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

Physiotherapists' adherence to Clinical Practice Guidelines in fibromyalgia: a cross-sectional online survey

To evaluate the level of knowledge and adherence to Clinical Practice Guidelines on fibromyalgia of physiotherapists in Spain. A cross-sectional study using an ad-hoc online survey was implemented to assess aspects on the assessment, treatment, and decision of the length of the therapeutic approach on fibromyalgia. Based on the results, professionals were classified as adherent, partially adherent, or non-adherent. The level of agreement with several statements on the condition was also evaluated across the professionals surveyed to evaluate the potential consensus. A total of 240 physiotherapists met inclusion criteria, amongst which 68 (28.33%) were adherent. The academic level of studies (Chi-square = 48.601, p-value = 0.001) and having had previous training in fibromyalgia (Chi-square = 151.011, p-value = 0.001) displayed statistically significant differences across adherence-based groups. Consensus was reached for 15 out of 24 statements. Our findings highlight the presence of an acceptable level of knowledge and adherence to clinical practice guidelines in the field of fibromyalgia among physiotherapists in Spain.Practice implicationsOur results also reveal the existence of an evidence-to-practice gap in the field, with potential room for improvement: further efforts on promoting and reinforcing the importance of evidence-based therapies are needed, from university teaching plans to clinical updates for daily practice.

Physiotherapist- and patient-reported barriers to guideline implementation of active physiotherapeutic management of low back pain: A theory-informed qualitative study

BACKGROUND AND OBJECTIVE

Adoption of low back pain (LBP) guidelines in physiotherapeutic management is a well-documented problem. Thereby, an in-depth understanding of the barriers to implement an active approach for both patients and physiotherapists is needed.

DESIGN

Semi-structured interviews were conducted with physiotherapists and patients with non-specific LBP. Interviews, guided by the Theoretical Domains Framework (TDF), were analyzed using the Qualitative Analysis Guide of Leuven.

RESULTS

A total of 20 participants were interviewed, including ten physiotherapists and ten patients. Our findings reveal that patients and physiotherapists face each 23 barriers spanning 14 TDF domains. The TDF domain "social influences" revealed the most barriers, followed by "beliefs about consequences" and "environmental context" for patients and physiotherapists, respectively. Five barriers did overlap between both groups (lack of guideline awareness, incorrect exercise performance, interdisciplinary communication gaps, time constraints and challenges in patient compliance).

CONCLUSIONS

Barriers to LBP guideline recommended physiotherapeutic practices span all 14 TDF domains. Consequently, future implementation interventions need to address multiple TDF domains for effective LBP guideline implementation.

Patient and clinician perspectives of online-delivered exercise programmes for chronic musculoskeletal conditions: a mixed-methods systematic review

PURPOSE

To synthesize common or differing perceptions of patients' and clinicians' that influence uptake of online-delivered exercise programmes (ODEPs) for chronic musculoskeletal (MSK) conditions.

METHODS

Eight databases were searched from inception to April 2023 for studies including (1) patients with and/or clinicians delivering ODEPs for chronic MSK conditions, and (2) synchronous ODEPs, where information is exchanged simultaneously (mode A); asynchronous ODEPs, with at least one synchronous feature (mode B); or no ODEPs, documenting past experiences and/or likelihood of participating in an ODEP (mode C). Critical Appraisal Skills Programme checklists were used to assess study quality. Perceptions of patients' and clinicians' influencing uptake of ODEPs were extracted. Quantitative and qualitative data were synthesised and integrated.

RESULTS

Twenty-one studies were included (twelve quantitative, seven qualitative, and two mixed-methods) investigating the perceptions of 1275 patients and 534 clinicians on ODEP mode A (n = 7), mode B (n = 8), and mode C (n = 6). Sixteen of the 23 identified perceptions related to satisfaction, acceptability, usability, and effectiveness were common, with 70% of perceptions facilitating uptake and 30% hindering uptake.

CONCLUSIONS

Findings highlight the need to promote targeted education for patients and clinicians addressing interconnected perceptions, and to develop evidence-based perception-centred strategies encouraging integrated care and guideline-based management of chronic MSK conditions.

How Much Physiotherapy, Chiropractic, and Osteopathy Care Do Compensated Australian Workers with Low Back Pain Receive? A Retrospective Cohort Study

OBJECTIVES

To identify the prevalence and frequency of physiotherapy, chiropractic, and/or osteopathy care in Australians with workers' compensation claims for low back pain (LBP).

METHODS

We included workers with accepted workers' compensation claims longer than 2 weeks from the Australian states of Victoria, Queensland, South Australia, and Western Australia. Workers were grouped by whether they attended physiotherapy, chiropractic, and/or osteopathy in the first 2 years of their claim. Descriptive statistics and logistic regression were used to describe differences between groups. Descriptive statistics and negative binomial regression were used to describe differences in the number of attendances in each group.

RESULTS

Most workers had at least one physical therapy attendance during the period of their claim (n = 23,619, 82.0%). Worker state, socioeconomic status, and remoteness were the largest contributing factors to likelihood of physical therapy attendance. Most workers only attended physiotherapy (n = 21,035, 89.1%, median of 13 times). Far fewer only attended chiropractic (n = 528, 2.2%, median of 8 times) or only osteopathy (n = 296, 1.3%, median of 10 times), while 1,750 (7.5%) attended for care with more than one type of physical therapy (median of 31 times).

CONCLUSION

Most Australian workers with workers' compensation time loss claims for LBP attend physiotherapy at least once during their claims. State of claim is the strongest predictor of which physical therapy profession they attend, possibly due to regional availability. Workers who see a physiotherapist have significantly more attendances. Future research should explore the relationship between these patterns of care and claimant outcomes, including work disability duration.

Decision Support for Managing Common Musculoskeletal Pain Disorders: Development of a Case-Based Reasoning Application

BACKGROUND

Common interventions for musculoskeletal pain disorders either lack evidence to support their use or have small to modest or short-term effects. Given the heterogeneity of patients with musculoskeletal pain disorders, treatment guidelines and systematic reviews have limited transferability to clinical practice. A problem-solving method in artificial intelligence, case-based reasoning (CBR), where new problems are solved based on experiences from past similar problems, might offer guidance in such situations.

OBJECTIVE

This study aims to use CBR to build a decision support system for patients with musculoskeletal pain disorders seeking physiotherapy care. This study describes the development of the CBR system SupportPrim PT and demonstrates its ability to identify similar patients.

METHODS

Data from physiotherapy patients in primary care in Norway were collected to build a case base for SupportPrim PT. We used the local-global principle in CBR to identify similar patients. The global similarity measures are attributes used to identify similar patients and consisted of prognostic attributes. They were weighted in terms of prognostic importance and choice of treatment, where the weighting represents the relevance of the different attributes. For the local similarity measures, the degree of similarity within each attribute was based on minimal clinically important differences and expert knowledge. The SupportPrim PT's ability to identify similar patients was assessed by comparing the similarity scores of all patients in the case base with the scores on an established screening tool (the short form Örebro Musculoskeletal Pain Screening Questionnaire [ÖMSPQ]) and an outcome measure (the Musculoskeletal Health Questionnaire [MSK-HQ]) used in musculoskeletal pain. We also assessed the same in a more extensive case base.

RESULTS

The original case base contained 105 patients with musculoskeletal pain (mean age 46, SD 15 years; 77/105, 73.3% women). The SupportPrim PT consisted of 29 weighted attributes with local similarities. When comparing the similarity scores for all patients in the case base, one at a time, with the ÖMSPQ and MSK-HQ, the most similar patients had a mean absolute difference from the query patient of 9.3 (95% CI 8.0-10.6) points on the ÖMSPQ and a mean absolute difference of 5.6 (95% CI 4.6-6.6) points on the MSK-HQ. For both ÖMSPQ and MSK-HQ, the absolute score difference increased as the rank of most similar patients decreased. Patients retrieved from a more extensive case base (N=486) had a higher mean similarity score and were slightly more similar to the query patients in ÖMSPQ and MSK-HQ compared with the original smaller case base.

CONCLUSIONS

This study describes the development of a CBR system, SupportPrim PT, for musculoskeletal pain in primary care. The SupportPrim PT identified similar patients according to an established screening tool and an outcome measure for patients with musculoskeletal pain.

Scientific approach, attitudes, and perspectives on research among Swedish physiotherapy students-a cross-sectional study

BACKGROUND

Scientific evidence is important to evidence-based practice. Hence, the application of evidence-based practice requires relevant skills and an understanding of science, which therefore need to be learned and trained during the undergraduate program in physiotherapy. The aim of this study was to investigate attitudes, perceived competence, and conditions for a scientific approach among physiotherapy students in Sweden, and to compare attitudes and perceived competence between students in different program years.

METHODS

Physiotherapy students from six universities (n = 1499) were invited to respond to a digital survey. The survey contained questions regarding attitudes toward science, perceived competence in research interpretations and open comments regarding requirements for a strengthened scientific approach during education. Comparisons between education years were performed with ANOVA/Kruskal‒Wallis test (scale outcomes) and logistic regression (binary outcomes).

RESULTS

A total of 466 students responded to the survey. In total, 57% (n = 266) of the students had a high interest in science. No significant difference in interest in science was found between students in the three program years, but 75% (n = 347) reported increased interest during the program. A perceived high ability to understand the structure and performance of scientific studies was reported by 31% (n = 144), to evaluate the methodology by 16% (n = 72) and to interpret statistical results from scientific studies by 12% (n = 55). The lowest perceived competence was reported among students in their second year (p < 0.05). A majority of the students (88%; n = 410) reported a perceived personal need for strengthened conditions for a scientific approach, with suggested prerequisites during education via increased theoretical and applied understanding of the research.

