Shoulder problems in chronic stroke

Shoulder problems in chronic stroke


Stroke is defined as a sudden expression of neurological malfunction caused by circulatory disturbances resulting in effects in main regions of brain ( and considered to be the single major cause of serious disability in the UK (Banks and Pearson et al., 2004). Usually stroke is classified based on causes, anatomy or management strategies. A demographic study indicated the incidence of stroke to be 20% lesser in females than males. The risk of stroke is twice or thrice higher in African-Americans compared to whites, and hence the risk of death due to stroke (AHA, 1998; PSRG, 1996). Survivability of the subjects is often related to the type of stroke which is further complicated by pre-existent conditions hypertension, heart diseases and diabetes and also other factors like age, sex and other predisposing factors (Banks and Pearson et al., 2004). People who suffer with stroke are reported to acquire sudden disabilities which may be mild or severe (Different Strokes, 2002) and of these shoulder problems with pain are more prevalent in almost 20% of elderly population (Daigneault and Cooney, 1998).

Various studies have been conducted to assess the effectiveness of different intervention techniques like analgesia, transcutaneous electrical stimulation, steroid injections and shoulder strapping (Price, 2002).

Researcher workers tend to use qualitative methods to find the core facts in the natural conditions with an attempt to explain the processes involved and the role of the patients in a disease condition, therapy program or any subject on which the study is based. The quality of life in people after stroke cannot be evaluated until steps are taken to explore the ideas of peoples themselves and we can understand that a particular scheme emerges following every such exercise (Greenhalgh and Taylor, 1997). Most of the studies which assess the quality of life after stroke follow Barthel Index to evaluate the improvement and the patient's physical activity (Mahoney and Barthel, 1965).

What is qualitative study?

It is the method to find out the ideas in a particular area with a goal to collect more information which is used in making hypotheses. The possible hypothesis in a research involving chronic stroke patients with shoulder problems will be related to the vital role of rehabilitation in improving shoulder conditions. Qualitative findings were also used to test the underlying behavioural theory upon which the intervention was based (Kinmonth et al., 1999).

It is a theoretical way to explain the deeper truth in disease conditions like stroke. In most cases, smaller focused groups are preferred than large sample size (Mays and Pope, 2000). This favours easy probing to investigate the matter in depth using approaches like classic ethnography, proven theory or shadowing. Pilot testing is a very useful qualitative method that can facilitate in developing a better quantitative strategy. This makes the quantitative approach more reliable and valid (Mays and Pope, 2000).

Various studies have been carried out to assess the quality of life (QOL) after stroke through questionnaires, interviews and group discussions (Martin et al., 2002). Qualitative methods seek to examine causal effects in relationships between variables in an objective and unbiased manner, and more concerned with the quality of the process of the research. Open-ended questionnaires allow any pre-conceived assumptions of the researcher to be challenged and the participants can explain the actual effect of intervention on their lives (Willig, 2001). Semi-structured interviews offer a more standardized approach to data collection. They are widely used in qualitative designs and are appropriate to many different forms of qualitative research and data can be collected and analyzed in a variety of ways (Willig, 2001). Focus groups are also used to support the qualitative study owing to its ability to generate useful ideas through interaction between the participants. Randomized trials (Price, 2002) and focus group methods are relatively efficient and quick way to elicit patients' interpretations on functionality of the intervention and their ability to cope with physical stress especially the chronic shoulder problems after stroke (Kitzinger, 1995). For a qualitative study to be strong and acceptable, it has to be vivid in description, analytically precise, heuristically relevant and methodologically compatible (Burns, 1989).

In many cases, a qualitative study often starts with a very easy question to answer which is further guided through a specific direction to be relevant to the study. In a study carried out by Pound et al. (2009), the patients were asked to narrate the story of how they got stroke with an initial question like “What happened on the day you had your stroke?”. This is a main advantage of the qualitative method since it encourages the participants to talk voluntarily and also gives good scope for probing and exploring the subject in-depth. Also, it is possible to obtain the data regarding how stroke and post-stroke disabilities have affected their life (Pound et al., 2009). It was also stated that the qualitative data gathered could be presented for the development of questionnaires to examine the subjective effect of stroke on the quality of life in post-stroke patients which is an indispensable advantage (Pound et al., 2009).

