Compliance with the guidelines for acute ankle sprain for physiotherapists is moderate in the Netherlands: an observational study

Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review

OBJECTIVES

Physicians often refer patients with musculoskeletal conditions to physical therapy. However, it is unclear to what extent physical therapists' treatment choices align with the evidence. The aim of this systematic review was to determine what percentage of physical therapy treatment choices for musculoskeletal conditions agree with management recommendations in evidence-based guidelines and systematic reviews.

DESIGN

Systematic review.

SETTING

We performed searches in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine, Scopus and Web of Science combining terms synonymous with 'practice patterns' and 'physical therapy' from the earliest record to April 2018.

PARTICIPANTS

Studies that quantified physical therapy treatment choices for musculoskeletal conditions through surveys of physical therapists, audits of clinical notes and other methods (eg, audits of billing codes, clinical observation) were eligible for inclusion.

PRIMARY AND SECONDARY OUTCOMES

Using medians and IQRs, we summarised the percentage of physical therapists who chose treatments that were recommended, not recommended and had no recommendation, and summarised the percentage of physical therapy treatments provided for various musculoskeletal conditions within the categories of recommended, not recommended and no recommendation. Results were stratified by condition and how treatment choices were assessed (surveys of physical therapists vs audits of clinical notes).

RESULTS

We included 94 studies. For musculoskeletal conditions, the median percentage of physical therapists who chose recommended treatments was 54% (n=23 studies; surveys completed by physical therapists) and the median percentage of patients that received recommended physical therapy-delivered treatments was 63% (n=8 studies; audits of clinical notes). For treatments not recommended, these percentages were 43% (n=37; surveys) and 27% (n=20; audits). For treatments with no recommendation, these percentages were 81% (n=37; surveys) and 45% (n=31; audits).

CONCLUSIONS

Many physical therapists seem not to follow evidence-based guidelines when managing musculoskeletal conditions. There is considerable scope to increase use of recommended treatments and reduce use of treatments that are not recommended.

PROSPERO REGISTRATION NUMBER

CRD42018094979.

Physiotherapists' views on the Australian Physiotherapy Association's Choosing Wisely recommendations: a content analysis

OBJECTIVES

Choosing Wisely holds promise for increasing awareness of low-value care in physiotherapy. However, it is unclear how physiotherapists' view Choosing Wisely recommendations. The aim of this study was to evaluate physiotherapists' feedback on Choosing Wisely recommendations and investigate agreement with each recommendation.

SETTING

The Australian Physiotherapy Association emailed a survey to all 20 029 physiotherapist members in 2015 seeking feedback on a list of Choosing Wisely recommendations.

PARTICIPANTS

A total of 9764 physiotherapists opened the email invitation (49%) and 543 completed the survey (response rate 5.6%). Participants were asked about the acceptability of the wording of recommendations using a closed (Yes/No) and free-text response option (section 1). Then using a similar response format, participants were asked whether they agreed with each Choosing Wisely recommendation (sections 2-6).

PRIMARY AND SECONDARY OUTCOMES

We performed a content analysis of free-text responses (primary outcome) and used descriptive statistics to report agreement and disagreement with each recommendation (secondary outcome).

RESULTS

There were 872 free-text responses across the six sections. A total of 347 physiotherapists (63.9%) agreed with the 'don't' style of wording. Agreement with recommendations ranged from 52.3% (electrotherapy for back pain) to 76.6% (validated decision rules for imaging). The content analysis revealed that physiotherapists felt that blanket rules were inappropriate (range across recommendations: 13.9%-30.1% of responses), clinical experience is more valuable than evidence (11.7%-28.3%) and recommendations would benefit from further refining or better defining key terms (7.3%-22.4%).

CONCLUSIONS

Although most physiotherapists agreed with both the style of wording for Choosing Wisely recommendations and with the recommendations, their feedback highlighted a number of areas of disagreement and suggestions for improvement. These findings will support the development of future recommendations and are the first step towards increasing the impact Choosing Wisely has on physiotherapy practice.

