Think of the Discussion section of a research article as the most holistic or integrative of all the IMRaD sections.
Each of the others (Introduction, Methods, and Results), described in this column previously, is more self-contained, focusing on more specific purposes. The Introduction section grounds the research question in previous work and introduces the hypothesis that the research tests; the Methods section outlines exactly how that hypothesis will be tested; the Results section describes what happened when it is tested.
The Discussion section ties all these other sections together. It elaborates on their meanings, then makes recommendations for future research and practice. While researchers are careful to stick only to the facts in the previous sections, the Discussion section weaves context, imagination, and creativity with empirical facts. This combination interprets the study’s results for the reader, building a solid foundation for taking knowledge to the next step—a new study or a real-life practice.
Discussion Framework
While this final section is usually called Discussion, you may see other names for it, depending on the author and the journal: Conclusions, Comments, Recommendations, or something similar. In any case, it is the final section of the main article. Some usual things to look for in this section include:
1. Grounding the study in its larger context (similar to what the Introduction did with the literature review and the hypothesis).
2. The strengths and weaknesses of this study and how they affected the big picture of the study’s meaning (similar to how the Methods explained the issues involved in testing the research question).
3. What the Results mean (expanding on the Results section by adding interpretation).
4. What you should do with these Results (practice recommendations).
5. What future studies would be useful and why (research recommendations).
Let’s look at examples of how these elements may be presented in actual studies. After the last few months of reviewing the IMRaD format, you are in a position to appreciate what the authors have to say for themselves, with a minimum of interpretation. (Free, full-text references to the articles I cite are available in the links in the Notes section of this article.)
Grounding the Study
We can begin by putting the Results back into the context of the literature connected with the subject of the study. In the acute-postoperative pain discussion from Mitchinson et al. and in the preterm infant discussion from Hernandez-Reif et al., respectively, researchers remind the reader how the present studies connect to groundwork laid in other research.
The present study was designed to have adequate statistical power to detect the effect [of decreasing pain intensity and perception of “unpleasantness”] seen previously and to examine the short-term effect of massage on pain, anxiety, and functional recovery.1
Preterm infants are exposed daily to numerous stressors while being treated in the Neonatal Intensive Care Unit (NICU), resulting in their display of heightened motor activity and stress behaviors. Attenuation of these stress behaviors is desirable since chronic exposure to stress has been associated with medical and neurodevelopmental problems in the neonate.2
These discussions push the knowledge further, for future researchers to use as background someday.
Strengths and Weaknesses
Research always involves various trade-offs; no research study can have perfect methodology. A good research article addresses its strengths and limitations up front so the reader can decide how much weight to give those factors. In her Discussion, Mitchinson points out the risk of comparing apples with oranges in her study, compared to previous ones:
Although there were methodological differences between the preliminary study and this study, the long-term effects of massage on pain perception were preserved.3
Similarly, in an article about osteoarthritis of the knee, Perlman et al. mention the study’s limitations. The Discussion cites that while the Hawthorne effect, where a study participant performs up or down to researcher expectations:
May have been a factor in our results, both intragroup and intergroup differences were significant at 8 weeks, and the improvements in the intervention group largely persisted at the 16-week follow-up, which was 8 weeks after the subjects finished the weekly massage sessions. We used Swedish massage because it is one of the more common and readily accessible or practiced techniques in the United States. There was limited precedent for selecting frequency, duration, or even type of massage. There may prove to be more—and less—effective approaches, and this will need to be elucidated in subsequent studies.4
Interpreting Results
Getting into interpretation and meaning of the reported Results is an exciting and creative part of scientific discussion. Notice below how the researchers keep their results tied to the empirical facts of the study, even while they talk about possible meanings of those facts and how they are (or should be) careful to distinguish what they know for sure from what might be true.