CONCLUSION

Even though this study does not fully cover physiotherapy students at all undergraduate programmes in Sweden, the results support that a scientific approach and training should be strengthened during education to enable physiotherapists to understand and interpret science and to fully apply an evidence-based approach in upcoming clinical practice. Both theoretical and applied knowledge and understanding are needed.

Using Twitter (X) to mobilise knowledge for First Contact Physiotherapists: A qualitative study

BACKGROUND

Twitter (now X) is a virtual social network commonly used by healthcare professionals. Little is known about whether it helps healthcare professionals to share, mobilise and co-create knowledge, or reduce the time between research knowledge being created and used in clinical practice (the evidence-to-practice gap). Musculoskeletal First Contact Physiotherapists (FCPs) are primary care specialists who diagnose and treat people with musculoskeletal conditions without needing to see their General Practitioner (family physician) first. They often work as a sole FCP in practice, hence are an ideal healthcare professional group with whom to explore knowledge mobilisation using Twitter.

OBJECTIVE

To explore how Twitter is, and can be used to mobilise knowledge, including research findings, to inform FCP clinical practice.

METHODS

Semi-structured interviews of FCPs with experience of working in English primary care. FCPs were purposively sampled based on employment arrangements and Twitter use. Recruitment was via known FCP networks and Twitter, supplemented by snowball sampling. Online interviews used a topic guide exploring FCP's perceptions and experiences of accessing knowledge, via Twitter, for clinical practice. Data were analysed thematically and informed by the knowledge mobilisation mindlines model. Public contributors were involved throughout.

RESULTS

Nineteen FCPs consented to interview (Twitter users n=14, female n=9). Three themes were identified: 1) How Twitter meets the needs of FCPs, 2) Twitter and a journey of knowledge to support clinical practice and 3) Factors impeding knowledge sharing on Twitter. FCPs described needs relating to isolated working practice, time demands and role uncertainty. Twitter provided rapid access to succinct knowledge, opportunity to network and peer reassurance regarding clinical cases, evidence and policy. FCPs took a journey of knowledge exchange on Twitter, including scrolling for knowledge, filtering for credibility and adapting knowledge for in-service training and clinical practice. Participants engaged best with images and infographics. FCPs described misinformation, bias, echo chambers, unprofessionalism, hostility, privacy concerns and blurred personal boundaries as factors impeding knowledge sharing on Twitter. Consequently, many did not feel confident to actively participate with Twitter.

CONCLUSIONS

This study explores how Twitter is, and can be used to mobilise knowledge to inform FCP clinical practice. Twitter can meet knowledge needs of FCPs through rapid access to succinct knowledge, networking opportunities and professional reassurance. The journey of knowledge exchange from Twitter to clinical practice can be explained by considering the mindlines model, which describes how FCPs exchange knowledge in online and offline contexts. Findings demonstrate that Twitter can be a useful adjunct to FCP practice although several factors impeded knowledge sharing on the platform. We recommend social media training and enhanced governance guidance from professional bodies to support the use of Twitter for knowledge mobilisation.

CLINICALTRIAL

Developing a low back pain guideline implementation programme in collaboration with physiotherapists and chiropractors using the Behaviour Change Wheel: a theory-driven design study

BACKGROUND

Low back pain is still the leading cause of disability and societal burden, with 619 million prevalent cases worldwide in 2020. Most countries produce clinical guidelines to support healthcare professionals in evidence-based care regarding low back pain. However, several studies have identified relatively poor uptake of guidelines. Tailored strategies to facilitate the implementation of guidelines have been argued to increase uptake. This study aimed to develop a contextually tailored implementation programme to enhance evidence-based low back pain care among Danish physiotherapists and chiropractors in primary care.

METHODS

A theory-driven implementation programme development study was conducted using the Behaviour Change Wheel, with high healthcare professional involvement. Data collection included four workshops with seven physiotherapists and six chiropractors from primary care clinics. The development process consisted of [1] establishing a theoretical frame, [2] involving participants, [3] understanding the behaviour, [4] designing the implementation programme, and [5] final implementation programme.

RESULTS

The target behaviours selected (guideline recommendations) for the implementation programme were (i) screening of psychosocial risk factors and (ii) offering patient education. The barriers and facilitators for the selected behaviours were described and linked to intervention functions and behavioural techniques. Finally, the implementation programme comprised five strategies: webinars, e-learning videos, communication exercises, peer learning, and group dialogue meetings. In addition, the programme consisted of implementation support: champions, a physical material folder, a weekly email reminder, a specially designed website and a visit from an implementation consultant. An essential element of the overall programme was that it was designed as a step-by-step implementation process consisting of 16 h of education and training distributed over 16 weeks.

CONCLUSIONS

A programme for implementing low back pain guideline recommendations was developed based on behaviour change theory and four co-design workshops involving healthcare professionals to overcome the contextually identified barriers. A theory-driven approach involving healthcare professionals was useful in identifying relevant target behaviours and tailoring the programme to consider contextual barriers and facilitators for implementation. The effectiveness of the final implementation programme will be evaluated in the project's next phase.

TRIAL REGISTRATION

Central Denmark Region, Registered November 11, 2021, act no. 1-16-02-93-19.

Patterns of physiotherapy attendance in compensated Australian workers with low back pain: a retrospective cohort study

ABSTRACT

Workers with low back pain (LBP) frequently seek care from physiotherapists. We sought to identify patterns of physiotherapy attendance and factors associated with these patterns in Australian workers with accepted compensation claims for LBP. We included workers with accepted workers' compensation claims for LBP from 4 Australian states between 2011 and 2015. We used trajectory modelling to identify distinct groups of workers based on the number (ie, volume) of monthly physiotherapy attendances over a 2-year period from claim acceptance. Descriptive statistics and logistic regression models were used to compare the characteristics of the groups. A small but significant proportion attend numerous times over a long period. 79.0% of the sample (N = 22,767) attended physiotherapy at least once in the 2 years after claim acceptance. Among these, trajectory modelling identified 4 distinct patterns of attendance. Most (N = 11,808, 51.9%) recorded a short-term low-volume pattern, 26.8% (n = 6089) recorded a short-term high-volume pattern, 14.3% (n = 3255) recorded a long-term low-volume pattern, and 7.1% (n = 1615) recorded a long-term high-volume pattern. Workers from Victoria (OR 0.34, 99% CI 0.31, 0.37), South Australia (OR 0.69, 99% CI 0.60, 0.80), and Western Australia (OR 0.79, 99% CI 0.69, 0.88) were significantly less likely to attend physiotherapy than workers from Queensland. Victorian workers were significantly more likely to be in one of the 2 long-term trajectory groups (OR 8.17, 99% CI 6.86, 9.73; OR 18.68, 99% CI 13.57, 25.70). In conclusion, most compensated Australian workers with LBP attend physiotherapy. Significant interjurisdictional differences between attendance patterns suggests that policy may play an important role in healthcare delivery.

Education can reassure people with rotator cuff-related shoulder pain: a 3-arm, randomised, online experiment

ABSTRACT

We aimed to investigate the immediate effect of best practice education (with and without pain science messages) and structure-focused education on reassurance among people with rotator cuff-related shoulder pain. We conducted a 3-arm, parallel-group, randomised experiment. People with rotator cuff-related shoulder pain were randomised (1:1:1) to (1) best practice education (highlights that most shoulder pain is not serious or a good indicator of tissue damage and recommends simple self-management strategies); (2) best practice education plus pain science messages (which attempt to improve understanding of pain); and (3) structure-focused education (highlighting that structural changes are responsible for pain and should be targeted with treatment). Coprimary outcomes were self-reported reassurance that no serious condition is causing their pain and continuing with daily activities is safe. Secondary outcomes measured management intentions, credibility and relevance of the education, and similarity to previous education. Two thousand two hundred thirty-seven participants were randomised and provided primary outcome data. Best practice education increased reassurance that no serious condition is causing their pain (estimated mean effect 0.5 on a 0-10 scale, 95% confidence interval [CI] 0.2-0.7) and continuing with daily activities is safe (0.6, 95% CI 0.3-0.8) compared with structure-focused education . Adding pain science messages to best practice education slightly increased both measures of reassurance (0.2, 95% CI 0.0-0.4). Clinicians treating patients with rotator cuff-related shoulder pain should highlight that most shoulder pain is not serious or a good indicator of tissue damage and recommend simple self-management strategies. The benefit of adding pain science messages is small.

Assessment of Evidence-Based Practice (EBP) among physiotherapists in Cameroon: a cross-sectional survey

BACKGROUND

Evidence-Based Practice (EBP) is reported to ease effective and adequate decision making for all works of life including health professionals. Investigating the level of implementation of EBP among physiotherapists helps to identify barriers and propose solutions for its extensive implementation. Despite available data on EBP elsewhere, it remains limited or non-existent in Cameroon. This study was designed to establish the current state of EBP among physiotherapists in Cameroon, by assessing knowledge, practice, and barriers to its implementation.

METHODS

A cross-sectional survey was conducted online among French- and English-speaking physiotherapists in Cameroon over a period of six months from April to July 2023, using the EBP2 questionnaire. This enabled us to collect socio-demographic data from participants and information on their knowledge, understanding and practice of EBP and possible barriers to EBP according to 5 domains (Confidence, Relevance, Terminology, Practice, Compatibility) scored out of 100. Data were analysed using IBM SPSS 25.0 software and Pearson correlations (95% CI) and significance (p < 0.05).

