Development and Implementation of National Practice Guidelines: A Prospect for Continuous Quality Improvement in Physiotherapy

Clinical Practice Guideline for Physical Therapist Management of People With Rheumatoid Arthritis

OBJECTIVE

This guideline revises the 2008 Royal Dutch Society for Physical Therapy guideline for physical therapy for patients with rheumatoid arthritis (RA).

METHOD

This revised guideline was developed according to the Appraisal of Guidelines for Research and Evaluation tool and the Guidelines International Network standards. A multidisciplinary guideline panel formulated clinical questions based on perceived barriers in current care. For every clinical question, a narrative or systematic literature review was undertaken, where appropriate. The guideline panel formulated recommendations based on the results of the literature reviews, the values and preferences of patients and clinicians, and the acceptability, feasibility, and costs, as described in the Grading of Recommendations Assessment, Development and Evaluation evidence-to-decision framework.

RESULTS

The eventual guideline describes a comprehensive assessment based on the International Classification of Functioning, Disability and Health Core Set for RA. It also includes a description of yellow and red flags to support direct access. Based on the assessment, 3 treatment profiles are distinguished: (1) education and exercise instructions with limited supervision, (2) education and short-term supervised exercise therapy, and (3) education and intensified supervised exercise therapy. Education includes RA-related information, advice, and self-management support. Exercises are based on recommendations concerning the desired frequency, intensity, type, and time-related characteristics of the exercises (FITT factors). Their interpretation is compliant with the individual patient's situation and with public health recommendations for health-enhancing physical activity. Recommended measurement instruments for monitoring and evaluation include the Patient-Specific Complaint instrument, Numeric Rating Scales for pain and fatigue, the Health Assessment Questionnaire Disability Index, and the 6-minute walk test.

CONCLUSION

An evidence-based physical therapy guideline was delivered, providing ready-to-use recommendations on the assessment and treatment of patients with RA. An active implementation strategy to enhance its use in daily practice is advised.

IMPACT

This evidence-based practice guideline guides the physical therapist in the treatment of patients with RA. The cornerstones of physical therapist treatment for patients with RA are active exercise therapy in combination with education. Passive interventions such as massage, electrotherapy, thermotherapy, low-level laser therapy, ultrasound, and medical taping play a subordinate role.

Reliability, validity and discriminability of patient reported outcomes for non-specific low back pain in a nationwide physical therapy registry: A retrospective observational cohort study

BACKGROUND

A national clinical registry was established in the Netherlands containing data directly sampled from electronic health record systems of physical therapists (PTs). This registry aims to evaluate the potential of patient reported outcome measures (PROMs) to develop quality indicators (QIs) in physical therapy care.

PURPOSE

To test to what extent the collected PROM data are reliable, valid and discriminatory between practices in measuring outcomes of patients with non-specific low back pain (NSLBP).

METHODS

In this retrospective cohort study 865 PT practices with 6,560 PTs voluntarily collected PROM data of patients with NSLBP, using the Quebec Back Pain Disability Scale (QBPDS), the Numeric Pain Rating Scale (NPRS) and the Patient Specific Functioning Scale (PSFS). Reliability was determined by analysing the completeness of the dataset, the comparability by using national reference data, and through checking selection bias in the included patients. Validity was tested using the known-groups contrast between patients with (sub)acute vs. chronic NSLBP. To determine discriminative ability of outcomes between PT practices, case-mix corrected hierarchical multilevel analyses were performed.

RESULTS

Reliability was sufficient by confirming fifteen of the sixteen hypotheses: 59% of all patients opted in for data analysis, 42% of these included patients showed repeated measurement, comparing with reference data and potential selection bias showed < 5% between group differences, while differences between (sub)acute and chronic NSLB-groups were significantly larger than 5% (less treatment sessions, lager differences in outcomes in (sub)acute NSLB patients). In addition, all nine adjusted hierarchical multilevel models confirm that the collected dataset on outcomes in PT care is able to discriminate between practices using PROM results of patients with NSLBP (ICC-scores range 0.11-0.21).

