Implementation interventions to improve the management of non-specific low back pain: a systematic review

Mixed-Method Evaluation to Understand Clinician Perspectives of a Program to Implement High-Intensity Resistance Rehabilitation Into Skilled Nursing Facilities

OBJECTIVE

To assess rehabilitation clinicians' viewpoints regarding a multicomponent implementation program aimed at promoting high-intensity resistance rehabilitation (HIR), as well as practical implications for its use in skilled nursing facility (SNF) rehabilitation.

DESIGN

Prospective convergent mixed-method design.

SETTING

Eight rural SNFs within the Department of Veterans Affairs.

PARTICIPANTS

Physical rehabilitation clinicians (physical and occupational therapists, physical and occupational therapy assistants, recreational therapists, and kinesiotherapists) who engaged with the implementation program (n=38).

INTERVENTIONS

Clinicians engaged with the multicomponent implementation program to promote the use of HIR in clinical practice. The program components included clinician training (i.e., virtual didactic modules with synchronous case discussions), provision of resources (e.g., equipment, job aids), and facilitated implementation (e.g., external implementation facilitator support, distributed tips and tricks).

MAIN OUTCOME MEASURES

Acceptability of Intervention Measure, Training Acceptability Rating Scale, study-specific questionnaires, and qualitative focus groups exploring perceived acceptability, feasibility, and effect on work experience.

RESULTS

Questionnaires revealed high levels of implementation program acceptability and perceived effect, alongside moderate levels of feasibility. Focus group themes supported these findings, explaining high acceptability and effect through differentiation from other trainings and prolonged engagement. Feasibility results were explained qualitatively by facilitatory factors (i.e., team participation, reduced caseloads, training characteristics) and inhibitory factors (i.e., training timing, self-paced scheduling logistics, lack of protected time and space). There was no reported negative effect on clinician work experience.

CONCLUSIONS

According to SNF clinician perspectives, a positive HIR implementation experience may be enhanced through implementation programs that provide prolonged engagement and a self-paced structure with built-in accountability. Leadership and organizational support appear important to protect time and space for clinicians who experience competing priorities to successfully facilitate evidence uptake. Future work can evaluate the applicability across various contexts beyond rural VA SNFs.

Context factors for implementation of clinical recommendations for chronic musculoskeletal pain

BACKGROUND

 Implementing evidence-informed clinical practice recommendations is important for managing chronic musculoskeletal pain (CMSP) to address the multidimensional impact of the condition. Successful implementation of recommendations requires understanding the multiple context factors that influence CMSP management in different settings.

AIM

 This study aims to explore contextual factors that could influence the implementation of evidence-informed clinical practice recommendations for the primary health care of adults with CMSP.

SETTING

 The study focused on the primary health care (PHC) sector in Cape Town, South Africa.

METHODS

 A qualitative descriptive study was conducted. A multidisciplinary panel of 13 local health care professionals participated in focused group discussions. The participants considered multimodal clinical recommendations derived from published clinical practice guidelines. In four focus group discussions (three or four members per group), the panel generated and documented context factors that would influence implementing the recommendations in practice. Inductive content analysis was performed to identify categories and themes.

RESULTS

 The five contextual themes generated indicated health care system organisation, human resource requirements, provider practice patterns, patient empowerment and integration into policy as imperative for the successful implementation of recommendations.

CONCLUSION

 There are diverse context factors that could influence the implementation of clinical recommendations for managing CMSP in PHC settings. Identifying these factors as barriers or facilitators is beneficial for developing effective knowledge translation strategies.Contribution: The study findings indicate that an integrated systems approach supported by health care policy and multisectoral collaboration is needed to successfully implement clinical recommendations to address the impact of CMSP.

Assessing MRI referrals' appropriateness for low back pain post a radiology-initiated intervention

INTRODUCTION

This study evaluated a pilot intervention to reduce low-value Magnetic Resonance Imaging (MRI) referrals for Low Back Pain (LBP).