RESULTS

A total of 110 physiotherapists practising in the 10 regions of Cameroon participated in the study. The majority were male (54.5%), the median age was 34 years (age range 20 to 50), the median year of graduation was 2019 (range 2004 to max 2022) with 72.7% never having knowledge or training in EBP. Participants scored below 50/100 for 3 domains (confidence, relevance, and compatibility) showing poor general knowledge and understanding of EBP, although they generally had a positive attitude towards EBP. The use of EBP in practice was low (26.3/100 SD. 6.5), despite that they appeared to have a good understanding of research terminology (55.4 SD. 17.2). Level of study of participants did not appear to significantly influence domain scores (P > 0.05). The main barriers to practice were lack of time (75.1%), workload (66%), cost of access to information resources like databases for seek informations about recent support protocols (60%), ease of access to computers (49%), and lack of resources or skills (49%).

CONCLUSION

Physiotherapists in Cameroon have a poor knowledge of EBP and a low level of practice of EBP, despite an overall positive attitude towards it. These results could inform stakeholders of higher education on the need to improve training of physiotherapy students in the domain of EBP in Physiotherapy. Also, it will help in raising the level of scientific research and promoting the implementation of EBP in Cameroon.

A critical review of the role of manual therapy in the treatment of individuals with low back pain

The number of low back pain (LBP) cases is projected to increase to more than 800 million by 2050. To address the substantial burden of disease associated with this rise in prevalence, effective treatments are needed. While clinical practice guidelines (CPG) consistently recommend non-pharmacological therapies as first-line treatments, recommendations regarding manual therapy (MT) in treating low back pain vary. The goal of this narrative review was to critically summarize the available evidence for MT behind these recommendations, to scrutinize its mechanisms of action, and propose some actionable steps for clinicians on how this knowledge can be integrated into a person-centered approach. Despite disparate recommendations from CPG, MT is as effective as other available treatments and may be offered to patients with LBP, especially as part of a treatment package with exercise and education. Most of the effects of MT are not specific to the technique. MT and other interventions share several mechanisms of action that mediate treatment success. These mechanisms can encompass patients' expectations, prior experiences, beliefs and convictions, epistemic trust, and nonspecific contextual effects. Although MT is safer than opioids for patients with LBP, this alone is insufficient. Our goal is to encourage clinicians to shift away from outdated and refuted ideas in MT and embrace a person-centered approach rooted in a comprehensive biopsychosocial framework while incorporating patients' beliefs, addressing illness behaviors, and seeking to understand each patient's journey.

Effects of Lifestyle Interventions on the Improvement of Chronic Non-Specific Low Back Pain: A Systematic Review and Network Meta-Analysis

Chronic non-specific low back pain (CNSLBP) is a highly prevalent musculoskeletal condition that has a great socioeconomic impact on health systems. Instead of focusing on mechanical causes and direct workload in the development of CNSLBP, genetics, psychosocial environment, lifestyle and quality of life are coming to the forefront in its approach. The main objective was to analyze whether interventions aimed at modifying lifestyle can be effective in improving pain intensity and functional disability in CNSLBP. A search in PubMed, Web of Science, Scopus and SportDiscus databases was performed. Both a univariate and a multivariate network meta-analysis were applied with the difference pre/post-treatment. A total of 20 studies were included for qualitative analysis, of which 16 were randomized clinical trials with a moderate-high methodological quality and were part of the quantitative analysis. The interventions that had the greatest effect in reducing pain intensity were cognitive therapy combined with functional exercise programs, lumbar stabilization exercise and resistance exercise; meanwhile, for functional disability, they were functional exercise programs, aerobic exercise and standard care. In conclusion, a multimodal intervention aimed at changing one's lifestyle that encompasses cognitive, behavioral, and physical aspects seems to be highly effective in improving pain intensity and functional disability caused by CNSLBP; however, it is not yet known if these improvements are maintained in the long term.

Exploring mental health approaches and curriculum in physiotherapy: an Australasian perspective

BACKGROUND

Exposure to mental health problems are becoming increasingly more frequent within physiotherapy. Physiotherapists recognize the need for a biopsychosocial approach, however their knowledge, assessment, and treatment skills specific to mental health problems requires further research.

PURPOSE

To profile the level of education and perception of education that physiotherapists have acquired specific to mental health problems; and to profile an understanding of the current practice of physiotherapists specific to mental health problems.

METHODS

An online survey addressed the aims of the study and collected data from physiotherapists in Australia and New Zealand (open between 20th of October 2022 to the 20th of March 2023).

RESULTS

139 respondents were included in the analysis. Physiotherapists had a perception that a significantly greater amount of coursework related to mental health needed to be included within their initial degree compared to what they received (mean difference of 20.0%, 95% CI: 17.5 to 22.5). This trend was evident irrespective of the degree level or the year of graduation. Higher perceived knowledge of anxiety (MD of 11.4, p = 0.001, ES: 0.5) and depression (MD of 11.8, p = 0.001, ES: 0.5) was evident in outpatient care physiotherapists. Lack of perceived knowledge is a reason for whether an assessment or treatment strategy is used with patients experiencing a mental health problem. Motivational interviewing and mindfulness were the most frequently used psychologically based techniques.

CONCLUSION

This study reveals the need to increase the amount of mental health and psychologically based techniques within Physiotherapy curriculum.

Current practice, guideline adherence, and barriers to implementation for Achilles tendinopathy rehabilitation: a survey of physical therapists and people with Achilles tendinopathy

Objective

To explore clinical practice patterns of physical therapists (PTs) who treat people with Achilles tendinopathy (AT), and identify perceived barriers and facilitators for prescribing and engaging with therapeutic exercise among PTs and people with AT.

Methods

Two cross-sectional surveys were electronically distributed between November 2021 and May 2022; one survey was designed for PTs while the second was for people with AT. Survey respondents answered questions regarding their physical therapy training and current practice (PTs), injury history and management (people with AT), and perceived barriers and facilitators (PTs and people with AT).

Results

341 PTs and 74 people with AT completed the surveys. In alignment with clinical practice guidelines, more than 94% of PTs surveyed (97% of whom had some form of advanced musculoskeletal training) prioritise patient education and therapeutic exercise. Patient compliance, patient knowledge, and the slow nature of recovery were barriers to prescribing therapeutic exercise reported by PTs, while time, physical resources, and a perceived lack of short-term treatment effectiveness were barriers for people with AT.

Conclusions

Consistent with clinical practice guidelines, PTs with advanced training reported prioritising therapeutic exercise and education for managing AT. However, both PTs and people with AT identified many barriers to prescribing or engaging with therapeutic exercise. By addressing misconceptions about the time burden and ineffectiveness of exercise, and by overcoming access issues to exercise space and equipment, PTs may be able to improve intervention adherence and subsequently outcomes for people with AT.

Patient-related barriers and enablers to the implementation of high-value physiotherapy for chronic pain: a systematic review

OBJECTIVE

To identify and synthesize patient-related barriers to and enablers of the implementation of high-value physiotherapy (HVP) for chronic pain. Furthermore, to review what patient-related interventions have been used to facilitate the implementation of HVP for chronic pain, as well as their efficacy.

METHODS

We systematically searched the APA PsycInfo, Embase, CINAHL, Medline, Scopus, and PEDro databases for peer-reviewed studies (published in English) of adults with chronic pain. We used the Theoretical Domains Framework of behavior change to synthesize identified themes relating to barriers and enablers. Outcomes from studies reporting on interventions were also qualitatively synthesized.

RESULTS

Fourteen studies reported on barriers and enablers, 8 of which related to exercise adherence. Themes common to barriers and enablers included perceived efficacy of treatment, interrelationship with the physiotherapist, exercise burden, and the patient's understanding of exercise benefits. Other barriers included fear of movement, fragmented care, and cost. Ten studies explored interventions, 9 of which aimed to improve exercise adherence. Of these, evidence from 4 randomized controlled trials of technology-based interventions demonstrated improved exercise adherence among intervention groups compared with controls.

CONCLUSION

Patients with chronic pain experience barriers to HVP, including their beliefs, the nature of their interaction with their physiotherapist, perceived treatment efficacy, and cost. Enablers include rapport with their physiotherapist, achievable exercises, and seamless cost-effective care. Technology-based interventions have demonstrated effectiveness at increasing exercise adherence. Our findings suggest that interventions seeking to enhance implementation of HVP need to consider the multifactorial barriers experienced by patients with chronic pain.

STUDY REGISTRATION

Open Science Framework (https://doi.org/10.17605/OSF.IO/AYGZV).

Approaches to osteoarthritis: a qualitative study among physical therapists in Maharashtra, India

BACKGROUND AND OBJECTIVE

Osteoarthritis (OA) is a major and growing problem in India. Better knowledge dissemination and implementation of evidence-based practice in Indian physical therapy require a better understanding of approaches to OA (i.e. perceptions of the condition and its management by Indian physical therapists (PTs)) which was the aim of our study.

DESIGN AND METHOD

We used qualitative content analysis to analyze semi-structured interviews with 19 PTs from Maharashtra state, purposefully selected to represent both sexes, different ages and different educational and professional backgrounds.

FINDINGS

We identified a main overarching theme of meaning, OA as a degenerative and irreversible condition with the four descriptive themes Assessment, Standardized treatment protocol, Leadership and Patient compliance as PTs' approaches to OA. The descriptive themes indicate that much focus seems to be on pain, physical impairments and biomechanics, with initial treatments being mainly passive. Communication appears to be mainly unidirectional with the PTs instructing the patients, who are expected to comply with PTs instructions. Clinical practice guidelines (CPGs) were not mentioned.

CONCLUSIONS

Our findings can inform the design of awareness campaigns on evidence-based OA management and increase the understanding of the educational needs of students and PTs in non-Western countries. It is important to recognize that CPGs are mainly based on studies carried out in Western countries and that there are context-specific barriers to implementation in other parts of the world that have large populations.