LIMITATIONS

Although we have shown the reliability, validity and discriminative ability of the dataset in the quest to develop QIs, we are aware that reducing missing values in patient records and the selective participation of PTs that belong to the innovators needs attention in the next stages of implementation to avoid bias in the results.

CONCLUSION

PROMs of patients with NSLBP collected in the national clinical registry of KNGF are reliable, valid and able to discriminate between primary care PT practices.

A clinical practice guideline for physical therapy in patients with hip or knee osteoarthritis

OBJECTIVE

The purpose of this paper is to revise the 2010 Dutch guideline for physical therapy (PT) in patients with hip or knee osteoarthritis (OA), issued by the Royal Dutch Society for Physical Therapy (KNGF).

METHOD

This revised guideline was developed according to the Appraisal of Guidelines for Research and Evaluation (AGREE) and Guidelines International Network (G-I-N) standards. A multidisciplinary guideline panel formulated clinical questions based on perceived barriers to current care. A narrative or systematic literature review was undertaken in response to each clinical question. The panel formulated recommendations based on evidence and additional considerations, as described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence-to-Decision framework.

RESULTS

A comprehensive assessment should be based on the International Classification of Functioning Disability and Health (ICF) core set for OA, including the identification of OA-related red flags. Based on the assessment, four treatment profiles were distinguished: (1) education and instructions for unsupervised exercises, (2) education and short-term supervised exercise therapy, (3) education and longer term supervised exercise therapy, and (4) education and exercise therapy before and/or after total hip or knee surgery. Education included individualized information, advice, instructions, and self-management support. Exercise programs were tailored to individual OA-related issues, were adequately dosed, and were in line with public health recommendations for physical activity. Recommended measurement instruments included the Patient-Specific Complaints Instrument, the Numeric Pain Rating Scale, the Hip Disability and Osteoarthritis Outcome Score/the Knee Injury Osteoarthritis Outcome Score, and the Six Minute Walk Test.

CONCLUSION

An evidence-based PT guideline for the management of patients with hip or knee OA was developed. To improve quality of care for these patients, an extensive implementation strategy is necessary.

Dutch guidelines for physiotherapy in patients with stress urinary incontinence: an update

Introduction and hypothesis

Stress urinary incontinence (SUI) is the most common form of incontinence impacting on quality of life (QOL) and is associated with high financial, social, and emotional costs. The purpose of this study was to provide an update existing Dutch evidence-based clinical practice guidelines (CPGs) for physiotherapy management of patients with stress urinary incontinence (SUI) in order to support physiotherapists in decision making and improving efficacy and uniformity of care.

Materials and methods

A computerized literature search of relevant databases was performed to search for information regarding etiology, prognosis, and physiotherapy assessment and management in patients with SUI. Where no evidence was available, recommendations were based on consensus. Clinical application of CPGs and feasibility were reviewed. The diagnostic process consists of systematic history taking and physical examination supported by reliable and valid assessment tools to determine physiological potential for recovery. Therapy is related to different problem categories. SUI treatment is generally based on pelvic floor muscle exercises combined with patient education and counseling. An important strategy is to reduce prevalent SUI by reducing influencing risk factors.

Results

Scientific evidence supporting assessment and management of SUI is strong.

Conclusions

The CPGs reflect the current state of knowledge of effective and tailor-made intervention in SUI patients.

A qualitative study of barriers to the implementation of a rheumatoid arthritis guideline among generalist and specialist physical therapists

BACKGROUND

Although the increasing complexity and expansion of the body of knowledge in physical therapy have led to specialized practice areas to provide better patient care, the impact of specialization on guideline implementation has been scarcely studied. Objectives The objective of this study was to identify the similarities and differences in barriers to the implementation of a Dutch rheumatoid arthritis (RA) guideline by generalist and specialist physical therapists. Design This observational study consisted of 4 focus group interviews in which 24 physical therapists (13 generalist and 11 specialist physical therapists) participated.

