Do musculoskeletal physiotherapists believe the NICE guidelines for the management of non-specific LBP are practical and relevant to their practice? A cross sectional survey

Determinants of clinical practice guidelines' utilization for the management of musculoskeletal disorders: a scoping review

Context

Many clinical practice guidelines have been developed for the management of musculoskeletal disorders (MSDs). However, there is a gap between evidence-based knowledge and clinical practice, and reasons are poorly understood. Understanding why healthcare providers use clinical practice guidelines is essential to improve their implementation, dissemination, and adherence.

Aim

To identify determinants of clinical practice guidelines’ utilization by health care providers involved in the assessment and management of MSDs.

Method

A scoping review of the literature was conducted. Three databases were searched from inception to March 2021. Article identification, study design, methodological quality, type of healthcare providers, MSDs, barriers and facilitators associated with guidelines’ utilization were extracted from selected articles.

RESULTS: 8671 citations were retrieved, and 43 articles were selected. 51% of studies were from Europe, and most were quantitative studies (64%) following a cross-sectional design (88%). Almost 80% of articles dealt with low back pain guidelines, and the most studied healthcare providers were general practitioners or physiotherapists. Five main barriers to guideline utilization were expressed by providers: 1) disagreement between recommendations and patient expectations; 2) guidelines not specific to individual patients; 3) unfamiliarity with “non-specific” term, or with the bio psychosocial model of MSDs; 4) time consuming; and 5) heterogeneity in guideline methods. Four main facilitators to guideline utilization were cited: 1) clinician’s interest in evidence-based practice; 2) perception from clinicians that the guideline will improve triage, diagnosis and management; 3) time efficiency; and 4) standardized language.

Conclusion

Identifying modifiable determinants is the first step in developing implementation strategies to improve guideline utilization in clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04204-w.

Management of low back pain: Treatment provision within private practice in the UK in the context of clinical guidelines

OBJECTIVE

To summarise the combination of treatments private UK-based physiotherapists use with patients who have low back pain (LBP) and the extent to which the treatments used are consistent with clinical guideline recommendations.

DESIGN

Cross-sectional observational survey.

METHODS

Data were collected from physiotherapists within private UK-based clinics using an online standardised data collection system to record the treatment they provided for patients who had LBP with/without leg pain. Treatment data were classified into those that are 'recommended', 'not recommended' and had 'no recommendation'.

RESULTS/FINDINGS

Treatment provided to 8003 patients were included in the analyses. Most patients (95.0%) were provided with a 'recommended' treatment. Approximately half of the patients who received 'recommended' treatment were also provided with other treatments that were either 'not recommended' (16.7%), had 'no recommendation' (16.6%) or a combination of both (13.0%). Few patients were provided with only treatments that were 'not recommended' and/or treatment with 'no recommendation' (4.6%).

CONCLUSION

This study provides insight into the self-reported practice of participating physiotherapists and highlights how they generally adopted a multimodal treatment model for patients with LBP. Consistent with the National Institute for Health and Care Excellence guidelines, most patients received information and advice often in conjunction with exercise and manual therapy. Only a small proportion of patients were provided with treatments that are 'not recommended' and/or treatment that had 'no recommendation'. These findings are useful in documenting the implementation of clinical guidelines given the need for practitioners to balance the best available evidence with patient expectation and preference and to facilitate the therapeutic alliance.

Tailored training for physiotherapists on the use of clinical practice guidelines: A mixed methods study

INTRODUCTION

Clinical practice guidelines (CPG) are vehicles for translating evidence into practice, but effective CPG-uptake requires targeted training. This mixed methods research project took a staged evidence-based approach to develop and test a tailored training programme (TTP) that addressed organisational and individual factors influencing CPG-uptake by South African physiotherapists treating patients with low back pain in primary healthcare settings.

METHODS

This multi-stage mixed methods study reports the development, contextualisation and expert content validation of a TTP to improve CPG-uptake. Finally, the TTP was evaluated for its feasibility and acceptability in its current format.

RESULTS

The TTP (delivered online and face-to-face) contained minimal theory, and focussing on practical activities, clinical scenarios and discussions. Pre-TTP, physiotherapists expressed skepticism about the relevance of CPG in daily practice. However, post-TTP they demonstrated improved knowledge, confidence, and commitment to CPG-uptake.