Physiotherapists' barriers and facilitators to the implementation of a behaviour change-informed exercise intervention to promote the adoption of regular exercise practice in patients at risk of recurrence of low back pain: a qualitative study

BACKGROUND

Recurrences of low back pain (LBP) are frequent and associated with high levels of disability and medical costs. Regular exercise practice may be an effective strategy to prevent recurrences of LBP, however, the promotion of this behaviour by physiotherapists seems to be challenging. This study aims to explore physiotherapists' perceived barriers and facilitators to the implementation of a behaviour change-informed exercise intervention to promote the adoption of regular exercise practice by patients at risk of recurrence of low back pain.

METHODS

Two focus groups with primary healthcare physiotherapists were conducted, based on a semi-structured interview schedule informed by the Behaviour Change Wheel, including the Capability, Opportunity, Motivation-Behaviour (COM-B) model and the Theoretical Domains Framework (TDF). All focus groups were held through videoconference, audio and video recorded and transcribed verbatim. A deductive content analysis, using a coding matrix based on the COM-B and TDF, was performed by two independent researchers. A third researcher was approached to settle disagreements.

RESULTS

In total, 14 physiotherapists participated in the focus groups. The analysis revealed a total of 13 barriers (4 COM-B components and 7 TDF domains) and 23 facilitators (5 COM-B and 13 TDF) to physiotherapists' implementation of a behaviour change-informed exercise intervention. The most common barriers were the lack of skills and confidence to implement the proposed intervention. These were explained by the fact that it differs from the usual practice of most participants and requires the learning of new skills applied to their contexts. However, for those who had already implemented other similar interventions or whose rationale is aligned with the new intervention, there seemed to exist more positive determinants, such as potential benefits for physiotherapists and the profession, improvement of quality of care and willingness to change clinical practice. For others who did not previously succeed in implementing these types of interventions, more context-related barriers were mentioned, such as lack of time to implement the intervention, schedule incompatibilities and lack of material and human resources.

CONCLUSIONS

This study identified modifiable barriers and facilitators to physiotherapists' implementation of a behaviour change-informed exercise intervention for patients at risk of recurrence of LBP in primary healthcare. The findings of this study will allow the systematic and theory-based development of a behaviour change-informed training programme, aimed at physiotherapists and supporting the successful implementation of the exercise intervention.

Physiotherapists' experiences of implementation of the BetterBack model of care for low back pain in primary care - a focus group interview study

INTRODUCTION

The BetterBack model of care (MoC), a best practice physiotherapy MoC for low back pain (LBP), was implemented in Swedish primary care to improve management of patients with LBP and provide patients with support tools to better self-manage episodes of LBP.

PURPOSE

The objective was to describe how physiotherapists in primary care experienced the implementation of the BetterBack MoC for LBP.

METHODS

Focus group interviews were conducted with physiotherapists in 2018-2019, 14-18 months after the introduction of the BetterBack MoC. Data were analyzed using qualitative content analysis.

RESULTS

Five focus group interviews with 23 (15 female and 8 male) physiotherapists, age range 24-61 years were analyzed. A supportive organization and adaptation to the local culture, combined with health care professionals' attitudes and collaboration between physiotherapists emerged as important factors for a successful implementation and for long-term sustainability of the MoC. Physiotherapists had differing opinions if the implementation led to change in clinical practice. Improved confidence in how to manage patients with LBP was expressed by physiotherapists.

CONCLUSIONS

Several barriers and facilitators influence the implementation of a best practice physiotherapy MoC for LBP in primary care, which need to be considered in future implementation and sustainability processes.

Development of a low back pain care pathway in an academic hospital system: results of a consensus process

BACKGROUND

Low back pain (LBP) is the leading cause of disability worldwide and a significant component of healthcare expenditures. Clinical practice guidelines (CPGs) have been highlighted as a key resource to improve the quality of care. This study aimed to develop a clinical pathway for LBP based on CPGs in an academic health system.

METHODS

We conducted a modified Delphi study of clinicians caring for patients with LBP who were asked to rate 21 CPG-informed seed statements through an online survey. The goal was to identify statements that achieved a minimum of 80% consensus among panelists.

RESULTS

Thirty-five healthcare providers participated as panelists. The majority of participants were male (68.6%), had MD or DO (62.9%) degrees, and were clinicians (73.8%) working in neurosurgery (36.1%), orthopedics (25.7%), emergency medicine (14.3%), or physical therapy (11.4%). Initially, consensus was reached on 20 of 21 seed statements. One statement did not reach consensus in the initial round and was revised into two separate statements based on feedback from panelists. One of these statements achieved consensus in the second review round. All statements reaching consensus were incorporated into a care pathway consisting of diagnosis, evaluation, and treatment for LBP.

CONCLUSION

Healthcare providers across various disciplines supported statements interpreting current CPGs related to care for LBP. This study represents a step toward supporting guideline-concordant care for LBP. Additional research is needed to assess how such pathways impact actual clinical care.

Barriers to the use of clinical practice guidelines: a qualitative study of Danish physiotherapists and chiropractors

PURPOSE

Low back pain (LBP) is the leading cause of disability worldwide. Providing evidence-based practice (EBP) for patients with LBP is more cost-effective compared with non-EBP. To help health care professionals provide EBP, several clinical practice guidelines have been published. However, a relatively poor uptake of the guidelines has been identified across various countries. To enhance future implementation of EBP, the aim of this study was to explore barriers to using LBP guidelines in clinical practice.

MATERIALS AND METHODS

A qualitative constructivist grounded theory design was employed in order to gain an in-depth understanding of the barriers. Semi-structured interviews (+/- observations) of nine physiotherapists and nine chiropractors from primary care in the Central Denmark Region were conducted.

RESULTS

Two key barriers were found to using guidelines in practice: (1) a scepticism due to doubts about validity and applicability of the guidelines, which emerged particularly among physiotherapists; and (2) a deep biomechanical professional identity, due to perceived role, interest, lack of skills, and patient preferences, which emerged particularly among chiropractors.

CONCLUSIONS

For guidelines to be better implemented in practice, these key barriers must be addressed in a tailored strategy. Furthermore, this study showed a difference in barriers between the two professions.

Osteopathy Referrals to and from General Practitioners: Secondary Analysis of Practitioner Characteristics from an Australian Practice-Based Research Network

Australian osteopaths engage in multidisciplinary care and referrals with other health professionals, including general practitioners (GPs), for musculoskeletal care. This secondary analysis compared characteristics of Australian osteopaths who refer to, and receive referrals from, GPs with osteopaths who do not refer. The analysis was undertaken to identify pertinent characteristics that could contribute to greater engagement between Australian osteopaths and GPs. Data were from the Australian osteopathy practice-based research network comprising responses from 992 osteopaths (48.1% response rate). Osteopaths completed a practice-based survey exploring their demographic, practice, and clinical management characteristics. Backward logistic regression identified significant characteristics associated with referrals. Osteopaths who reported sending referrals (n = 878, 88.5%) to GPs were more likely than their non-referring colleagues to receive referrals from GPs (aOR = 4.80, 95% CI [2.62-8.82]), send referrals to a podiatrist (aOR = 3.09, 95% CI [1.80-5.28]) and/or treat patients experiencing degenerative spinal complaints (aOR = 1.71, 95% CI [1.01-2.91]). Osteopaths reporting receiving referrals (n = 886, 89.3%) from GPs were more likely than their non-referring colleagues to send referrals to GPs (aOR = 4.62, 95% CI [2.48-8.63]) and use the Medicare EasyClaim system (aOR = 4.66, 95% CI [2.34-9.27]). Most Australian osteopaths who report engaging in referrals with GPs for patient care also refer to other health professionals. Referrals from GPs are likely through the Chronic Disease Management scheme. The clinical conditions resulting in referrals are unknown. Further research could explore the GP-osteopath referral network to strengthen collaborative musculoskeletal care. The outcomes of this study have the potential to inform Australian osteopaths participating in advocacy, public policy and engagement with Australian GPs.

Acceptance and use of a clinical decision support system in musculoskeletal pain disorders - the SupportPrim project

BACKGROUND

We have developed a clinical decision support system (CDSS) based on methods from artificial intelligence to support physiotherapists and patients in the decision-making process of managing musculoskeletal (MSK) pain disorders in primary care. The CDSS finds the most similar successful patients from the past to give treatment recommendations for a new patient. Using previous similar patients with successful outcomes to advise treatment moves management of MSK pain patients from one-size fits all recommendations to more individually tailored treatment. This study aimed to summarise the development and explore the acceptance and use of the CDSS for MSK pain patients.

METHODS

This qualitative study was carried out in the Norwegian physiotherapy primary healthcare sector between October and November 2020, ahead of a randomised controlled trial. We included four physiotherapists and three of their patients, in total 12 patients, with musculoskeletal pain in the neck, shoulder, back, hip, knee or complex pain. We conducted semi-structured telephone interviews with all participants. The interviews were analysed using the Framework Method.

RESULTS

Overall, both the physiotherapists and patients found the system acceptable and usable. Important findings from the analysis of the interviews were that the CDSS was valued as a preparatory and exploratory tool, facilitating the therapeutic relationship. However, the physiotherapists used the system mainly to support their previous and current practice rather than involving patients to a greater extent in decisions and learning from previous successful patients.

CONCLUSIONS

The CDSS was acceptable and usable to both the patients and physiotherapists. However, the system appeared not to considerably influence the physiotherapists' clinical reasoning and choice of treatment based on information from most similar successful patients. This could be due to a smaller than optimal number of previous patients in the CDSS or insufficient clinical implementation. Extensive training of physiotherapists should not be underestimated to build understanding and trust in CDSSs.