METHODS

Physical therapists were asked to discuss barriers to the implementation of the RA guideline. Data were analyzed qualitatively using a directed approach to content analysis. Both the interviews and the interview analysis were informed by a previously developed conceptual framework.

RESULTS

Besides a number of similarities (eg, lack of time), the present study showed important, although subtle, differences in barriers to the implementation of the RA guideline between generalist physical therapists and specialist physical therapists. Generalist physical therapists more frequently reported difficulties in interpreting the guideline (cognitive barriers) and had less favorable opinions about the guideline (affective barriers) than specialist physical therapists. Specialist physical therapists were hampered by external barriers that are outside the scope of generalist physical therapists, such as a lack of agreement about the roles and responsibilities of medical professionals involved in the care of the same patient.

CONCLUSIONS

The identified differences in barriers to the implementation of the RA guideline indicated that the effectiveness of implementation strategies could be improved by tailoring them to the level of specialization of physical therapists. However, it is expected that tailoring implementation strategies to barriers that hamper both generalist and specialist physical therapists will have a larger effect on the implementation of the RA guideline.

Supervised exercise therapy for intermittent claudication: current status and future perspectives

Intermittent claudication (IC) has a high prevalence in the older population and is closely associated with cardiovascular and cerebrovascular disease. High mortality rates are reported due to ongoing atherosclerotic disease. Because of these serious health risks, treatment of IC should address reduction of cardiovascular events (and related morbidity/mortality) and improvement of the poor health-related quality of life (QoL) and functional capacity. In several randomized clinical trials and systematic reviews, supervised exercise therapy (SET) is compared with non-supervised exercise, usual care, placebo, walking advice or vascular interventions. The current evidence supports SET as the primary treatment for IC. SET improves maximum walking distance and health-related QoL with a marginal risk of co-morbidity or mortality. This is also illustrated in contemporary international guidelines. Community-based SET appears to be at least as efficacious as programs provided in a clinical setting. In the Netherlands, a national integrated care network (ClaudicatioNet) providing specialized care for patients with IC is currently being implemented. Besides providing a standardized form of SET, the specialized physical therapists stimulate medication compliance and perform lifestyle coaching. Future research should focus on the influence of co-morbidities on prognosis and effect of SET outcome and the potential beneficial effects of SET combined with a vascular intervention.

Taiwan quality indicator project and hospital productivity growth

The Taiwan Quality Indicator Project (TQIP) is a quality management program that measures and monitors the healthcare quality of hospitals in Taiwan. This paper examines the impact of TQIP participation on hospital productivity growth with the application of the Malmquist productivity change index based on data envelopment analysis (DEA). Analyzing operations data from 31 TQIP regional hospitals over the period 1998-2004, we find that TQIP hospitals improved their productivity in the post-TQIP period. This improvement is attributable to quality change and relative efficiency progress. The simultaneous enhancement in both quality and relative efficiency coincides with the philosophy of total quality management (TQM) spirit, and confirms the efficiency improvement and quality assurance functions of TQIP.

Low Back Pain in Changi General Hospital: An Observational Study

Aims:

The aim is to study the profile of local low back pain (LBP) patients and their physiotherapy management in an outpatient physiotherapy clinic.

Methods:

A retrospective study was done with records of LBP patients attending the Musculoskeletal Physiotherapy Clinic at Changi General Hospital from January to June 2009. Age, LBP onset, occupation, time off work, investigation results, and functional outcomes were obtained.