DISCUSSION

The phased-construction of the TTP addressed South African primary healthcare physiotherapists' needs and concerns, using validated evidence-based educational approaches. The TTP content, delivered by podcasts and face-to-face contact, was feasible and acceptable in terms of physiotherapists' time constraints, and it appeared to be effective in improving all outcome domains. This TTP is now ready for intervention to a wider audience.

Methodological Quality of Physical Therapy Guidelines and Their Suitability for Adaptation: A Scoping Review

OBJECTIVE

Clinical practice guidelines (CPGs) can be characterized to the extent that they specifically address physical therapists and mainly contain recommendations for physical therapist interventions. The primary aim of this study was to identify existing physical therapy CPGs regardless of medical condition, with a secondary aim of assessing their methodological quality to determine whether they are potentially suitable for adaptation.

METHODS

Systematic searches of the Medline and Physiotherapy Evidence Database were performed (August 2019), and the websites of World Confederation for Physical Therapy members were screened (September 2019). Only CPGs published in German or English were included. Two independent reviewers screened records according to previously defined inclusion criteria. Information was extracted regarding country of origin, year of publication, and clinical subject area addressed. Four independent reviewers assessed the quality of physical therapy CPGs using the Appraisal of Guidelines Research and Evaluation instrument. A descriptive data analysis was performed.

RESULTS

Thirty-five CPGs met the inclusion criteria; 46% (16/35) of the included CPGs were from the United States, and 31% (11/35) were from the Netherlands. Assessment using the Appraisal of Guidelines Research and Evaluation tool resulted in the following domain scores, presented as median percentage (interquartile range): domain 1 (scope and purpose), 76 (63-92); domain 2 (stakeholder involvement), 63 (55-76); domain 3 (rigor of development), 67 (53-75); domain 4 (clarity of presentation), 74 (67-77); domain 5 (applicability), 44 (30-57); and domain 6 (editorial independence), 52 (35-66).

CONCLUSIONS

In general, the methodological quality of the included CPGs was moderate to good. Possibilities of adapting recommendations from existing CPGs should be considered with the development of new physical therapy CPGs.

IMPACT STATEMENT

This study can raise awareness of existing physical therapy CPGs and can support their application by physical therapists. Further, the study can support decisions on adapting existing CPGs with the planning of new physical therapy CPGs.

Attitudes, skills and use of evidence-based practice among UK osteopaths: a national cross-sectional survey

BACKGROUND

Evidence-based practice (EBP) is a clinical decision-making framework that supports quality improvement in healthcare. While osteopaths are key providers of musculoskeletal healthcare, the extent to which osteopaths engage in EBP is unclear. Thus, the aim of this cross-sectional study was to investigate UK osteopaths' attitudes, skills and use of EBP, and perceived barriers and facilitators of EBP uptake.

METHODS

UK-registered osteopaths were invited to complete the Evidence-Based Practice Attitude and Utilisation Survey (EBASE) online.

RESULTS

Of the 5200 registered osteopaths in the UK, 9.9% (517/5200) responded to the invitation, and 7.2% (375/5200) completed the EBASE (< 20% incomplete answers). The demographic characteristics of the survey sample were largely similar to those of the UK osteopathy workforce. The osteopaths reported overall positive attitudes towards EBP, with most agreeing that EBP improves the quality of patient care (69.3%) and is necessary for osteopathy practice (76.5%). The majority reported moderate-level skills in EBP, and most (80.8%) were interested in improving these skills. Participating osteopaths typically engaged in EBP activities 1-5 times over the last month. Barriers to EBP uptake included a lack of time and clinical evidence in osteopathy. Main facilitators of EBP included having access to online databases, internet at work, full-text articles, and EBP education materials.

CONCLUSIONS

UK osteopaths were generally supportive of evidence-based practice, had moderate-level skills in EBP and engaged in EBP activities infrequently. The development of effective interventions that improve osteopaths' skills and the incorporation of EBP into clinical practice should be the focus of future research.

A Longitudinal Observational Clinical Study of Neurophysiological and Patient-Reported Responses to a Program of Physiotherapy for Acute and Subacute Low Back Pain

OBJECTIVES

The purpose of this study was to document the baseline neurophysiological status (skin conductance activity levels) of patients presenting for physiotherapy with acute and subacute low back pain (symptoms of up to 12 weeks' duration) and to observe the magnitude and direction of sympathetic nervous system (SNS) changes (skin conductance responses [SCRs]) occurring as a result of receiving guideline-endorsed physiotherapy treatment.