Adding Brief Pain Science or Ergonomics Messages to Guideline Advice Did Not Increase Feelings of Reassurance in People With Acute Low Back Pain: A Randomized Experiment

OBJECTIVE: To investigate the effects of adding pain science or ergonomics messages to guideline advice on feelings of reassurance and management intentions among people with acute low back pain (LBP). DESIGN: Three-arm parallel-group randomized experiment. METHODS: We recruited people with acute LBP (pain for ≤6 weeks) to participate in an online experiment. Participants were randomized at a 1:1:1 ratio to one of three groups: guideline advice alone or guideline advice with the addition of brief pain science or ergonomics messages. The intervention was delivered via prerecorded videos in all 3 groups. Coprimary outcomes were reassurance that (1) no serious condition is causing LBP and (2) continuing with daily activities is safe. Secondary outcomes were perceived risk of developing chronic pain, management intentions (bed rest, see a health professional, see a specialist, and imaging), credibility, and relevance of the advice in addressing the participant's concerns. RESULTS: Two thousand two hundred ninety-seven responses (99.3% of 2,313 randomized) were analyzed. Adding brief pain science or ergonomics messages to guideline advice did not change reassurance that LBP was not caused by serious disease. The addition of ergonomics advice provided worse reassurance that it is safe to continue with daily activities compared to guideline advice (mean difference [MD], -0.33; 95% CI: 0.13, 0.53). There was no difference between groups on management intentions. CONCLUSION: Adding pain science or ergonomics messages to guideline advice did not increase reassurance or change management intentions in people with acute LBP. Ergonomics messages may lead to reduced feelings of reassurance. J Orthop Sports Phys Ther 2023;53(12)1-11. Epub 26 September 2023. doi:10.2519/jospt.2023.12090.

Utilization of Methods for Pain Treatment and Management Among Older Adults with Chronic Pain

BACKGROUND

Older adults have a high prevalence of chronic pain, which can have a substantial effect on their health and quality of life. Patients' use of effective pain relief methods is a central part of the treatment and management of chronic pain. The utilization of pain relief methods and their perceived effectiveness are important knowledge for treating and managing chronic pain for clinicians and older adults. However, this has been poorly investigated.

AIM

We aimed to survey the methods used by older people to treat and manage chronic pain as well as their perceived effectiveness.

METHODS

A total of 2,000 questionnaires were sent to a random sample of people aged 65 years of age or older living in Sweden and 1,141 questionnaires were returned in usable condition. A total of 433 participants reported having chronic pain and completed the Pain Management Inventory to map the use and perceived effectiveness of used treatment and management methods.

RESULTS

The prevalence of chronic pain was 38% and the most used pain treatment methods were passive approaches, i.e., rest (60%), distractions (53%), non-prescribed medicine (49%), and prescribed medicine (44%). A total of 72% of respondents used either prescribed or non-prescribed medicine. The most used active treatment was physical activity (52%). The perceived effectiveness varied to a large extent for each method, and, on average, no treatment method seemed to be more effective than any other.

CONCLUSIONS

Knowledge about the actual use of pain treatment methods and the varied perceived effectiveness can guide clinicians in recommending new approaches or alternatives to manage chronic pain in older adults. How used methods are aligned with current clinical recommendations could be further explored in the future.

Guideline-Adherent Physiotherapy for Patients With Hip and Knee Osteoarthritis in Germany: Protocol for an Implementation Research Project Using the Theoretical Domains Framework and the Behavior Change Wheel

BACKGROUND

Hip and knee osteoarthritis is common and leads to pain, stiffness, and disability. Clinical practice guidelines provide recommendations based on the best available evidence to assist health care professionals and patients in clinical decision-making. However, several studies have reported a gap between guideline recommendations and clinical practice in physiotherapy. Improved implementation strategies and the removal of existing barriers may facilitate the transfer of evidence into clinical practice and contribute to optimized quality of care.

OBJECTIVE

This paper presents the protocol for a study that aims to describe the current physiotherapy practice in patients with hip and knee osteoarthritis and to investigate physiotherapists' adherence to clinical practice guidelines, to identify and specify barriers to and facilitators of guideline use and implementation, and to develop and pilot test a theory-based tailored implementation intervention aiming to increase guideline use in osteoarthritis care.

METHODS

The research project is divided into 4 parts. During the first part, we will conduct a nationwide web-based survey among German physiotherapists to evaluate the current management of hip and knee osteoarthritis and to evaluate whether treatment aligns with guideline recommendations. Subsequently, semistructured interviews will be conducted to specify barriers to and facilitators of guideline use and implementation among physiotherapists (part 2). On the basis of these findings, in part 3, we will develop a theory-driven implementation intervention based on the Theoretical Domains Framework and the Behavior Change Wheel, which will be evaluated in a controlled pilot study in terms of effectiveness, feasibility, and acceptability (part 4).

RESULTS

Data collection of the web-based survey among German physiotherapists (part 1) was completed in December 2021. The semistructured interviews (part 2) were conducted between January and September 2023. Recruitment of physiotherapy practices to participate in the development of the implementation intervention is expected to start in January 2024.

CONCLUSIONS

This research project aims to develop a theory-driven implementation intervention to facilitate the transfer of evidence from hip and knee osteoarthritis guidelines in physiotherapy practice. We hypothesize that successful implementation will lead to increased guideline adherence in physiotherapists, which in turn will improve the quality of care. The results from our project will provide valuable knowledge concerning the development process and effectiveness of tailored implementation interventions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47834.

Adapting a Clinical Practice Guideline for Management of Patients with Knee and Hip Osteoarthritis by Hong Kong Physiotherapists

Knee and hip osteoarthritis are common disabling conditions globally. Although numerous international clinical practice guidelines exist to guide physiotherapy management, not all recommendations issued from these guidelines can be translated to other contexts without considering the cultural acceptability and clinical implementability of targeted countries. Because the ADAPTE framework provides a robust methodology to adapt guidelines to the local context, this study used its methodology to adapt high-quality guideline recommendations to promote optimal physiotherapy care for knee and hip osteoarthritis in Hong Kong. The ADAPTE framework was used and modified to complete the adaptation process. International clinical practice guidelines were identified from eight guideline clearinghouses and six electronic databases. Two independent reviewers critically appraised the eligible guidelines using the AGREE II tool. We extracted and tabulated recommendations from high-quality guidelines. A voting-based consensus among interdisciplinary experts was conducted to decide on suitable recommendations for the Hong Kong context and whether there was a need to modify them. Pertinent recommendations were then translated into the traditional Chinese language. Our team members suggested modifying four tools and adding one to explore the patient's feedback on the recommendations, to the ADAPTE framework. The adaptation was performed on three high-quality guidelines. We adapted 28 and 20 recommendations for treating knee and hip osteoarthritis, respectively. We recommend a multimodal treatment for managing knee and hip osteoarthritis. Land- and aquatic-based exercises, patient education, and self-management were strongly recommended for patients with knee osteoarthritis. Land- and aquatic-based exercises were strongly recommended for patients with hip osteoarthritis. This is the first adaptation study in Hong Kong. It provides guidance to local physiotherapists on managing patients with knee and hip osteoarthritis. Future studies should test the effectiveness of implementing this adapted guideline to improve local physiotherapy care in Hong Kong.

Suicidal Risk Behaviors in Adolescents With Rare Neurodevelopmental Disorders: The Role of Sex, Autistic Traits, and Mental Health Difficulties

OBJECTIVE

Autistic traits are associated with mental health difficulties and risk of suicidal risk behaviors among adolescents. Little is known about how autistic traits affect the mental health of adolescents with rare neurodevelopmental disorders (RNDs). The aim of this study was to investigate the relationship between autistic traits, mental health difficulties, and suicidal risk behaviors in adolescents with RNDs.

METHODS

Parents (N = 93) completed the Child Behavior Checklist, Social Communication Questionnaire, and Social Responsiveness Scale about their adolescent (Mage = 13.1, SD = 2.3, 62.4% females) with an RND (e.g., sex chromosome aneuploidies, Fragile X syndrome, 22q11.2 deletion syndrome). The data were analyzed with hierarchical logistic regression analysis.

RESULTS

The prevalence of suicidal risk behaviors (16.1%) was similar to that reported among autistic youth and was higher among boys than girls. More autistic traits were associated with suicidal risk behaviors in bivariate analysis. In multivariate analysis, more anxiety/depressive symptoms were associated with more suicidal risk behaviors and externalizing problems associated with suicidal risk behaviors beyond autistic traits and anxiety/depressive symptoms.

CONCLUSION

Adolescents with RNDs are at risk of suicidal risk behaviors, especially those with higher levels of autistic traits, anxiety/depressive symptoms, and externalizing problems. Assessment of autistic traits, mental health difficulties, and suicide risk may be indicated for adolescents with RNDs to determine if corresponding intervention is needed.

Barriers and facilitators to implementation of APTA's breast cancer-related lymphedema diagnosis and intervention clinical practice guidelines

PURPOSE

The purpose of this study was to identify barriers and facilitators influencing implementation of the diagnosis and intervention clinical practice guidelines (CPGs) related to the management of patients with breast cancer-related lymphedema (BCRL).

METHODS

A descriptive, cross-sectional web-based survey was conducted. Participants included physical therapists and assistants who were members of the APTA's Academy of Oncologic Physical Therapy and Lymphology Association of North America. Desriptive statisitcs were computed for all demographic and barriers and facilitators data. Individual exploratory factor analyses (EFA) were performed on survey items for both CPGs to identify themes of barriers and facilitators to implementation.

RESULTS

A total of 180 respondents completed the survey. 34.9% of respondents read the diagnosis CPG and 22.4% read the intervention CPG. A total of 77.8% reported that they did not have issues in changing their clinical routines and 69.5% did not have resistance working according to CPGs. The EFA resulted in 3 themes for each CPG, accounting for 46% of the variance for the diagnostic CPG and 54% of the variance for the intervention CPG. The 3 themes, clinician characteristics, patient demographics, therapist practice setting and beliefs/values, were weighted differently for each EFA.

