themselves can determine the worthiness of the study and will acknowledge the author and the sources I use for my dissertation. I will follow the referencing guidelines provided by the Brookes University so that all sources have been acknowledged and well-referenced.
RIGOUR
The rigour of any research is to carry it in systematic way and it should be practicable. To ensure that my study is rigrous, I will present the information gathered in the literature review in a systematic logical order, the data will be critically appraised using an appropriate appraisal tool, in order to identify the credible and trustworthy data. Credibility of the study will be strengthened through (O'Leary 2005)-
systematic research must be well designed using inclusion and exclusion criteria
broadly represented by exploring multiple sources
I'll ensure to interpret the results of research in ascertainable manner.I will avoid interpreting my findings vaguely and widely to make them justifiable and conclusive.
I'll provide up to date information about anterior cruciate ligament reconstruction, and its relation to neuromuscular and strength training.
I will show better and developed understanding of these clinical concepts.
LIMITATIONS-
Though literature review has its own advantage like that it has some limitations as well-
Gaps in identifying and critiquing the literature
The most important limitation keeping masters course in mind is Time and Resources.
Time restrains in writing and searching literatures.
Financial restraints to access more articles via databases and inter library loans.
Searching strategy- Searching Strategy: The literature of health care has increased so much that it has become difficult to access each and every relevant document specifically related to your research work (Evans 2002).
Since only articles in English will b included, there are chances that important information in other language could be ignored.
Since only published RCT's will be included, there are chances that important information could be ignored from other types of literature and risk for bias against using only published research(Easterbrook et al1991)
Though conclusions and results are derived by using several references but they are based on researcher's own perception and interpretations there is chance of getting biased conclusions.
TIME FRAMEWORK-
When doing research it is important to manage your time. Blaxter et al (2006) think flexibility is important because it is difficult to estimate the time that the different research sections will take, some will take longer than you expected. Research will start in Sept 2010 and researcher will submit it in Sept 2011(see appendix for time framework)
Dissemination
The aims of dissemination, is to make research more accessible, to raise awareness and prepare individuals for change (Bury 1998). Dissemination will depend upon the findings of the study, the evidence base, as to whether the results and conclusion will identify areas of practice that will need to be changed. As part of project the researcher will share result with his dissertation supervisor and to others via Oxford Brookes University library. Such type of dissemination may result helpful in asset to spread awareness about neuromuscular exercises in anterior cruciate ligament reconstruction.
Conclusion-
This research proposal has outlined the process that I will undertake in order to answer the research question: the background to the proposal, the theoretical perspective, methodology, research design, and analysis and data collection. I have identified the critical appraisal tools to be used to critique the data, with an acknowledgement of the ethical considerations and potential limitations for the study. Doing literature review is challenging and will definitely help me in gaining valuable skills in both my professional as well as personal life as the process is very focused and organized. I believe that the literature review will enhance understanding of the subject and ultimately improve patient's outcome.
REFRENCE LIST:
Aveyard H (2007) Doing a literature Review in Health and Social Care. Open University Press.
Barrack RL, Skinner HB, Buckley SL(1989). Proprioception in the anterior cruciate deficient knee. Am J Sports Med;17:1-6
Barroso J, Gallop CJ, Sandelowski M, Meynell J, Pearce PF, Collins LJ (2003). The challenges of searching for & retrieving qualitative studies, Western Journal of Nursing Research. 25(2): 153-78
Borsa PA, Lephart SM, lrrgang JJ, Safran MR, Fu FH(1997). The effects of joint position and direction of joint motion on proprioceptive sensibility in anterior cruciate ligamentdeficient athletes. Am J Sports Med.,25:336-340
Burls (2009) What is Critical Appraisal. Evidence Based Medicine. 2nd ED.Available at: www.whatisseries.co.uk
Bury TJ (1998) Getting research in to practice: changing behaviour. In Bury TJ and Mead JM Evidence- Based Healthcare: A Practical Guide to Therapist. Oxford: Butterworth- Heinemann, 66-84.
Corrigan JP, Cashman WF, Brady MP(1992). Proprioception in the cruciate deficient knee. J Bone Joint Surg Br..74:247-250.
Creswell J W(2009) Qualitative,Quantitative and Mixed Method Approaches(3rd edition) London:Sage Publication.