METHODS

A pragmatic, prospective, longitudinal, observational study recording SNS skin conductance (SC) responses and patient reported outcome measure changes to a program of guideline-endorsed physiotherapy treatment for low back pain symptoms of up to 12 weeks' duration. Sixty patients received a guideline-endorsed physiotherapy treatment program. Continuous neurophysiological recordings of SC activity levels were taken throughout each treatment. Patient reported outcome measure data were extracted from inception, midpoint, and discharge. Within and between treatment analyses determined the nature of SC changes and correlations to longitudinal changes in pain and function. Skin conductance changes were measured within and between treatment episodes at treatment inception, midpoint, and discharge and observed correlations between the magnitude of SCRs, pain abatement (numeric pain rating scale), and functional restoration (Oswestry Disability Index).

RESULTS

Skin conductance changes were significant during all "treatment" periods (P = .044), with the greatest magnitude of sympathoexcitatory responses occurring at inception (219%). The treatment modality providing the maximum SNS response was a high-velocity lumbar rotation manipulation. Positive correlations were identified between SCRs, Oswestry Disability Index improvements (r = 0.82, P < .0005), and pain abatement (r = 0.459, P < .0005).

CONCLUSIONS

Patients with low back pain exhibited neurophysiological treatment responses indicative of a symptom-related neuroplastic state of dorsal horn sensitization that may be receptive to early manual therapy intervention.

Current and future perspectives on lumbar degenerative disc disease: a UK survey exploring specialist multidisciplinary clinical opinion

OBJECTIVES

Despite lumbar degenerative disc disease (LDDD) being significantly associated with non-specific low back pain and effective treatment remaining elusive, specialist multidisciplinary clinical stakeholder opinion remains unexplored. The present study examines the views of such experts.

DESIGN

A reliable and valid electronic survey was designed to establish trends using theoretical constructs relating to current assessment and management practices. Clinicians from the Society of Back Pain Research (SBPR) UK were invited to take part. Quantitative data were collated and coded using Bristol Online Surveys (BOS) software, and content analysis was used to systematically code and categorise qualitative data.

SETTING

Specialist multidisciplinary spinal interest group in the UK.

PARTICIPANTS

38/141 clinically active, multidisciplinary SBPR members with specialist spinal interest participated. Among them, 84% had >9 years postgraduate clinical experience.

INTERVENTIONS

None.

OUTCOME MEASURES

Frequency distributions were used to establish general trends in quantitative data. Qualitative responses were coded and categorised in relation to each theme and percentage responses were calculated.

RESULTS

LDDD symptom recurrence, in the absence of psychosocial influence, was associated with physical signs of joint stiffness (26%), weakness (17%) and joint hypermobility (6%), while physical factors (21%) and the ability to adapt (11%) were postulated as reasons why some experience pain and others do not. No one management strategy was supported exclusively or with consensus. Regarding effective modalities, there was no significant difference between allied health professional and medic responses (p=0.1-0.8). The future of LDDD care was expressed in terms of improvements in patient communication (35%), patient education (38%) and treatment stratification (24%).

CONCLUSIONS

Results suggest that multidisciplinary expert spinal clinicians appear to follow UK-based assessment guidelines with regard to recurrent LDDD; there are, however, inconsistencies in the management approaches supported. This reflects the current literature and the lack of specific, formalised guidance. LDDD treatment stratification and further research are explicitly supported.

How do hand therapists conservatively manage acute, closed mallet finger? A survey of members of the British Association of Hand Therapists

Introduction

Previous research concerning the conservative management of mallet finger has focused on splint application, with limited representation of supplementary rehabilitation and best practice. This research sought to investigate the practice and opinions of members of the British Association of Hand Therapists regarding their current treatment and to determine whether any specific exercise prescription or rehabilitation protocols are followed.

Methods

British Association of Hand Therapists members were contacted via e-mail and requested to complete an online survey. Thirty-five responses (5.7% response rate), 30 (4.8% response rate) of which were fully completed were obtained over the eight-week data collection period. The questionnaire consisted of 30 questions (20 quantitative and 10 qualitative) concerning therapists’ roles and condition management. Responses were analysed in terms of response frequencies, percentages and thematic text analysis.

Results

The results demonstrated current clinical practices in line with available best-evidenced practice. Conservative therapeutic management is diverse and varied. Therapists believe their role to be significant in optimising outcome success.

Discussion

Exercises and other interventions supplementary to splinting are commonly utilised in the therapeutic management of acute, closed mallet finger. This research found hand therapists implement a diverse range of clinical skills in order to optimise outcome success. Recommendations for best practice and further research are presented.