METHODS

This before-after intervention study analysed MRI referrals for LBP at two private imaging centres in Norway. MRI referrals for LBP obtained before and after an intervention of information campaigns and sending a return letter to clinicians for declined referrals were evaluated on information, quality, and justification rates. Four radiologists and two radiographers assessed the referrals. A point system was used to calculate referral quality. Each referral was given a score 'good' when rated above 5.5 and 'poor' below 2.5. Justification was based on assessors categorised rating as justified, unjustified or need more information. Stata Statistical Software (Release 18) was used for analysis. A mixed model analysed variations of the referrals pre- and post-intervention. A p-value of <.05 in variations was considered statistically significant.

RESULTS

A total n = 300 patients' referrals (150 referrals pre- and post-intervention) were collected and assessed. Post-intervention, 68% of referrals were justified, up from 63% pre-intervention. The assessment showed a 4% decrease in referrals with poor scores and a 2% increase in those rated as good or intermediate quality post-intervention. These changes were not statistically significant.

CONCLUSION

It is important to state that it was not possible in our study to identify the subgroup of referrals that are known to be from clinicians who had received a return letter, although the information campaign targeted all referrers. Despite the limitations our findings suggest that providing reasons for declined referrals can serve as an educational tool for clinicians and contribute to the reduction of low value MRI for LBP.

IMPLICATIONS FOR PRACTICE

Radiology department initiatives that raise awareness and offer referral criteria guidance to clinicians can serve as valuable educational tools, and further emphasize the importance of providing comprehensive information in MRI referrals for LBP.

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.

Comparison of aquatic physiotherapy and therapeutic exercise in patients with chronic low back pain

OBJECTIVE

To investigate and compare the effectiveness of aquatic physiotherapy and therapeutic exercise in the physical and functional performance of patients with chronic low back pain.

METHODS

Twenty-six participants were randomized into 3 groups, namely an aquatic physiotherapy group (AG), a therapeutic exercise group (EG), and a control group (CG). The pain, disability, and quality of life were compared before and after the exercise protocols for 2 months, twice a week, on alternate days, for 60 min. For statistical analyses, the Kruskal-Wallis test was used to test the difference between the groups; the Wilcoxon test and the effect size were used for before-and-after comparisons.

RESULTS

Twenty participants completed the study. There was a significant difference improvement in pain between the AG and the EG (p = 0.004), between the EG and the CG (p = 0.05), and in social role functioning between the groups (p = 0.02). No differences were observed in the other analyzed variables between the groups. Compared to the pre-treatment state, there were significant improvements in the AG in terms of pain (p = 0.02), functionality (p = 0.03), and general health status (p = 0.04).

CONCLUSION

The AG group showed significant and clinical improvement in pain, disability, and quality of life. Improvements related to social aspects were found in the EG compared to the CG. The water provides a safe environment that facilitates the onset of exercise, so aquatic physiotherapy could be considered the first recommendation for patients with low back pain.

Listening to Remotely Monitored Home-based Preferred Music for Pain in Older Black Adults with Low Back Pain: A Pilot Study of Feasibility and Acceptability

BACKGROUND

Low back pain (LBP) is a complex condition that is widespread among older Black adults. Nonpharmacologic interventions are recommended as first-line therapy, but their use in practice is limited, possibly due to misunderstanding of their analgesic characteristics.

AIM

To determine the feasibility and acceptability of listening to preferred music at home to relieve pain in older Black adults aged 65 years or older with LBP.

METHOD

We recruited 20 community-dwelling older adults (≥65 years) with LBP to use noise-isolating headphones to listen to their preferred music for 20 minutes twice daily for four days via the MUSIC CARE® app. Feasibility was determined using enrollment, adherence, and attrition rates, and acceptability was determined using the Treatment Acceptance and Preference (TAP) scale. Average pain scores were self-reported using the Numeric Rating Scale (NRS) after the second intervention of the day. Pain scores were evaluated using paired sample t test and repeated-measures ANOVA.

RESULTS

Enrollment, adherence, and attrition rates were 95.25%, 100.00%, and 0.00%, respectively. Most participants rated the TAP scale at ≥3, indicating acceptance. Pain scores decreased significantly from baseline (M = 46.90, SD = 21.47) to post-intervention (M = 35.70, SD = 16.57), t (19) = 2.29, p = .03. Repeated measures ANOVA showed a significant decrease in mean pain scores over time [F (2.36, 44.88) = 5.61, p = .004, η2 = .23].