The few demerits of this method is that the low response rate and small interview group which make the information gathered less reliable due to the insignificant representation. The sample group always may not be a true representative of the population being studied (Pound et al., 2009). Another obstacle in a qualitative is active participation of the patients. For example, in the study by Pound et al. (2009), most of the patients being interviewed initially were participating in another similar quantitative research by the North East Thames Stroke Outcome Study. This had obviously placed a limitation on the qualitative study with regards to time.

What is quantitative study?

Quantitative methods are based on a logical and structured way to address a question and measure the effect of interventions. Here the emphasis is mainly on use of objective, valid and reliable measurement tools (French et al., 2001). These methods are basically designed to establish the relationships between the dependant and independent variables (Polgar & Thomas, 2000) which are expressed as precise and unbiased sets of measurements of length, size, etc. or even verbally. Experimental data would be collected and statistically analysed so that causal relationships between chronic shoulder problems and improvement by rehabilitation with restoration of muscle power can be established and expressed numerically (Niessen et al., 2009).

There are various methods of collecting quantitative data like cohort studies, randomized-controlled trials, questionnaires of which questionnaires are the most used to cover a large population size (Polgar & Thomas, 2000). Case control study with 21 patients has indicated that the post-stroke shoulder problems have resulted in altered proprioception and increased scapular lateral rotation. It was also found that the readings on unparalysed side could be used as an indicator for development of shoulder problems and pain on the other side (Niessen et al., 2009).

In randomized controlled trials, the samples are selected at random with a definite population size. This however may not be error proof as random sampling may not cover the entire population and there is considerable planning and expenditure (Polgar and Thomas, 2000). Questionnaires can be helpful to cover a large population with specific close-ended questions but often fails to account for the extra mural factors like the social and cultural values of the participant and also the group designs may be error prone if not planned properly.

The distinct advantage of using quantitative methods is that they can be readily applied to measures of biodiversity value like ethnicity, gender, age group, and any such group with one or multiple representations (Greenhalgh & Taylor, 1997).

The patients participating in the study on different days yield different measurements and sometimes the first set of readings recorded were not concurrent with the second set (Niessen et al., 2009). This is very time consuming and also expensive as many trials needed to be repeated to get an optimal volume of data (Niessen et al., 2009).

What is multiple method research?

If the qualitative and quantitative studies are combined, then it is called mixed method or multi-method approach. The combination of the methods to be used in the research study is determined by the research workers based on various factors like desired results, availability of raw data, time, cost, etc. (Bryman, 2008)but this however is practically subject to controversy

Here the qualitative and quantitative methods support each other to increase the scope and reliability of the research study. An integrated approach to study stroke was carried out by Clarke (2003). Qualitative methods were used to understand the effects of stroke on the quality of life in community dwelling patients while the quantitative data was statistically processed to point the social supports and educational resources available to help the disabled. When these methods were used together, it was possible to get a clear subjective idea of how the quality of life has changed following stroke in those individuals (Clarke, 2003).

In the above research, the use of quantitative methods was not accurate since the underlying reasons to various relationships between the variables had to be assumed in the statistical designs. Moreover, triangulation is a complex process which requires clear objective, plan and skill (Clarke, 2003).

Even though there are numerous possibilities for integrating the methods, triangulation is the most used due to the easiness and better repeatable results (Clarke, 2003).


Qualitative data consumes more time to be obtained and examined compared to quantitative data so mostly smaller groups are preferred. Qualtitative approach gives elaborate, detailed outcomes, and also more cost-effective than quantitative methods (Niessen, 2009). The main drawback of quantitative approach is that it assumes the world around us to be steady and constant always obeying a particular set of rules while the qualitative approach has a much broader scope where there are always multiple possibilities and anything and everything might change subject to the individuality of the setting and the participants of the study (Clarke, 2003).

On an expanded spectrum of thoughts, the results from both qualitative and quantitative methods are vital for any research work. Mixed methods approach is promising and increases the possibilities of outcomes. When combined these data gave a subjective view on the effect of stroke in the quality of life of patients. The patients that have undergone shoulder problem and pain reported improvement following proper rehabilitation. Quantitative analysis of data from national databases gave a good idea of the role of stroke in well-being of the patients. This supported the in-depth interviews with stroke survivors to identify various factors which play vital role in moderation of quality of life and post-stroke adaptation. This also permits the possibility of such further studies that may use intergrated approaches much efficiently and hence to understand the stroke scenario better thereby to device techniques and programs for prevention and management of shoulder pain and problems. Such studies would be appropriate depending on the aim and goal of the research workers (Clarke, 2003).


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