What is the quality of clinical practice guidelines for the treatment of acute lateral ankle ligament sprains in adults? A systematic review

BACKGROUND

Acute lateral ankle ligament sprains (LALS) are a common injury seen by many different clinicians. Knowledge translation advocates that clinicians use Clinical Practice Guidelines (CPGs) to aid clinical decision making and apply evidence-based treatment. The quality and consistency of recommendations from these CPGs are currently unknown. The aims of this systematic review are to find and critically appraise CPGs for the acute treatment of LALS in adults.

METHODS

Several medical databases were searched. Two authors independently applied inclusion and exclusion criteria. The content of each CPG was critically appraised independently, by three authors, using the Appraisal of Guidelines for REsearch and Evaluation (AGREE II) instrument online version called My AGREE PLUS. Data related to recommendations for the treatment of acute LALS were abstracted independently by two reviewers.

RESULTS

This study found CPGs for physicians and physical therapists (Netherlands), physical therapists, athletic trainers, physicians, and nurses (USA) and nurses (Canada and Australia). Seven CPGs underwent a full AGREE II critical appraisal. None of the CPGs scored highly in all domains. The lowest domain score was for domain 5, applicability (discussion of facilitators and barriers to application, provides advice for practical use, consideration of resource implications, and monitoring/auditing criteria) achieving an exceptionally low joint total score of 9% for all CPGs. The five most recent CPGs scored a zero for applicability. Other areas of weakness were in rigour of development and editorial independence.

CONCLUSIONS

The overall quality of the existing LALS CPGs is poor and majority are out of date. The interpretation of the evidence between the CPG development groups is clearly not consistent. Lack of consistent methodology of CPGs is a barrier to implementation.

SYSTEMATIC REVIEW

Systematic review registered with PROSPERO ( CRD42015025478 ).

HOW DOES THE BRAZILIAN ORTHOPEDIC SURGEONS TREAT ACUTE LATERAL ANKLE SPRAIN?

Acute lateral ankle sprain (ALAS) is a common injury, but its treatment has yet to be firmly established. The purpose of this study was to investigate how Brazilian Orthopedists (including residents) manage the diagnosis, classification, treatment and complications of ALAS.

METHODS

A multiple-choice questionnaire was developed with the aim of addressing the main aspects of the treatment of ALAS. The questionnaire was made available on the official website of the Brazilian Society of Orthopedics and Traumatology between June 15 and August 1, 2004.

RESULTS

444 questionnaires were included in the analysis. The results showed agreement among most of the interviewees in the following regards: 90.8% used a classification method to guide treatment of the sprain; 59% classified the ankle sprain with certainty; 63.7% used rigid immobilization in cases of totally torn ligaments; 60.6% used anti-inflammatory medication in cases of partial ligament tears; and 75.9% reported that residual pain was the most frequent complication. There was no consensus regarding the immobilization method for partial ALAS, given that immobilization and functional treatment were chosen with the same frequency (47%). There was no significant difference between the responses from residents and from orthopedists (p = 0.81).

CONCLUSIONS

Orthopedists and orthopedic residents in Brazil have difficulty classifying ALAS and there is no consensus about the best therapeutic option for partial ALAS.

Promoting physical therapists' use of research evidence to inform clinical practice: part 2--a mixed methods evaluation of the PEAK program

BACKGROUND

Clinicians need innovative educational programs to enhance their capacity for using research evidence to inform clinical decision-making. This paper and its companion paper introduce the Physical therapist-driven Education for Actionable Knowledge translation (PEAK) program, an educational program designed to promote physical therapists' integration of research evidence into clinical decision-making. This, second of two, papers reports a mixed methods feasibility study of the PEAK program among physical therapists at three university-based clinical facilities.

METHODS

A convenience sample of 18 physical therapists participated in the six-month educational program. Mixed methods were used to triangulate results from pre-post quantitative data analyzed concurrently with qualitative data from semi-structured interviews and focus groups. Feasibility of the program was assessed by evaluating change in participants' attitudes, self-efficacy, knowledge, skills, and self-reported behaviors in addition to their perceptions and reaction to the program.

