[Appropriateness of physiotherapy care in Germany: a scoping review]

[DNVF Memorandum: Objectives and Methods of Physical Activity-Related Health Services Research]

The DNVF Memorandum: Objectives and Methods of Physical Activity-Related Health Services Research summarizes, for the first time, the highly interdisciplinary and interprofessional field of physical activity-based health care in the German healthcare system. In addition to providing a conceptual framework and definition of key measures and concepts in physical activity-related health care research, existing research gaps and needs are identified, and methods for advancing this relatively young field of research are described. A particular focus of this study is the relevant outcome parameters and their standardized assessment using established and valid measurement tools. The memorandum aims to establish a general understanding of the complex subject of promoting physical activity and sports therapy in the context of healthcare, to give an impulse to new research initiatives, and to integrate the currently available strong evidence on the effectiveness of physical activity and exercise into healthcare.

Appropriateness of exercise therapy delivery in chronic low back pain management: cross-sectional online survey of physiotherapy practice in Germany

BACKGROUND

In Germany, exercise therapy represents the most commonly prescribed physiotherapy service for non-specific, chronic low back pain (NSCLBP). So far, little is known about current practice patterns of German physiotherapists in delivering this intervention. Thus, the aim of this study was to investigate the appropriateness of exercise therapy delivered to NSCLBP patients in German physiotherapy care and to identify practitioner-related drivers of appropriate exercise delivery.

METHODS

We used a vignette-based, exploratory, cross-sectional, online-survey study design (76-items; data collection between May and July 2023). Eligible participants were required to hold a professional degree in physiotherapy and were required to be practicing in Germany. Access links to anonymous online surveys were spread via established German physiotherapy networks, educational platforms, social media, e-mail lists, and snowball sampling. Appropriateness of exercise therapy was calculated by an equally weighted total score (400 points) including scales on shared-decision-making, exercise dose selection, pain knowledge and self-management promotion. "Appropriate exercise delivery" was determined by a relative total score achievement of > 80%. "Partly appropriate exercise delivery" was determined by a relative total score achievement of 50-79%, and "inappropriate exercise delivery" by a score achievement of < 50%. Practitioner-related drivers of exercise appropriateness were calculated by bivariate and multiple linear regression analyses.

RESULTS

11.9% (N = 35) of 298 physiotherapists' exercise delivery was considered "appropriate", 83.3% (N = 245) was "partly appropriate", and 4.8% (N = 14) was "inappropriate". In the final multiple regression model, most robust parameters positively influencing appropriate delivery of exercise therapy were increased scientific literacy (B = 10.540; 95% CI [0.837; 20.243]), increased average clinical assessment time (B = 0.461; 95% CI [0.134; 0.789]), increased self-perceived treatment competence (B = 7.180; 95% CI [3.058; 11.302], and short work experience (B = - 0.520; 95% CI [-0.959; - 0.081]).

CONCLUSION

Appropriate exercise delivery in NSCLBP management was achieved by only 11.9% of respondents. However, the vast majority of 95.2% of respondents was classified to deliver exercise therapy partly appropriate. Long work experience seemed to negatively affect appropriate exercise delivery. Positive influences were attributed to scientific literacy, the average clinical assessment time per patient as well as the perceived treatment competence in NSCLBP management.

REGISTRATION

Open science framework: https://doi.org/10.17605/OSF.IO/S76MF .

Therapist versus Machine-Immediate Effects of Manual versus Mechanical Lymphatic Drainage in Patients with Secondary Lymphedema

Background: Complex decongestive therapy (CDT) is the standard and basic therapy for lymphedema. The central component of CDT is manual lymphatic drainage (MLD). In addition to CDT, other measures such as intermittent pneumatic compression therapy (IPCT) (active compression machine therapy) are available. In this prospective research study, the objective and subjective effects of MLD and IPCT on lymphedema of the lower extremity were investigated and both therapies were directly compared. Furthermore, the patients' body mass index (BMI) and stage of lymphedema were tested for their effect on the respective therapy. Methods: Patients participating in the study received both therapies (MLD and IPCT) on the same lymphedema-affected limb at an interval of two days. The objective volumetric therapy effect was measured by the digital volume measurement of the affected limb. The subjective effects of the therapies were measured using two specially designed questionnaires. Results: A total of 40 patients were included in the study. There was no significant difference in the volume differences between the interventions, BMI categories, lymphedema, or treatment order regarding the immediate and two-day effect. Conclusions: No significant difference was found in the subjective or objective therapy efficacy of the two methods. Intermittent pneumatic compression therapy is considered a comparable therapeutic procedure when properly indicated.