Results:

Ninety-four records were screened. Majority of patients (59.6%) were aged between 30–50 years old. Sixty-six percent were engaged in occupations that involved sustained postures. Majority of patients (91.5%) had minor/no trauma in association to the onset of their symptoms. Although majority of patients (64.9%) did not take any time off work to manage their LBP, a total of 640 days were lost off work due to LBP. Majority of patients (93.6%) underwent radiological investigations. There was no significant correlation between radiating symptoms and presence of nerve root compression on MRI (p = 0.144). In addition, pathology did not significantly impact on rehabilitative outcome in our sample (p = 0.397, p = 0.602). A review of clinical practice with regards to ordering radiological investigations may be required to minimise radiation exposure and increase cost effectiveness. Patients improved from a mean of 4.00 to 9.10 on the Patient Specific Functional Scale (PSFS) within an average of 3.65 sessions. There was a significant relationship between earlier onset of therapy and better functional improvement on the PSFS (r= −0.299, p = 0.026). Starting a physiotherapy service in our accident and emergency department may be a good consideration to implement in our hospital.

Conclusions:

Sustained postures may contribute to LBP in local patients. Disability and time lost off work as result of LBP appears to be a significant problem locally. Radiology has no correlation with symptoms, nor rehabilitative outcomes. Pathology may have only limited value in determining treatment or prognosis in nontraumatic LBP. A tailored physiotherapy approach towards education, manual therapy and exercises may be effective in improving functional capabilities in local LBP patients. Earlier onset of physiotherapy is associated with better functional recovery in LBP patients.

The development of a clinical practice stroke guideline for physiotherapists in The Netherlands: A systematic review of available evidence

PURPOSE

To develop a clinical practice guideline for the physiotherapy management of patients with stroke as support for the clinical decision-making process, especially with respect to the selection of appropriate interventions, prognostic factors and outcome measures.

INTRODUCTION

Physiotherapists have a high caseload of patients with stroke, so there is a need to identify effective evidence-based physiotherapy procedures. The availability of a guideline that includes information about prognostic factors, interventions, and outcome measures would facilitate clinical decision-making.

METHOD

A systematic computerized literature search was performed to identify evidence concerning the use of: (i) prognostic factors related to functional recovery; (ii) physiotherapy interventions in patients with stroke; and (iii) outcome measures to assess patients' progress in functional health. Experts, physiotherapists working in the field of stroke rehabilitation, and a multidisciplinary group of health professionals reviewed the clinical applicability and feasibility of the recommendations for clinical practice and their comments were used to compose the definitive guideline.

RESULTS

Of 9482 relevant articles, 322 were selected. These were screened for methodological quality. Seventy-two recommendations for clinical practice were retrieved from these articles and included in the guideline: Six recommendations concerned the prediction of functional recovery of activities of daily living (ADL), including walking ability and hand/arm use; 65 recommendations concerned the choice of physiotherapy interventions; and 1 recommendation concerned the choice of outcome instrument to use. A core set of seven reliable, responsive, and valid outcome measures was established, to determine impairments and activity limitations in patients with stroke.

CONCLUSIONS

The guideline provides physiotherapists with an evidence-based instrument to assist them in their clinical decision making regarding patients with stroke. As most of the recommendations included in the guideline came from studies of patients in the post acute and chronic phase of stroke, and in general involved patients with less severe and uncomplicated stroke, more needs to be learned about the more complex cases.

A qualitative application of the diffusion of innovations theory to examine determinants of guideline adherence among physical therapists

BACKGROUND

Evidence-based practice has become a major issue in physical therapy. Many evidence-based guidelines, however, are not used extensively after dissemination, and interventions aimed at increasing guideline adherence often have limited effects.

OBJECTIVE

As a prerequisite for changing this situation, the aims of this study were to gain an in-depth understanding of the determinants of guideline adherence among physical therapists in the Netherlands and to evaluate the opportunities of a theoretical framework in this respect.

DESIGN AND METHODS

This observational study consisted of 3 focus group interviews (n=12, 10, and 8) between November 2002 and January 2003. Physical therapists were asked to discuss their opinions about and experiences with the Dutch guidelines for low back pain. Data were analyzed qualitatively using a directed approach to content analysis. Both the interview route and the analysis of the interviews were informed by Rogers' Diffusion of Innovations Theory.