CONCLUSION

Most respondents did not read either CPG, however, report a willingness to make changes to clinical practice and utilization of CPGs. For those who have attempted to implement the CPGs, this study was the first to identify the barriers and facilitators impacting the implementation of the CPGs related to the management of BCRL.

IMPLICATIONS FOR CANCER SURVIVORS

The results will inform the development of targeted implementation strategies to improve access to and adherence to recommendations from the CPGs ultimately improving the efficiency and efficacy of care delivery to patients.

Factors influencing physiotherapists implementation of high value care in the management of nonspecific low back pain in Indian healthcare settings: A qualitative study

BACKGROUND

Non-specific low back pain is a common musculoskeletal condition that often requires the involvement of physiotherapists for effective management. However, there is limited understanding of the factors influencing physiotherapists' implementation of high-value care in the management of non-specific low back pain (NSLBP), particularly in Indian healthcare settings.

OBJECTIVE

The aim of this study was to explore the barriers and facilitators of implementation of high-value care in managing NSLBP from the perspective of physiotherapists practicing in Indian healthcare settings.

DESIGN

Descriptive qualitative design.

METHODS

We adopted a descriptive phenomenological approach and purposefully selected physiotherapists (N = 15) from diverse healthcare settings, encompassing varying years of clinical experience, to capture a broad range of perspectives. Semi-structured face-to-face interviews were conducted via the Zoom video conferencing platform. Each interview lasted on average for 30-45 min, and no follow-up interviews were conducted. Data were analyzed using thematic analysis with an inductive approach.

RESULTS

Our analysis revealed three major themes and seven sub-themes uncovering barriers and facilitators of implementation of high-value care. These themes include misconceptions about low back pain and its management among physiotherapists, their perceived lack of autonomy in clinical decision-making due to external influences, and the significance of aligning treatment plans with patient goals while considering evidence-based care.

CONCLUSION

The study results provide insights into the unique challenges associated with implementation of high-value care for non-specific low back pain in Indian healthcare settings.

Should we give patients what they want? Patient expectations and financial pressures need to be addressed to increase uptake of evidence-based practice

Contextual factors such as patient expectations and financial pressures are overlooked challenges for Physiotherapists (PTs) and other rehabilitation professionals trying to implement evidence-based practice (EBP), particularly in private practice settings. In today's hypercompetitive pain management market, PTs may risk detrimental impacts to their reputation and livelihood if they do not give patients what they want, even if what they want does not align with clinical guidelines and research evidence. The aim of this professional practice paper is to shed light on these real-world challenges and encourage discussion among the PT community about strategies to increase uptake of EBP that involve multiple stakeholders such as PT training programs, professional organizations, researchers and clinic owners, which all have a role to play in supporting the translation of evidence into practice in our profession.

Guideline adherent screening and referral: do third year Doctor of Physical Therapy students identify red and yellow flags within descriptive patient cases? a United States based survey study

INTRODUCTION

The need for early detection and appropriate management of flags in physical therapy has been established. The lack of early detection has been shown to lead to poor outcomes such as serious pathology, increased disability, prolonged symptoms, and increased healthcare utilization.

OBJECTIVE

The main purpose of this survey study was to assess third-year Doctor of Physical Therapy (DPT) students' adherence to clinical practice guidelines specifically in the identification and management of red and yellow flags through a case-based approach.

METHODS

A survey including three different flag case scenarios was sent to DPT students in 15 geographically diverse physical therapy programs. Previously published case scenarios measuring adherence to practice guidelines were used. Correlational analyses were performed to link student demographic details and guideline adherent management.

RESULTS

The survey was completed by 64 students. Guideline adherent management was greater for red flags (85%) than yellow flag cases (25% and 42%). No significant relationship was noted between the student details and guideline adherent management.

CONCLUSION

DPT students may need additional educational content related to yellow flag screening. Educators may consider utilizing published red and yellow flag cases to guide decision-making and highlight best screening practices.

Promoting physical activity via physical therapist following knee replacement: A pilot randomized controlled trial

BACKGROUND

Outpatient physical therapy may be an opportune time to promote aerobic physical activity after knee replacement; however, it is unknown if it is feasible to integrate a physical activity intervention within standard physical therapy.

OBJECTIVE

To examine the feasibility and acceptability of a physical activity intervention delivered within outpatient physical therapy for adults after knee replacement.

METHODS

As part of a cluster randomized trial, adults with knee replacement starting outpatient physical therapy were recruited across four physical therapy sites. Sites were randomized and physical therapists delivered either an enhanced physical activity intervention or a control condition. The enhanced physical activity intervention consisted of standard postoperative physical therapy plus goal setting, problem-solving, and use of motivational interviewing techniques to promote 150 minutes/week of aerobic moderate intensity physical activity. The control group received standard postoperative physical therapy only. Feasibility and acceptability were determined based on recruitment and retention rates at 12 weeks after surgery. Outcomes including objectively measured physical activity, pain, and self-reported function were examined at the baseline postoperative visit and 12 weeks later.

RESULTS

Thirty-three percent of candidates screened were randomized (n = 45) and retention at 12 weeks after surgery was 91% (no difference by condition). Moderate-intensity activity increased, pain decreased, and self-reported function improved, but there were no statistically significant group differences between baseline and 12 weeks.

CONCLUSION

Implementing a physical activity intervention within outpatient physical therapy for adults after knee replacement is feasible; however, in this pilot study, changes were not observed in moderate intensity physical activity as compared to standard postoperative physical therapy. Future studies are needed to explore additional low-cost strategies and the optimal time to promote physical activity after knee replacement.

Can language enhance physical therapists' willingness to follow Choosing Wisely recommendations? A best-worst scaling study

BACKGROUND

Choosing Wisely recommendations could reduce physical therapists' use of low-value care.

OBJECTIVE

To investigate whether language influences physical therapists' willingness to follow the Australian Physiotherapy Association's (APA) Choosing Wisely recommendations.

DESIGN

Best-worst Scaling survey METHODS: The six original APA Choosing Wisely recommendations were modified based on four language characteristics (level of detail, strength- qualified/unqualified, framing, and alternatives to low-value care) to create 60 recommendations. Physical therapists were randomised to a block of seven choice tasks, which included four recommendations. Participants indicated which recommendation they were most and least willing to follow. A multinomial logistic regression model was used to create normalised (0=least preferred; 10=most preferred) and marginal preference scores.

RESULTS

215 physical therapists (48.5% of 443 who started the survey) completed the survey. Participants' mean age (SD) was 38.7 (10.6) and 47.9% were female. Physical therapists were more willing to follow recommendations with more detail (marginal preference score of 1.1) or that provided alternatives to low-value care (1.3) and less willing to follow recommendations with negative framing (-1.3). The use of qualified ('don't routinely') language (vs. unqualified - 'don't') did not affect willingness. Physical therapists were more willing to follow recommendations to avoid imaging for non-specific low back pain (3.9) and electrotherapy for low back pain (3.8) vs. recommendation to avoid incentive spirometry after upper abdominal and cardiac surgery.

CONCLUSION

Physical therapists were more willing to follow recommendations that provided more detail, alternatives to low-value care, and were positively framed. These findings can inform the development of future Choosing Wisely recommendations and could help reduce low-value physical therapy.

The Efficacy of Electromagnetic Diathermy for the Treatment of Musculoskeletal Disorders: A Systematic Review with Meta-Analysis

OBJECTIVE

This study aims to establish the effect of electromagnetic diathermy therapies (e.g., shortwave, microwave, capacitive resistive electric transfer) on pain, function, and quality of life in treating musculoskeletal disorders.

METHODS

We conducted a systematic review according to the PRISMA statement and Cochrane Handbook 6.3. The protocol has been registered in PROSPERO: CRD42021239466. The search was conducted in PubMed, PEDro, CENTRAL, EMBASE, and CINAHL.

RESULTS

We retrieved 13,323 records; 68 studies were included. Many pathologies were treated with diathermy against placebo, as a standalone intervention or alongside other therapies. Most of the pooled studies did not show significant improvements in the primary outcomes. While the analysis of single studies shows several significant results in favour of diathermy, all comparisons considered had a GRADE quality of evidence between low and very low.

CONCLUSIONS

The included studies show controversial results. Most of the pooled studies present very low quality of evidence and no significant results, while single studies have significant results with a slightly higher quality of evidence (low), highlighting a critical lack of evidence in the field. The results did not support the adoption of diathermy in a clinical context, preferring therapies supported by evidence.

Physiotherapy for patients with hip and knee osteoarthritis in Germany: a survey of current practice

BACKGROUND

Osteoarthritis (OA) of the hip and the knee is common and leads to pain, stiffness and disability. Clinical practice guidelines (CPG) provide recommendations to assist healthcare professionals in clinical decision-making. Although evidence-based physiotherapy has been shown to be effective in the management OA, a gap between clinical practice and guideline recommendations exists. Little is known about OA management provided by physiotherapists in Germany and whether treatment aligns with CPGs. The objectives of this study were (1) to investigate the current physiotherapy practice in patients with hip and/or knee OA in Germany, (2) to evaluate physiotherapists' adherence to guideline recommendations and (3) to explore barriers and facilitators to guideline use.

METHODS

A cross-sectional online survey was conducted among physiotherapists. The questionnaire collected information on demographic characteristics, physiotherapists' management of hip and knee OA and the use of CPGs in clinical practice. Guideline adherence was evaluated by comparing the survey findings with guideline recommendations. Full adherence was assumed if all recommended treatment options were chosen.