RESULTS

All 18 therapists completed the program. The group experienced statistically significant improvements in evidence based practice self-efficacy and self-reported behavior (p < 0.001). Four themes were supported by integrated quantitative and qualitative results: 1. The collaborative nature of the PEAK program was engaging and motivating; 2. PEAK participants experienced improved self-efficacy, creating a positive cycle where success reinforces engagement with research evidence; 3. Participants' need to understand how to interpret statistics was not fully met; 4. Participants believed that the utilization of research evidence in their clinical practice would lead to better patient outcomes.

CONCLUSIONS

The PEAK program is a feasible educational program for promoting physical therapists' use of research evidence in practice. A key ingredient seems to be guided small group work leading to a final product that guides local practice. Further investigation is recommended to assess long-term behavior change and to compare outcomes to alternative educational models.

Guideline-based development and practice test of quality indicators for physiotherapy care in patients with neck pain

RATIONALE, AIMS AND OBJECTIVES

Little is currently known about the quality of physiotherapy care for patients with musculoskeletal pain. Neck pain was used as an example. The aim is to develop a set of quality indicators, including a practice test.

METHODS

A systematic method is used to develop potential process and outcome indicators. An expert and user panel is used to appraise the potential quality indicators regarding clarity, relevancy, feasibility, acceptability and improvement potential. An invitation to participate in the practice test was sent to physiotherapy practices. The resulting algorithm is used to calculate the degree to which physiotherapists met these indicators (0-100%). Differences in valid outcomes are tested for significance (Student's t-test; α = 0.05) and compared with established values for clinical relevance [minimal clinically important change (MCIC)].

RESULTS

A representative set of 40 quality indicators (28 process indicators and 12 outcome indicators) is selected from 44 initial guidelines and literature-based recommendations. The process indicators (n = 28) are classified per step of the clinical reasoning process of physiotherapy care. Of the 106 potential participants from 27 practices, 38 physiotherapists (35.8%) submitted data on 96 patients with non-specific neck pain. On average, the participating physiotherapists showed a 55.6% adherence to process indicators with a great variation in scores per step of the clinical reasoning process. The outcomes for 'pain', 'headache' and 'daily functioning' were significantly better compared with baseline, and the mean differences exceeded established values for MCICs.

CONCLUSION

Guardedly, we can conclude that a systematic approach is a valuable means to develop a preliminary set of process and outcome indicators for physiotherapy care for patients with non-specific neck pain, and a practice test should be an intrinsic part of such a systematic approach as it provides valuable information on the key attributes of the set indicators.

Excellent adherence and no contamination by physiotherapists involved in a randomized controlled trial on reactivation of COPD patients: a qualitative process evaluation study

OBJECTIVE

To assess the adherence of physiotherapists to the study protocol and the occurrence of contamination bias during the course of a randomized controlled trial with a recruitment period of 2 years and a 1-year follow-up (COPE-II study).

STUDY DESIGN AND SETTING

In the COPE-II study, intervention patients received a standardized physiotherapeutic reactivation intervention (COPE-active) and control patients received usual care. The latter could include regular physiotherapy treatment. Information about the adherence of physiotherapists with the study protocol was collected by performing a single interview with both intervention and control patients. Patients were only interviewed when they were currently receiving physiotherapy. Interviews were performed during two separate time periods, 10 months apart. Nine characteristics of the COPE-active intervention were scored. Scores were converted into percentages (0%, no aspects of COPE-active; 100%, full implementation of COPE-active).

RESULTS

Fifty-one patients were interviewed (first period: intervention n = 14 and control n = 10; second period: intervention n = 18 and control n = 9). Adherence with the COPE-active protocol was high (median scores: period 1, 96.8%; period 2, 92.1%), and large contrasts in scores between the intervention and control group were found (period 1: 96.8% versus 22.7%; period 2: 92.1% versus 25.0%). The scores of patients treated by seven physiotherapists who trained patients of both study groups were similar to the scores of patients treated by physiotherapists who only trained patients of one study group.