RESULTS

Our study yielded in-depth insights into the various determinants of guideline adherence. Overall, the participants had rather unfavorable opinions about issues related to the dissemination of the guidelines (first phase of the diffusion process) and provided relatively little information on the subsequent adoption process (second phase of the diffusion process). The theoretical framework appeared to be a useful tool to properly structure the focus group interviews, to systematically analyze the data collected, and to determine that supplementary interviews would be necessary to cover the entire diffusion process.

CONCLUSIONS

Our findings indicated that the diffusion process of guidelines among physical therapists was not yet completed. The use of theory can provide added value to guideline implementation studies.

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.

A randomized physiotherapy trial in patients with fecal incontinence: design of the PhysioFIT-study

Background

Fecal incontinence (FI) is defined as the recurrent involuntary excretion of feces in inappropriate places or at inappropriate times. It is a major and highly embarrassing health care problem which affects about 2 to 24% of the adult population. The prevalence increases with age in both men and women.

Physiotherapy interventions are often considered a first-line approach due to its safe and non-invasive nature when dietary and pharmaceutical treatment fails or in addition to this treatment regime. Two physiotherapy interventions, rectal balloon training (RBT) and pelvic floor muscle training (PFMT) are widely used in the management of FI. However, their effectiveness remains uncertain since well-designed trials on the effectiveness of RBT and PFMT versus PFMT alone in FI have never been published.

Methods/Design

A two-armed randomized controlled clinical trial will be conducted. One hundred and six patients are randomized to receive either PFMT combined with RBT or PFMT alone. Physicians in the University Hospital Maastricht include eligible participants. Inclusion criteria are (1) adults (aged ≥ 18 years), (2) with fecal incontinence complaints due to different etiologies persisting for at least six months, (3) having a Vaizey incontinence score of at least 12, (4) and failure of conservative treatment (including dietary adaptations and pharmacological agents). Baseline measurements consist of the Vaizey incontinence score, medical history, physical examination, medication use, anorectal manometry, rectal capacity measurement, anorectal sensation, anal endosonography, defecography, symptom diary, Fecal Incontinence Quality of Life scale (FIQL) and the PREFAB-score. Follow-up measurements are scheduled at three, six and 12 months after inclusion. Skilled and registered physiotherapists experienced in women's health perform physiotherapy treatment. Twelve sessions are administered during three months according to a standardized protocol.

Discussion

This section discusses the decision to publish a trial protocol, the actions taken to minimize bias and confounding in the design, explains the choice for two treatment groups, discusses the secondary goals of this study and indicates the impact of this trial on clinical practice.

Trial registration

The Netherlands Trial Register ISRCTN78640169.

Passive movement therapy in patients with moderate to severe paratonia; study protocol of a randomised clinical trial (ISRCTN43069940)

BACKGROUND

Paratonia, a form of hypertonia, is associated with loss of mobility and with the development of contractures especially in the late stages of the dementia. Passive movement therapy (PMT) currently is the main physiotherapeutic intervention. General doubt about the beneficial effects of this widely used therapy necessitates a randomised clinical trial (RCT) to study the efficacy of PMT on the severity of paratonia and on the improvement of daily care.

METHODS/DESIGN

A RCT with a 4-week follow-up period. Patients with dementia (according to the DSM-IV-TR Criteria) and moderate to severe paratonia are included in the study after proxy consent. By means of computerised and concealed block randomisation (block-size of 4) patients are included in one of two groups. The first group receives PMT, the second group receives usual care without PMT. PMT is given according to a protocol by physical therapist three times a week for four weeks in a row. The severity of paratonia (Modified Ashworth scale), the severity of the dementia (Global Deterioration Scale), the clinical improvement (Clinical Global Impressions), the difficulty in daily care (Patient Specific Complaints) and the experienced pain in daily care of the participant (PACSLAC-D) is assessed by assessors blind to treatment allocation at baseline, after 6 and 12 treatments. Success of the intervention is defined as a significant increase of decline on the modified Ashworth scale. The 'proportion of change' in two and four weeks time on this scale will be analysed. Also a multiple logistic regression analysis using declined/not declined criteria as dependent variable with correction for relevant confounders (e.g. stage of dementia, medication, co-morbidity) will be used.