Based on her results, Mitchinson sees a place for massage in the hospital, to treat pain after surgery:
The daily mean short-term changes for the pain intensity, pain unpleasantness, and anxiety scores all showed significant improvement from preintervention to postintervention measurements. Although short-term improvement was significant for all 3 groups for each of the 3 outcome variables, the massage group had a significantly greater improvement in short-term outcomes than did the individual-attention or the control group. In this study, significant decreases in the rates of both pain intensity and unpleasantness were seen during the first 4 postoperative days in subjects receiving massage. In addition, we have demonstrated the feasibility of incorporating massage into routine postoperative care.5
In her Discussion, Cynthia Price sees her work as providing potentially important insight for reducing dissociation symptoms among survivors of sexual abuse and posttraumatic stress disorder (PTSD) and supports it with various outcome measures and statistical analysis:
The study results indicated, as hypothesized, an incremental decrease in dissociation across time for both the body therapy interventions, suggesting that dissociation reduction in body therapy as an adjunct to psychotherapy is an unfolding process that builds on itself step by step. Participants each had a minimum of 2 years in psychotherapy at the outset of study, and yet significant change in dissociation experiences occurred during the course of the intervention and the follow-up period. The overall similar rate of change for both groups suggests that dissociation responds to a variety of bodywork approaches; in this study these approaches included a standardized massage, massage with body literacy, body awareness work, and delving—a practice of inner body mindfulness. The hypothesis that dissociation reduction would be positively associated with change on all outcome variables was upheld, suggesting a link between dissociation reduction and positive health outcomes with this population. This link was supported by correlation results demonstrating that change between any two points on dissociation was associated with change between the same two points on all outcome variables across time for participants in both intervention groups.6
Practice Recommendations
Possibilities of this sort lead very naturally into recommendations for practice. Mitchinson makes such a clinical recommendation:
Historically, massage was a common experience for postsurgical patients. As health care systems have become more complex and administrative demands on nursing time have increased, the tradition of nurse-administered massage has been largely lost. With the recent emphasis on assessing pain as the fifth vital sign tempered by renewed concerns for patient safety, it is time to reintegrate the use of effective and less dangerous approaches to relieve patient distress.7
The more specific the recommendation, the easier it is to see how it might apply to your practice and how to put it into effect. Not all recommendations in research literature, however, are that specific. Van Tilburg et al., in writing about complementary and alternative medicine for functional bowel disorders, make recommendations about filling knowledge gaps and increasing accessibility, leaving a great deal of deciding about how to do so to the reader:
Not all patients may be able to afford CAM due to its out-of-pocket costs. By moving CAM therapies with proven effectiveness into regular care, and providing insurance reimbursement for them, CAM can become more widely available. For this to occur we need to fill current knowledge gaps about treatment effectiveness (such as in herbal therapies) and make treatments already known to be effective, such as hypnotherapy and psychotherapy, more readily accessible.8
Research Recommendations
In addition to making recommendations for practice, the researcher can propose directions for future research, in order to build on the results in the current study. Price points out some possible new directions in research on traumatic dissociation indicated by her study’s outcomes:
In summary, the study results indicate that dissociation follows a declining pattern for women in body therapy during sexual abuse recovery, and supports future research examining dissociation reduction as a mediator of health outcomes in body therapy. The positive association between dissociation reduction and health outcomes in this sample—in which there were symptoms of moderate dissociation and depersonalization with no indication of dissociative disorder—suggests that depersonalization experiences may be associated with important health concerns and barriers to sexual abuse recovery for this population. Reassociation with the bodily self may be a key to healing problematic dissociation and improving mental and physical health in this population. This is a unique perspective offered by body therapy in trauma recovery, an untapped resource for the study of dissociation—its presentation and its treatment.9
All of these excerpts give just a sample of the amazing variety of studies that can be done about the useful and beneficial possibilities for our healing art—possibilities that are explored most fully in the Discussion section. They also set an implicit agenda for us: how will we make use of these possibilities? How can we add to the conversation?
Now that we’ve finished reviewing the standard IMRaD format, we’ll be experimenting with new approaches in upcoming articles. If you have a particular research-related question that you would like to see addressed here, drop me an e-mail with your thoughts and requests.
Ravensara S. Travillian is a massage practitioner and biomedical informatician in Seattle, Washington. She has practiced massage at the former Refugee Clinic at Harborview Medical Center and in private practice. In addition to teaching research methods in massage since 1996, she is the author of an upcoming book on research literacy in massage. Contact her at researching.massage@gmail.com.
Notes
1. Allison R. Mitchinson et al., “Acute Postoperative Pain Management Using Massage as an Adjuvant Therapy: a Randomized Trial,” Archives of Surgery 142, no. 12 (December 2007): 1158–67. Available at http://archsurg.ama-assn.org/cgi/reprint/142/12/1158 (accessed April 2009).
2. Maria Hernandez-Reif et al., “Preterm Infants Show Reduced Stress Behaviors and Activity After 5 Days of Massage Therapy,” Infant Behavior and Development 30, no. 4 (December 2007): 557–61. Available at www.pubmedcentral.nih.gov/picrender.fcgi?artid=2254497&blobtype=pdf (references cited by original text omitted; accessed April 2009).
3. Mitchinson et al., “Acute Postoperative Pain Management Using Massage as an Adjuvant Therapy: a Randomized Trial.”
4. Adam I. Perlman et al., “Massage Therapy for Osteoarthritis of the Knee: a Randomized Controlled Trial,” Archives of Internal Medicine 166, no. 22 (December 2006): 2,533–8. Available at http://archinte.ama-assn.org/cgi/reprint/166/22/2533 (accessed April 2009).
5. Mitchinson et al., “Acute Postoperative Pain Management Using Massage as an Adjuvant Therapy: a Randomized Trial.”
6. Cynthia Price, “Dissociation Reduction in Body Therapy During Sexual Abuse Recovery,” Complementary Therapies in Clinical Practice 13, no. 2 (May 2007): 116–28. Available at www.pubmedcentral.nih.gov/picrender.fcgi?artid=1965500&blobtype=pdf (accessed May 2009).
7. Mitchinson et al., “Acute Postoperative Pain Management Using Massage as an Adjuvant Therapy: a Randomized Trial.”
8. Miranda AL van Tilburg et al., “Complementary and Alternative Medicine Use and Cost in Functional Bowel Disorders: a Six Month Prospective Study in a Large HMO,” BMC Complementary and Alternative Medicine 8 (July 2008): 46. Available at http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=2499988&blobtype=pdf (accessed April 2009).
9. Cynthia Price, “Dissociation Reduction in Body Therapy During Sexual Abuse Recovery.”