CONCLUSION

The adherence of physiotherapists with the COPE-active protocol was high, remained unchanged over time, and no obvious contamination bias occurred.

An investigation of West Sussex general dental practitioners' awareness, attitudes and adherence to NICE dental recall guidelines

AIMS

The overall aim of this study was to determine whether general dental practitioners (GDPs) in West Sussex were aware of and followed National Institute for Health and Clinical Excellence (NICE) guidelines on dental recalls. The study also aimed to identify factors in the GDPs' practice of dentistry that could affect their adherence to NICE guidelines and to gain some insight into their views on this topic and how these might affect their adherence.

METHODS

A postal questionnaire, which had previously been piloted, and an explanatory letter were sent to a random sample of 195 GDPs representing 50% of the GDPs contracted to the West Sussex Primary Care Trust. Those who did not respond were sent the questionnaire and letter for a second time. The questionnaire consisted of 50 questions that covered awareness of, attitudes towards and adherence to the NICE guidelines on dental recalls, risk factors, and the GDPs' practising profile. Resulting data were entered into a database and, where appropriate, statistically tested with the chi-square test, with the level of statistical probability set at P<0.5.

RESULTS

Data were obtained from the 50 questions in the questionnaires. Only key results are presented in this abstract. Ten of the 195 GDPs had either moved away from the area or were orthodontists. The final sample was therefore 185, of whom 117 returned questionnaires, a response rate of 63%. Seventy-three per cent of the respondents had qualified in United Kingdom. Sixty-five per cent were male. The mean age of respondents was 43 years. Seventy-one per cent worked as GDPs within the General Dental Services (GDS) or Personal Dental Services. Concerning NICE recall guidelines, 94% stated that they were aware of them, 61% said they agreed with them, and 64% that they adhered to them. Female GDPs were statistically far more likely to state that they followed NICE guidelines ( P =0.0043). Seventy per cent of GDPs reported that they still recalled their patients at six-month intervals and only 3% that they recalled their patients according to need. Eighty-five per cent reported taking radiographs at two-year intervals and/or according to patient need, and 68% that they gave oral hygiene advice six monthly or at every recall. Risk assessments were reported as being always carried out by 65% of responding GDPs for caries, 83% for periodontal disease, and 81% for oral cancer. Ninety per cent reported that they thought risk factors were relevant when setting the recall interval and 82% thought that six-monthly recalls allowed appropriate screening to take place.

CONCLUSIONS

Only 3% of responding GDPs recalled their patients according to patient need, in line with NICE recall guidelines, although the majority of GDPs agreed with the guidelines and stated that they adhered to them; however, this was in contrast to the 70% of GDPs who continued to recall at six-month intervals. The majority of GDPs thought that less frequent recalls would not allow for early caries, periodontal disease and oral malignancy diagnosis, and did not think that access to NHS dentistry would be improved. They also did not believe that excessive NHS money was spent on over-frequent dental examinations. There would appear to be significant obstacles to altering the recall habits of dentists because of the way that dentists practise.

Physiotherapists' compliance with ankle injury guidelines is different for patients with acute injuries and patients with functional instability: an observational study

QUESTIONS

What are the characteristics of patients with acute ankle injuries or functional instability of the ankle? Do physiotherapists treat these patients according to evidence-based guidelines? What are the determinants of adherence to the guidelines?

DESIGN

Observational study using multi-level analyses of data from the National Information Service for Allied Health Care in the Netherlands. This network continuously collects healthcare-related information on characteristics of patients and their referral, health problem, and treatment plan.

PARTICIPANTS

1413 patients treated for ankle injuries.

OUTCOME MEASURES

Adherence to the guidelines was measured using three quality indicators: number of sessions, interventions, and accomplished treatment goals.