RESULTS

In total, 447 (74.9%) of 597 eligible physiotherapists completed the survey. Data from 442 participants (mean age 41.2 ± 12.8 years; 288 female (65.1%)) were included in the analysis. The most common treatment choices for both hip and knee OA were exercise therapy (hip OA: 424/442, 95.9%; knee OA: 426/442, 96.4%), self-management advice (hip OA: 413/442, 93.2%; knee OA: 395/442, 89.4%) and education (hip OA: 325/442, 73.5%; knee OA: 331/442, 74.9%), followed by manual therapy (hip OA: 311/442, 70.4%; knee OA: 311/442, 70.4%) and joint traction (hip OA: 208/442, 47.1%; knee OA: 199/442, 45.0%). Full guideline adherence was found in 17.2% (76/442) of physiotherapists for hip OA management and in 8.6% (38/442) for knee OA. Less than half of the respondents (212/430, 49.3%) were aware of an OA guideline.

CONCLUSIONS

In accordance with current guideline recommendations, most physiotherapists provide exercise therapy and education for patients with hip and/or knee OA. Interventions with low or conflicting evidence were also frequently provided. The limited awareness of existing OA guidelines and the low guideline adherence indicate an insufficient implementation of CPGs in German physiotherapy practice.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00026702). Registered 14 October 2021.

How do people perceive different advice for rotator cuff disease? A content analysis of qualitative data collected in a randomised experiment

OBJECTIVES

To explore how people perceive different advice for rotator cuff disease in terms of words/feelings evoked by the advice and treatment needs.

SETTING

We performed a content analysis of qualitative data collected in a randomised experiment.

PARTICIPANTS

2028 people with shoulder pain read a vignette describing someone with rotator cuff disease and were randomised to: bursitis label plus guideline-based advice, bursitis label plus treatment recommendation, rotator cuff tear label plus guideline-based advice and rotator cuff tear label plus treatment recommendation. Guideline-based advice included encouragement to stay active and positive prognostic information. Treatment recommendation emphasised that treatment is needed for recovery.

PRIMARY AND SECONDARY OUTCOMES

Participants answered questions about: (1) words/feelings evoked by the advice; (2) treatments they feel are needed. Two researchers developed coding frameworks to analyse responses.

RESULTS

1981 (97% of 2039 randomised) responses for each question were analysed. Guideline-based advice (vs treatment recommendation) more often elicited words/feelings of reassurance, having a minor issue, trust in expertise and feeling dismissed, and treatment needs of rest, activity modification, medication, wait and see, exercise and normal movements. Treatment recommendation (vs guideline-based advice) more often elicited words/feelings of needing treatment/investigation, psychological distress and having a serious issue, and treatment needs of injections, surgery, investigations, and to see a doctor.

CONCLUSIONS

Words/feelings evoked by advice for rotator cuff disease and perceived treatment needs may explain why guideline-based advice reduces perceived need for unnecessary care compared to a treatment recommendation.

Management of Low Back Pain: Do Physiotherapists Know the Evidence-Based Guidelines?

BACKGROUND

Clinical practice guidelines promote bio-psychosocial management of patients suffering from low back pain (LBP). The objective of this study was to examine the current knowledge, attitudes and beliefs of physiotherapists about a guideline-adherent approach to LBP and to assess the ability of physiotherapists to recognise signs of a specific LBP in a clinical vignette.

METHODS

Physiotherapists were recruited to participate in an online study. They were asked to indicate whether they were familiar with evidence-based guidelines and then to fill in the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS), Back Pain Attitudes Questionnaire (Back-PAQ), Neurophysiology of Pain Questionnaire (NPQ), as well as questions related to two clinical vignettes.

RESULTS

In total, 527 physiotherapists participated in this study. Only 38% reported being familiar with guidelines for the management of LBP. Sixty-three percent of the physiotherapists gave guideline-inconsistent recommendations regarding work. Only half of the physiotherapists recognised the signs of a specific LBP.

CONCLUSIONS

The high proportion of physiotherapists unfamiliar with guidelines and demonstrating attitudes and beliefs not in line with evidence-based management of LBP is concerning. It is crucial to develop efficient strategies to enhance knowledge of guidelines among physiotherapists and increase their implementation in clinical practice.

Effectiveness of Postoperative Physiotherapy Compared to Postoperative Instructions by Treating Specialist Only in Patients With an Ankle Fracture: A Systematic Review

Background

In current literature, the benefit of postoperative physiotherapy versus postoperative instructions by treating specialist only remains unclear. The aim of this review is to systematically assess existing literature regarding the functional outcome of postoperative physiotherapy compared to postoperative instructions by treating specialist only in the rehabilitation of patients with an ankle fracture. The secondary aim is to determine if there is a difference in ankle range of motion, strength, pain, complications, quality of life, and patient's satisfaction between these 2 rehabilitation methods.

Methods

For this review, the PubMed/MEDLINE, PEDro, Embase, Cochrane, and CINAHL databases were searched for studies that compared postoperative rehabilitation groups.

Results

The electronic data search detected 20 579 articles. After exclusion, 5 studies with a total of 552 patients were included. Overall, no significant benefit in functional outcome of postoperative physiotherapy was seen compared to the instructions-only group. One study even found a significant benefit in favor of the instructions-only group. An exemption for beneficial effect of the use of physiotherapy could be made for younger patients, as 2 studies described younger age as a factor for better outcomes (functional outcome and ankle range of motion) in the postoperative physiotherapy group. Patients' satisfaction, described by one study, was found to be significantly higher in the physiotherapy group (P = .047). All other secondary aims showed no significant difference.

Conclusion

Because of the limited number of studies and the heterogeneity among studies, a valid conclusion about the general effect of physiotherapy cannot be formed. However, we identified limited evidence suggesting a possible benefit of physiotherapy in younger patients with an ankle fracture in functional outcome and ankle range of motion.

A Systems Approach for Assessing Low Back Pain Care Quality in Veterans Health Administration Chiropractic Visits: A Cross-Sectional Analysis

OBJECTIVE

The purpose of this study was to explore a systemwide process for assessing components of low back pain (LBP) care quality in Veterans Health Administration (VHA) chiropractic visits using electronic health record (EHR) data.

METHODS

We performed a cross-sectional quality improvement project. We randomly sampled 1000 on-station VHA chiropractic initial visits occurring from October 1, 2017, to September 30, 2018, for patients with no such visits within the prior 12 months. Characteristics of LBP visits were extracted from VHA national EHR data via structured data queries and manual chart review. We developed quality indicators for history and/or examination and treatment procedures using previously published literature and calculated frequencies of visits meeting these indicators. Visits meeting our history and/or examination and treatment indicators were classified as "high-quality" visits. We performed a regression analysis to assess associations between demographic/clinical characteristics and visits meeting our quality criteria.

RESULTS

There were 592 LBP visits identified. Medical history, physical examination, and neurologic examination were documented in 76%, 77%, and 63% of all LBP visits, respectively. Recommended treatments, such as any manipulation, disease-specific education/advice, and therapeutic exercise, occurred in 75%, 69%, and 40% of chronic visits (n = 383), respectively. In acute/subacute visits (n = 37), any manipulation (92%), manual soft tissue therapy (57%), and disease-specific advice/education (54%) occurred most frequently. Female patients and those with a neck pain comorbid diagnosis were significantly less likely to have a "high-quality" visit, while other regression associations were non-significant.

CONCLUSION

This study explored a systemwide process for assessing components of care quality in VHA chiropractic visits for LBP. These results produced a potential framework for uniform assessment of care quality in VHA chiropractic visits for LBP and highlight potential areas for improvements in LBP care quality assessments.

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 ).

Knowledge and appropriateness of care of family physicians and physiotherapists in the management of shoulder pain: a survey study in the province of Quebec, Canada

BACKGROUND

Shoulder pain is difficult to diagnose and treat with half of those affected still symptomatic six months after initial consultation. This may be explained by primary care management not conforming to evidence-based practice. This survey evaluated physiotherapists (PTs) and family physicians' (FPs) knowledge and appropriateness of care in shoulder pain management.

METHODS

A survey sent to PTs and FPs in the province of Quebec, Canada presented four clinical vignettes with cases of rotator cuff (RC) tendinopathy, acute full-thickness RC tear, adhesive capsulitis and traumatic anterior glenohumeral instability. Respondents indicated diagnosis, indications for imaging, specialists' referrals, and choice of treatments. Answers were compared to recommendations from clinical practice guidelines (CPGs). Participants' responses were compared between types of providers with Fisher's exact test.

RESULTS

Respondents (PTs = 175, FPs = 76) were mostly women with less than ten years of experience. More than 80% of PTs and 84% of FPs correctly diagnosed cases presented. Despite this practice not being recommended, more FPs than PTs recommended an imaging test in the initial management of RC tendinopathy (30% compared to 13%, p = 0.001) and adhesive capsulitis (51% compared to 22%, p = 0.02). For full-thickness RC tear and shoulder instability, up to 72% of FPs and 67% of PTs did not refer to a specialist for a surgical opinion, although recommended by CPGs. For RC tendinopathy, 26% of FPs and 2% of PTs (p < 0.001) would have prescribed a corticosteroid infiltration, which is not recommended in the initial management of this disorder. For adhesive capsulitis, significantly more FPs (76%) than PTs (62%) (p < 0.001) suggested an intra-articular corticosteroid infiltration, as recommended by CPGs. For all presented vignettes, up to 95% of family physicians adequately indicated they would refer patients for physiotherapy. In prioritizing rehabilitation interventions, up to 42% of PTs did not consider active exercises as a priority and up to 65% selected passive modalities that are not recommended for all shoulder pain vignettes.