DISCUSSION

This study is the first RCT of this size to gain further insight on the effect of passive movement therapy on the severity of paratonia.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN43069940.

Comparison of international guideline programs to evaluate and update the Dutch program for clinical guideline development in physical therapy

Background

Clinical guidelines are considered important instruments to improve quality in health care. Since 1998 the Royal Dutch Society for Physical Therapy (KNGF) produced evidence-based clinical guidelines, based on a standardized program. New developments in the field of guideline research raised the need to evaluate and update the KNGF guideline program.

Purpose of this study is to compare different guideline development programs and review the KNGF guideline program for physical therapy in the Netherlands, in order to update the program.

Method

Six international guideline development programs were selected, and the 23 criteria of the AGREE Instrument were used to evaluate the guideline programs. Information about the programs was retrieved from published handbooks of the organizations. Also, the Dutch program for guideline development in physical therapy was evaluated using the AGREE criteria. Further comparison the six guideline programs was carried out using the following elements of the guideline development processes: Structure and organization; Preparation and initiation; Development; Validation; Dissemination and implementation; Evaluation and update.

Results

Compliance with the AGREE criteria of the guideline programs was high. Four programs addressed 22 AGREE criteria, and two programs addressed 20 AGREE criteria. The previous Dutch program for guideline development in physical therapy lacked in compliance with the AGREE criteria, meeting only 13 criteria.

Further comparison showed that all guideline programs perform systematic literature searches to identify the available evidence. Recommendations are formulated and graded, based on evidence and other relevant factors. It is not clear how decisions in the development process are made. In particular, the process of translating evidence into practice recommendations can be improved.

Conclusion

As a result of international developments and consensus, the described processes for developing clinical practice guidelines have much in common. The AGREE criteria are common basis for the development of guidelines, although it is not clear how final decisions are made. Detailed comparison of the different guideline programs was used for updating the Dutch program. As a result the updated KNGF program complied with 22 AGREE criteria. International discussion is continuing and will be used for further improvement of the program.

Evaluating research studies that address prognosis for patients receiving physical therapy care: a clinical update

A prognosis is a broad statement that predicts a patient's likely status, or degree of change, at some time in the future. Clinicians are likely to improve the accuracy of their judgments of prognosis by incorporating relevant research findings. In recent years, there has been substantial growth in the number of primary studies and systematic reviews addressing prognosis for people likely to receive physical therapy care. The purpose of this clinical update is to provide a framework for identifying, appraising, and utilizing these research findings to help make prognostic judgments.

Evidence-based analysis of physical therapy in Parkinson's disease with recommendations for practice and research

Physical therapy is often prescribed in Parkinson's disease. To facilitate the uniformity and efficacy of this intervention, we analyzed current evidence and developed practice recommendations. We carried out an evidence-based literature review. The results were supplemented with clinical expertise and patient values and translated into practice recommendations, developed according to international standards for guideline development. A systematic literature search yielded 6 systematic reviews and 23 randomized controlled trials of moderate methodological quality with sufficient data. Six specific core areas for physical therapy were identified: transfers, posture, reaching and grasping, balance, gait, and physical capacity. We extracted four specific treatment recommendations that were based on evidence from more than two controlled trials: cueing strategies to improve gait; cognitive movement strategies to improve transfers; exercises to improve balance; and training of joint mobility and muscle power to improve physical capacity. These practice recommendations provide a basis for current physical therapy in Parkinson's disease in everyday clinical practice, as well as for future research in this field.