RESULTS

Interventions and treatment goals were often aimed at the improvement of body functions, especially in patients with functional instability. Although not advised in the guidelines, manual manipulation was applied during treatment in 21% of the patients with functional instability. On average, patients with acute ankle injuries have a 38% chance of being treated according to the guidelines. Adherence can be explained partly by the duration of the complaint, whether the complaint is recurrent, the patient's age and the experience of the therapist, but it depends substantially on the therapist.

CONCLUSION

There is some discrepancy between the guidelines and practice, especially regarding the interventions applied to patients with functional instability. However, there is large variation between therapists. The sooner a patient presents for treatment and the greater the experience of the physiotherapist with ankle injuries, the greater the likelihood that treatment will follow the guidelines.

Managing ankle sprains in primary care: what is best practice? A systematic review of the last 10 years of evidence

To summarize the best available evidence in the last decade for managing ankle sprains in the community, data were collected using MEDLINE database from January 2000 to December 2009. Terms utilized: 'ankle injury primary care' (102 articles were found), 'ankle sprain primary care' (34 articles), 'ankle guidelines primary care' (25 articles), 'ankle pathways primary care' (2 articles), 'ankle sprain community' (18 articles), 'ankle sprain general practice' (22 articles), 'Cochrane review ankle' (58 articles). Of these, only 33 satisfied the inclusion criteria. The search terms identified many of the same studies. Two independent reviewers reviewed the articles. The study results and generated conclusions were extracted, discussed and finally agreed on. Ankle sprains occur commonly but their management is not always readily agreed. The Ottawa Ankle Rules are ubiquitous in the clinical pathway and can be reliably applied by emergency care physicians, primary care physicians and triage nurses. For mild-to-moderate ankle sprains, functional treatment options (which can consist of elastic bandaging, soft casting, taping or orthoses with associated coordination training) were found to be statistically better than immobilization for multiple outcome measures. For severe ankle sprains, a short period of immobilization in a below-knee cast or pneumatic brace results in a quicker recovery than tubular compression bandage alone. Lace-up supports are a more effective functional treatment than elastic bandaging and result in less persistent swelling in the short term when compared with semi-rigid ankle supports, elastic bandaging and tape. Semi-rigid orthoses and pneumatic braces provide beneficial ankle support and may prevent subsequent sprains during high-risk sporting activity. Supervised rehabilitation training in combination with conventional treatment for acute lateral ankle sprains can be beneficial, although some of the studies reviewed gave conflicting outcomes. Therapeutic hyaluronic acid injections in the ankle are a relatively novel non-surgical treatment but may have a role in expediting return to sport after ankle sprain. There is a role for surgical intervention in severe acute and chronic ankle injuries, but the evidence is limited.

Choice of treatment modalities was not influenced by pain, severity or co-morbidity in patients with knee osteoarthritis

BACKGROUND AND PURPOSE

Patients with knee osteoarthritis (OA) are commonly treated by physiotherapists in primary care. The physiotherapists use different treatment modalities. In a previous study, we identified variation in the use of transcutaneous electrical nerve stimulation (TENS), low level laser or acupuncture, massage and weight reduction advice for patients with knee OA. The purpose of this study was to examine factors that might explain variation in treatment modalities for patients with knee OA.

METHODS

Practising physiotherapists prospectively collected data for one patient with knee osteoarthritis each through 12 treatment sessions.We chose to examine factors that might explain variation in the choice of treatment modalities supported by high or moderate quality evidence, and modalities which were frequently used but which were not supported by evidence from systematic reviews. Experienced clinicians proposed factors that they thought might explain the variation in the choice of these specific treatments. We used these factors in explanatory analyses.

RESULTS

Using TENS, low level laser or acupuncture was significantly associated with having searched databases to help answer clinical questions in the last six months (odds ratio [OR] = 1.93, 95% confidence interval [CI] = 1.08-3.42). Not having Internet access at work and using more than four treatment modalities were significant determinants for giving massage (OR = 0.36, 95% CI = 0.19-0.68 and OR = 8.92, 95% CI = 4.37-18.21, respectively). Being a female therapist significantly increased the odds for providing weight reduction advice (OR = 3.60, 95% CI = 1.12-11.57). No patient characteristics, such as age, pain or co-morbidity, were significantly associated with variation in practice.