Research designs and instruments to detect physiotherapy overuse of low-value care services in low back pain management: a scoping review

BACKGROUND

The provision of low-value physiotherapy services in low back pain management is a known but complex phenomenon. Thus, this scoping review aims to systematically map existing research designs and instruments of the field in order to discuss the current state of research methodologies and contextualize results to domains and perspectives of a referred low-value care typology. Ultimately, results will be illustrated and transferred to conditions of the German health care setting as care delivery conditions of physiotherapy in Germany face unique particularities.

METHODS

The development of this review is guided by the analysis framework of Arksey and O'Malley. A two-stage, audited search strategy was performed in Medline (PubMed), Web of Science, and google scholar. All types of observational studies were included. Identified articles needed to address a pre-determined population, concept, and context framework and had to be published in English or German language. The publication date of included articles was not subject to any limitation. The applied framework to assess the phenomenon of low-value physiotherapy services incorporated three domains (care effectiveness; care efficiency; patient alignment of care) and perspectives (provider; patient; society) of care.

RESULTS

Thirty-three articles met the inclusion criteria. Seventy-nine percent of articles focused on the appropriateness of physiotherapeutic treatments, followed by education and information (30%), the diagnostic process (15%), and goal-setting practice (12%). Study designs were predominantly cross-sectional (58%). Data sources were mainly survey instruments (67%) of which 50% were self-developed. Most studies addressed the effectiveness domain of care (73%) and the provider perspective (88%). The perspective of patient alignment was assessed by 6% of included articles. None of included articles assessed the society perspective. Four methodical approaches of included articles were rated to be transferrable to Germany.

CONCLUSION

Identified research on low-value physiotherapy care in low back pain management was widely unidimensional. Most articles focused on the effectiveness domain of care and investigated the provider perspective. Most measures were indirectly and did not monitor low-value care trends over a set period of time. Research on low-value physiotherapy care in secondary care conditions, such as Germany, was scarce.

REGISTRATION

This review has been registered on open science framework ( https://osf.io/vzq7k https://doi.org/10.17605/OSF.IO/PMF2G ).

Research designs and instruments to detect physiotherapy overuse of low-value care services in low back pain management: a scoping review protocol

BACKGROUND

The provision of low-value care services in low back pain management is a problem of global scope. Inappropriate imaging, overmedication, and overused invasive therapies are prevalent in physician services. Yet, little is known about overused low-value physiotherapy services. Most studies addressing physiotherapy overuse in low back pain management arose from countries in which physiotherapy is established in primary care. However, measures and instruments addressing physiotherapy overuse limitedly fit legislative conditions of health systems in which physiotherapy is a service of secondary care. Thus, this scoping review's purpose is to map existing research designs and instruments aiming to detect overused low-value physiotherapy services taking specific healthcare settings and aspects of medical overuse into account.

METHODS

The development of this scoping review is guided by the Arksey and O'Malley framework. A two-step, peer-reviewed search strategy in accordance with the PRESS checklist will be conducted on MEDLINE (PubMed), Web of Science, and CINHAL. Additionally, gray literature will be searched on Google Scholar. Preprints of empirical studies will be included. Initially, two reviewers will independently screen articles for eligibility by title and abstract. A third reviewer will mediate discrepancies. Uncertainties will be eliminated by a full-text analysis or by contacting the corresponding authors. A four-step analytical process will guide result reporting focusing on major research questions outlined in this protocol. Numerical and narrative tables, graphics, and narrative summaries will be the methods to summarize and collate results. In the final step, the German health system will serve as an exemplary setting and frame to practically apply results.

DISCUSSION

Results of this scoping review will help researchers to systematically select overuse measures referring to aspects of the overuse typology, specific healthcare settings, and physiotherapy services. It will further provide information on the limitations of present studies and will give advice on how to address them. Moreover, this review will illustrate to what degree existing studies succeed to comprehensively cover the concept of the overuse typology.

SYSTEMATIC REVIEW REGISTRATION

This protocol has been registered on the open science framework ( https://doi.org/10.17605/OSF.IO/PMF2G ).