CONCLUSIONS

Most FPs and PTs were able to make adequate diagnoses and select appropriate treatments for shoulder pain, but practices opposed to evidence-based recommendations were chosen by several respondents. Further training of FPs and PTs may be needed to optimize primary care management of different shoulder disorders.

Knowledge and use of extrinsic feedback characteristics: A survey of current practice among Brazilian physical therapists

OBJECTIVES

This study aimed to identify the knowledge about the different characteristics of and the use of extrinsic feedback (EF) by Brazilian physical therapists.

METHODS

This is a cross-sectional study, and we used an internet-based survey with questions about knowledge and application of extrinsic feedback in clinical practice. We analyzed the responses in relation to the best available evidence on motor control and learning. We recruited Brazilian registered physical therapists from different regions in Brazil. Participants' demographics and survey responses were analyzed using descriptive statistics.

RESULTS

Two hundred and forty-six Brazilian physical therapists participated in the study. Most participants affirmed not knowing the definition of EF (55.69%), confirmed using some form of EF in their clinical practice (86.59%), and reported using it in 50% to 90% of their patients (26.42%). Brazilian physical therapists reported using mainly summary feedback (69.10%) with external focus of attention (63.41%). Participants reported using concurrent feedback (82.83%) and delivered it after every exercise repetition (63.82%). Most participants (43.09%) did not assess learning retention. Answers were similar regardless of education level or time from graduation.

CONCLUSIONS

The results of this survey suggest that Brazilian physical therapists do not have sufficient knowledge about the different characteristics of EF; however, they do consider EF useful and use it for most of their patients. Brazilian physical therapists adopted adequate content characteristics of EF but not adequate use of timing characteristics of EF.

Priorities in updating training paradigms in orthopedic manual therapy: an international Delphi study

PURPOSE

Orthopedic manual therapy (OMT) education demonstrates significant variability between philosophies and while literature has offered a more comprehensive understanding of the contextual, patient specific, and technique factors which interact to influence outcome, most OMT training paradigms continue to emphasize the mechanical basis for OMT application. The purpose of this study was to establish consensus on modifications & adaptions to training paradigms which need to occur within OMT education to align with current evidence.

METHODS

A 3-round Delphi survey instrument designed to identify foundational knowledge to include and omit from OMT education was completed by 28 educators working within high level manual therapy education programs internationally. Round 1 consisted of open-ended questions to identify content in each area. Round 2 and Round 3 allowed participants to rank the themes identified in Round 1.

RESULTS

Consensus was reached on 25 content areas to include within OMT education, 1 content area to omit from OMT education, and 34 knowledge components which should be present in those providing OMT. Support was seen for education promoting understanding the complex psychological, neurophysiological, and biomechanical systems as they relate to both evaluation and treatment effect. While some concepts were more consistently supported there was significant variability in responses which is largely expected to be related to previous training.

CONCLUSION

The results of this study indicate manual therapy educators understanding of evidence-based practice as support for all 3 tiers of evidence were represented. The results of this study should guide OMT training program development and modification.

Practice patterns of physical therapists and physical therapist assistants treating patients with breast cancer related lymphedema

Clinical Practice Guidelines (CPGs) aim to improve patient outcomes through implementation of proven interventions and decrease variation in practices. The relevance of this article is to describe the current state practice of physical therapists who diagnose and treat patients with Breast Cancer Related Lymphedema (BCRL). It also provides a description of physical therapist-reported adherence to the BCRL CPG recommendations which establishes the need for implementation interventions to improve adherence.

PURPOSE

The purpose of this study is to describe practice patterns of physical therapists (PT) and physical therapist assistants (PTA) who treat patients with breast cancer-related lymphedema and determine if they are adherent to best evidence recommendations for lymphedema diagnosis and intervention.

METHODS

An electronic survey to collect practice pattern data of PTs and PTAs who treat patients with BCRL was distributed. A descriptive and quantitative statistical analysis was performed.

RESULTS

Twenty-six percent of respondents read the American Physical Therapy Association sponsored lymphedema diagnosis clinical practice guideline (CPG) and 20% read the lymphedema intervention CPG. Lymphoscintigraphy was the only diagnosis or intervention tool with a significant difference in use between therapists who read versus did not read the CPGs. Adherence to "should do" recommendations was variable: bioimpedance (18.2%), volume calculation (49.3%), ultrasound (0%), patient reported outcome tools (64.9%), compression garments (43.9%), exercise (87.2%), and compression bandaging (56.8%).

CONCLUSIONS

There is variability in adherence to recommendations for both the lymphedema diagnosis and intervention CPGs. Interventions to improve implementation and adherence to CPG recommendations are warranted.

Physical activity for patients with chronic low back pain: What are physical therapists prescribing?

BACKGROUND

Despite the extensive evidence supporting physical activity (PA) for managing chronic low back pain (CLBP), little is known about PA prescription by physical therapists treating patients with CLBP.

OBJECTIVE

1) Explore how PA prescriptions provided by outpatient physical therapists treating patients with CLBP align with PA guidelines. 2) Examine the barriers and facilitators of PA prescription among physical therapists working with patients with CLBP.

METHODS

We conducted a qualitative study with outpatient physical therapists who treat CLBP. Semi-structured interviews provided an understanding of physical therapist experience with PA prescription among patients with CLBP. The interviews were transcribed, coded, and analyzed thematically.

RESULTS

The 18 participants had an average of 13.4 (6.4) years of clinical experience in outpatient physical therapy. Thematic analysis revealed: 1) Physical therapists' articulate knowledge of PA guidelines and importance of physical activity; 2) Patient factors take priority over the PA guidelines for people with CLBP; and 3) The importance of building and maintaining a strong patient-therapist relationship influences physical therapist prescription of PA for patients with CLBP.

CONCLUSION

When providing PA recommendations for patients with CLBP, general movement recommendations are emphasized in place of explicit PA prescriptions. Our findings highlight factors for consideration when prescribing movement and PA for patients with CLBP.

Physiotherapists' opinions, barriers, and enablers to providing evidence-based care: a mixed-methods study

BACKGROUND

Physiotherapists deliver evidence-based guideline recommended treatments only half of the time to patients with musculoskeletal conditions. Physiotherapists' behaviour in clinical practice are influenced by many cognitive, social, and environmental factors including time and financial pressures. Many initiatives aimed at improving physiotherapists' uptake of evidence-based care have failed to appreciate the context involved in clinical decisions and clinical practice. Therefore, we aimed to describe: i) opinions toward evidence; ii) how evidence is accessed; iii) factors influencing evidence access; iv) factors influencing evidence application, for physiotherapists working in regional areas.

METHODS

We used a mixed-methods study with online survey and focus groups. We included registered physiotherapists in the survey and physiotherapists practising in regional New South Wales in the focus groups. Quantitative and qualitative data were used to inform all research objectives. We used eight domains of the Transtheoretical Domains Framework to design survey questions. We analysed quantitative and qualitative data in parallel, then integrated both sources through by developing a matrix while considering the Transtheoretical Domains Framework domains to generate themes.

RESULTS

Fifty-seven physiotherapists participated in the study (survey only n = 41; focus group only n = 8; both survey and focus group n = 8). Participants reported that evidence was important, but they also considered patient expectations, colleagues' treatment choices, and business demands in clinical decision making. Physiotherapists reported they access evidence on average 30 minutes or less per week. Competing demands like business administration tasks are barriers to accessing evidence. Participants reported that patient expectations were a major barrier to applying evidence in practice. Environmental and systemic factors, like funding structures or incentives for evidence-based care, and social factors, like lacking or having a culture of accountability and mentorship, were reported as both barriers and enablers to evidence application.

CONCLUSIONS

This study provides context to physiotherapists' opinion, access, and application of evidence in clinical practice. Physiotherapists' provision of evidence-based care may be improved by enhancing structural support from workplaces to access and apply evidence and exploring discrepancies between physiotherapists' perceptions of patient expectations and actual patient expectations.

Physiotherapists’ knowledge of and adherence to evidence-based practice guidelines and recommendations for ankle sprains management: a cross-sectional study

Background

Lateral ankle sprain (LAS) is a common and burdensome injury. However, the quality of its management is scant. Nowadays, physiotherapy management of musculoskeletal diseases seems to be generally not based on research evidence. Studies that investigated the knowledge-to-practice gap in LAS management are yet to be carried out. Therefore, this research investigated physiotherapists’ knowledge of and adherence to LAS Clinical Practice Guidelines (CPGs) and recommendations.

Methods

A cross-sectional study based on an online survey structured in three sections. The first section collected demographic data. The second section showed two clinical cases (with positive and negative Ottawa Ankle Rules (OAR), respectively). The participants indicated which treatments they would adopt to manage them. Participants were classified as ‘following’, ‘partially following’, ‘partially not following’ and ‘not following’ the CPGs and recommendations. In the third section, participants expressed their agreement with different CPG and recommendation statements through a 1-5 Likert scale.

Results

In total, 483 physiotherapists (age: 34 ± 10; female 38%, male 61.5%, other 0.5%) answered the survey: 85% completed the first two sections, 76% completed all three sections. In a case of acute LAS with negative OAR, 4% of the participants were considered as ‘following’ recommended treatments, 68% as ‘partially following’, 23% as ‘partially not following’, and 5% as ‘not following’. In a case of acute LAS with positive OAR, 37% were considered ‘following’ recommended treatments, 35% as ‘partially following’, and 28% as ‘not following’. In the third section, the consensus was achieved for 73% of the statements.

Conclusion

This study showed that although there is a good knowledge about first-line recommended treatments, a better use of CPGs and recommendations should be fostered among physiotherapists. Our results identify an evidence-to-practice gap in LAS management, which may lead to non-evidence-based practice behaviors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05914-5.

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 ).