Easterbrook PJ, Berlin JA, Gopalan R, Matthews DR (1991). Publication bias in clinical trials, Lancet 337(8746): 867-72
Evans D (2002). Database searches for qualitative research. Journal of The Medical Library Association. 90: 290-293.
http://www.ehealthmd.com/library/acltears/acl_whatis.html
Fingled DL (2003) Metasynthesis: the state of the art so far. Qualitative Health Research 13(7): 893-904
Godling. L & Edwards. K. (2002.) Evidence-based practice. Nurse Researcher. 9(4): 45-57
Gray Cook, Lee Burton, Keith Fields(1999) Reactive Neuromuscular Training for the Anterior Cruciate Ligament-Deficient Knee:A Case Report,Orthopaedic and Sports Physical Therapy, Danville, 34(2): 194-201.
Greenhalgh T & Peacock R (2005). Effectiveness & efficiency of search methods in systematic reviews of complex evidence. British Medical Journal. 331, 1064-1065.
Greenhalgh T (2006) How to read a paper: the basics of evidence based medicine. Blackwell Publishing 3rd Ed.
Guba E.C. (1990). The alternative paradigm dialog .In E.C. Guba(Ed).the paradigm dialog, (pp.17-27). New York: Sage.
Hart C (2003) Doing a literature Review. Releasing the Social Science Research Imagination. Sage publications. London
Hek. G., Judd., M., & Moule. P., (2004.) Making Sense of Research. 2nd ed. London: Sage Publications Ltd.
Lanoë. M.E., (2002.) Reading Research: How to make it more approachable. 3rd ed. London: Baillière Tindall.
MacDonald PB, Hedden D, Pacin 0, Sutherland K.(1996) Proprioception in anterior cruciate ligament-deficient and reconstructed knees. Am / Sports Med;24:774-778.
May Arna Risberg, Marianne M, Hanne Krogstad, lnger Holm(2001) Journal of Orthopaedic & Sports Physical Therapy;3l (ll):620-631 http://www.jospt.org/issues/articleID.317/article_detail.asp
Myer GD, Paterno MV, Ford KR, Quatman CE, Hewett TE.(2006) Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase.J Orthop Sports Phys Ther.;36(6):385-402.
O'Leary Z (2005) Researching Real -World Problems:A Guide To Method Of Enquiry.London:Sage Publications.
Pitman MI, Nainzadeh N, Menche D, Gasalberti R, Song EK(1992)The intraoperative evaluation of the neurosensory function of the anterior cruciate ligament in humans using somatosensory evoked potentials. Arthroscopy, 442-447.
Punch ,F (2006) Developing effective Research Proposal. Chapter 6 . Sage Publications. London.
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Radhakrishma R, Yoder E, Ewing J (2007) Strategies for linking theoretical framework and research types. Proceedings of the 2007 AAAE Research Conference. Vol 34
Risberg M A and Holm I(2009),Americam Journal of sports medicine 37:1958-1965.
Schutte MJ, Dabezies EJ, Zimny ML, Happel LT(1987). Neural anatomy of the human anterior cruciate ligament. Bone Joint Surg Am.;69:243-247.
Sekaran, U (2000) Research methods for business. New York: John Wiley & Sons.
Seto JL, Orofino AS, Morrissey MC, Medeiros JM, Mason WJ(1988) Assessment of quadricepslhamstring strength, knee ligament stability, functional and sports activity levels five years after anterior cruciate ligament reconstruction.[Am] Sports Med;16:170-180.)
APPENDIX 1:
TIME LINE CHART
S E P'10
O C T
N O V
D E C
J A N.
F E B
M A R
A P R
M A Y
J U N
J U L
A U G
1
Choosing research topic
2
Preliminary literature review
â-
â-
3
Defining the research question
â-
4
Critiquing and reviews
â-
5
Analysis
â-
6
Writing methodology chapter
â-
7
Writing method chapter
â-
8
Writing discussion chapter
â-
9
Writing conclusion chapter
.
10
Writing introduction
.
11
Writing abstract
.
12
Formulating a title
.
13
Final organisation-refrencing
.
14
Proof reading of final dissertation
.
15
Making any corrections
.
16
Final proof reading
.
17
Submission of dissertation
.