CONCLUSIONS

Factors related to patient characteristics, such as pain severity and co-morbidity, did not seem to explain variation in treatment modalities for patients with knee OA. Variation was associated with the following factors: physiotherapists having Internet access at work, physiotherapists having searched databases for the last six months and the gender of the therapist. There is a need for more studies of determinants for physiotherapy practice.

Implementation of measurement instruments in physical therapist practice: development of a tailored strategy

BACKGROUND AND PURPOSE

The use of measurement instruments has become a major issue in physical therapy, but their use in daily practice is infrequent. The aims of this case report were to develop and evaluate a plan for the systematic implementation of 2 measurement instruments frequently recommended in Dutch physical therapy clinical guidelines: the Patient-Specific Complaints instrument and the Six-Minute Walk Test.

CASE DESCRIPTION

A systematic implementation plan was used, starting with a problem analysis of aspects of physical therapist practice. A literary search, structured interviews, and sounding board meetings were used to identify barriers and facilitators. Based on these factors, various strategies were developed through the use of a planning model for the process of change.

OUTCOMES

Barriers and facilitators were revealed in various domains: physical therapists' competence and attitude (knowledge and resistance to change), organization (policy), patients (different expectations), and measurement instruments (feasibility). The strategies developed were adjustment of the measurement instruments, a self-analysis list, and an education module. Pilot testing and evaluation of the implementation plan were undertaken. The strategies developed were applicable to physical therapist practice. Self-analysis, education, and attention to the practice organization made the physical therapists aware of their actual behavior, increased their knowledge, and improved their attitudes toward and their use of measurement instruments.

DISCUSSION

The use of a planning model made it possible to tailor multifaceted strategies toward various domains and phases of behavioral change. The strategies will be further developed in programs of the Royal Dutch Society for Physical Therapy. Future studies should examine the use of measurement instruments as an integrated part of the process of clinical reasoning. The focus of future studies should be directed not only toward physical therapists but also toward the practice organization and professional associations.

Multifaceted strategies may increase implementation of physiotherapy clinical guidelines: a systematic review

QUESTION

What is the effectiveness of strategies to increase the implementation of physiotherapy clinical guidelines?

DESIGN

Systematic review.

PARTICIPANTS

Physiotherapists treating any type of patients.

INTERVENTION

Single or multiple strategies to increase the implementation of physiotherapy clinical guidelines.

OUTCOME MEASURES

Professional practice, patient health, and cost of care.

RESULTS

Five papers reporting three cluster-randomised trials evaluated whether multifaceted strategies based on educational meetings increased the implementation of low back pain guidelines (2 trials) or whiplash guidelines (1 trial). Educational meetings were effective in increasing adherence to the following recommendations of low back pain guidelines: limiting the number of sessions (RD 0.13, 95% CI 0.03 to 0.23), using active intervention (RD 0.13, 95% CI 0.05 to 0.21), giving adequate information (RD 0.05, 95% CI 0.00 to 0.11), increasing activity level (RD 0.16, 95% CI 0.02 to 0.30), changing attitudes/beliefs about pain (RD 0.13, 95% CI 0.01 to 0.24). Educational meetings were effective in increasing adherence to the following recommendations of whiplash guidelines: reassuring the patient (RD 0.40, 95% CI 0.07 to 0.74), advising the patient to act as usual (RD 0.48, 95% CI 0.15 to 0.80), using functional outcome measures (RD 0.62, 95% CI 0.32 to 0.92). There was no evidence that patient health was improved or that the cost of care was reduced.

CONCLUSION

This review shows that multifaceted interventions based on educational meetings to increase implementation of clinical guidelines may improve some outcomes of professional practice but do not improve patient health or reduce cost of care. These findings are comparable with results among other health professions.