Cost-effectiveness of an active implementation strategy for the Dutch physiotherapy guideline for low back pain

BACKGROUND AND PURPOSE

The treatment for patients with low back pain varies considerably. The Dutch Physiotherapy Association issued an evidence-based physiotherapy guideline for non-specific low back pain. To establish changes in daily practice an active implementation strategy was developed. We evaluated the cost-effectiveness of this implementation strategy.

SUBJECTS

113 physiotherapists included 500 patients with low back pain.

METHODS

In the intervention group the guideline was implemented actively, in the control group the standard method of dissemination was used. The patients filled in questionnaires at baseline and 6, 12, 26 and 52 weeks later. Direct medical costs, productivity costs (due to absenteeism) and quality of life (EQ-5D) were calculated.

RESULTS

During the 1-year follow up, no differences were found in the quality of life, direct medical costs and productivity costs.

CONCLUSION

The active implementation strategy appears not to be cost effective as compared to the standard strategy.

Development of an implementation strategy for physiotherapy guidelines on low back pain

In the Netherlands, clinical practice physiotherapy guidelines are mainly implemented by using passive implementation strategies. It is well known that these strategies are not effective in establishing changes in behaviour of health care professionals. Therefore, a new implementation strategy was developed for the physiotherapy guidelines on low back pain. This paper describes the method for the design of this strategy. A survey was conducted of 100 physiotherapy practices to identify perceived barriers to implementation of the guidelines and the most important discrepancies between current practice and recommendations of the guidelines. The strategy was further developed using a model for changing professionals' behaviour and systematic reviews on the effectiveness of implementation interventions. The most frequently reported barriers for implementation of the guidelines are related to a lack of knowledge or skills of physiotherapists. The most frequently reported discrepancies between physiotherapy practice and guidelines recommendations were related to the focus of the diagnostic process on impairments, the common use of passive physiotherapeutic interventions, the frequent use of a pain-contingent approach, and the expectations of the patient. The new implementation strategy consisted of multiple interventions, namely education, discussion, role-playing, feedback and reminders. The strategy addressed perceived barriers and discrepancies between current practice and the recommendations of the guidelines.

Clinical practice guideline for the physiotherapy of patients with whiplash-associated disorders

STUDY DESIGN

A clinical practice guideline.

OBJECTIVES

To assist physiotherapists in decision making and to improve the efficacy and uniformity of care for patients with whiplash-associated disorders Grades I and II.

SUMMARY OF BACKGROUND DATA

Whiplash constitutes a considerable problem in health care. Many interventions are used in physiotherapy practice, despite increasing evidence for the use of active interventions. There is still no clinical practice guideline for the management of patients with whiplash-associated disorders. METHOD OF DEVELOPMENT: A computerized literature search of Medline, Cinahl, Cochrane Controlled Trial Register, Cochrane Database of Systematic Reviews, and the Database of the Dutch National Institute of Allied Health Professions was performed to search for information about the diagnostic process and the therapeutic process in whiplash patients. When no evidence was available, consensus between experts was achieved to develop the guideline. Practicing physiotherapists reviewed the clinical applicability and feasibility of the guideline, and their comments were used to improve it.

RECOMMENDATIONS

The diagnostic process consists of systematic history taking and a physical examination supported by reliable and valid assessment tools to document symptoms and functional disabilities. The primary goals of treatment are a quick return to normal activities and the prevention of chronicity. Active interventions such as education, exercise therapy, training of functions, and activities are recommended according to the length of time since the accident and the rate of recovery. The biopsychosocial model is used to address the consequences of whiplash trauma.

CONCLUSIONS

Scientific evidence for the diagnosis and physiotherapeutic management of whiplash is sparse; therefore, consensus is used in different parts of the guideline. The guideline reflects the current state of knowledge of the effective and appropriate physiotherapy in whiplash patients. More and better research is necessary to validate this guideline in the future.