Experiences of Rehabilitation Professionals with the Implementation of a Back School for Patients with Chronic Low Back Pain: A Qualitative Study

A standardized curriculum back school (CBS) has been recommended for further dissemination in medical rehabilitation in Germany. However, implementation of self-management education programs into practice is challenging. In low back pain care, individual factors of professionals could be decisive regarding implementation fidelity. The study aim was to explore attitudes and experiences of professionals who conducted the back school. Qualitative interviews were led with 45 rehabilitation professionals. The data were examined using thematic analysis. Three central themes were identified: (a) “back school as a common thread,” (b) “theory versus practice,” and (c) “participation and patient-centeredness.” The CBS and its manual were frequently described positively because they provide structure. However, specified time was mentioned critically and there were heterogeneous perceptions regarding flexibility in conducting the CBS. Theory and practice in the CBS were discussed concerning amount, distribution, and conjunction. Participation and patient-centeredness were mainly mentioned in terms of amount and heterogeneity of participation as well as the demand for competences of professionals. Factors were detected that may either positively or negatively influence the implementation fidelity of self-management education programs. The results are explorative and provide potential explanatory mechanisms for behavior and acceptance of rehabilitation professionals regarding the implementation of biopsychosocial back schools.

Strategies to promote practice nurse capacity to deliver evidence-based care

Purpose

– Evidence-based practice is pivotal to effective patient care. However, its translation into practice remains limited. Given the central role of primary care in many healthcare systems, it is important to identify strategies that bolster clinician-capacity to promote evidence-based care. The purpose of this paper is to identify strategies to increase Practice Nurse capacity to promote evidence-based sexual healthcare within general practice.

Design/methodology/approach

– A survey of 217 Practice Nurses in an Australian state and ten respondent-interviews regarding two resources to promote evidence-based sexual healthcare – namely, a clinical aide and online training.

Findings

– The perceived impact of both resources was determined by views on relevance and design – particularly for the clinical aide. Resource-use was influenced by role and responsibilities within the workplace, accessibility, and support from patients and colleagues.

Research limitations/implications

– This is the first Australian study to reveal strategies to promote evidence-based sexual healthcare among Practice Nurses. The findings provide a platform for future research on knowledge translation processes, particularly among clinicians who might be disengaged from sexual healthcare.

Practical implications

– Given the benefits of evidence-based practices, it is important that managers recognize their role, and the role of their services, in promoting these. Without explicit support for evidence-based care and recognition of the Practice Nurse role in such care, knowledge translation is likely to be limited.

Originality/value

– Knowledge translation among Practice Nurses can be facilitated by: resources-deemed informative, relevant, and user-friendly, as well as support from patients, colleagues, and their workplace.

Clinical decision making for using electro-physical agents by physiotherapists, an Israeli survey

Background

Electro-physical agents (EPAs) are fundamental components in the management arsenal of physiotherapy. The objective of this study was to provide a comprehensive understanding of the factors affecting the decisions made by Physiotherapists (PTs) when choosing to apply EPAs as a treatment modality.

Methods

A purpose-designed questionnaire was developed to investigate the contribution of 13 factors on the decision to use EPAs. Two hundred questionnaires were randomly distributed to PTs attending the annual conference of the Israeli Physiotherapy Society, 2014. The factors were grouped into six categories and Wilcoxon Sign Rank tests were applied to compare their impact on decision making.

Results

In total, 144 (72%) questionnaires were completed. Good internal consistency was found for the 13 component of the decisions factors (Cronbach’s coefficient alpha = 0.77) with unequal distribution of answers in each question (p < 0.01).

Eighty-one percent of the participants reported past experience, and 55 % mentioned research evidence as strong or very strong factors which influence their decision to use of EPAs. However, only 38% of the participants reported patients’ preferences as a strong or very strong factor. Comparisons between the six categories of the decision factors determined three levels of impact (rank scores) which were significantly different from each other (p < 0.01). Availability of equipment ranked the highest. The lowest level of impact included two categories, technology related issues and patients’ and physicians’ preferences.

Conclusion

The participating PTs were likely to make decisions which were strongly impacted by availability of equipment and operational factors. This research can be used to provide practicing PTs with a basis for a critical appraisal of their decision making regarding the application of EAPs. In addition, due to the strong impact of availability of equipment, health policy makers should verify that the available equipment is up to date with the best research evidence.