CONCLUSIONS

Listening to preferred music for 20 minutes twice a day is a feasible and acceptable intervention that can considerably reduce pain in older Black adults with LBP.

Evaluation of a blended learning approach on stratified care for physiotherapy bachelor students

BACKGROUND

Stratified models of care are valuable for addressing psychosocial factors which influence the outcome of patients with musculoskeletal disorders. Introducing such models in undergraduate training has the potential to propagate this knowledge with evidence and foster its implementation. The objective of this paper is to explore the perception and changes in the fear-avoidance beliefs of physiotherapy students participating in a developed blended learning course on stratified care.

METHODOLOGY

A mixed-methods with a convenient sample of two consecutive cohorts were given a blended learning course on stratified care for patients with low back pain. The blended learning course comprised scientific rudiments and application of stratified care in clinical practice conceptualised using the KERN' 6-step approach. The exam scores, perceptions, performance on self-reflection-tests and pre- and post-scores on The Tampa Scale for Kinesiophobia for Physiotherapists' (TSK-PT) were obtained. After gaining clinical experience, participants were invited to discuss their clinical experiences and perceptions in workshops. The quantitative data was analysed explorative-descriptively. The qualitative data was analysed following an inductive coding system with constant comparisons.

RESULTS

Ninety-one participants consented to the evaluation (mean age = 22.9 ± 1.6 years), 66% were female. Exam scores correlated with time spent in training (r = 0.30) and scores on self-reflection-tests 1 and 2 (r = 0.40 and r = 0.41). Participants in both cohorts described the learning resources as promoting their interest in the subject (72% and 94%), up-to-date (91% and 93%) and helpful (91% and 97%). The fear-avoidance scores for participants decreased from 53.5 (± 9.96) to 40.1 (± 12.4) with a large effect size (d = 1.18). The regression model [F (2, 49) = 1151.2, p < 0.001] suggests that pre-TSK-PT and the interest of participants in the training predicted post-TSK-PT. The workshop participants (n = 62) all worked in clinical practice. Emerging from the analysis were 4 categories (evolving to maturity in practice, perceiving determinants of stratified care, strategising for implementation and adopting an outlook for future practice).

CONCLUSION

The quality of engagement in learning, training strategy and interest in the subject contributes immensely to learning outcomes. This blended learning course was successful in reducing kinesiophobia and influencing the participants' attitude towards care with the potential of being translated into long-term practice.

Applying the behavioural change wheel to guide the implementation of a biopsychosocial approach to musculoskeletal pain care

Achieving high value, biopsychosocial pain care can be complex, involving multiple stakeholders working synergistically to support the implementation of quality care. In order to empower healthcare professionals to assess, identify and analyse biopsychosocial factors contributing to musculoskeletal pain, and describe what changes are needed in the whole-of-system to navigate this complexity, we aimed to: (1) map established barriers and enablers influencing healthcare professionals' adoption of a biopsychosocial approach to musculoskeletal pain against behaviour change frameworks; and (2) identify behaviour change techniques to facilitate and support the adoption and improve pain education. A five-step process informed by the Behaviour Change Wheel (BCW) was undertaken: (i) from a recently published qualitative evidence synthesis, barriers and enablers were mapped onto the Capability Opportunity Motivation-Behaviour (COM-B) model and Theoretical Domains Framework (TDF) using "best fit" framework synthesis; (ii) relevant stakeholder groups involved in the whole-of-health were identified as audiences for potential interventions; (iii) possible intervention functions were considered based on the Affordability, Practicability, Effectiveness and Cost-effectiveness, Acceptability, Side-effects/safety, Equity criteria; (iv) a conceptual model was synthesised to understand the behavioural determinants underpinning biopsychosocial pain care; (v) behaviour change techniques (BCTs) to improve adoption were identified. Barriers and enablers mapped onto 5/6 components of the COM-B model and 12/15 domains on the TDF. Multi-stakeholder groups including healthcare professionals, educators, workplace managers, guideline developers and policymakers were identified as target audiences for behavioural interventions, specifically education, training, environmental restructuring, modelling and enablement. A framework was derived with six BCTs identified from the Behaviour Change Technique Taxonomy (version 1). Adoption of a biopsychosocial approach to musculoskeletal pain involves a complex set of behavioural determinants, relevant across multiple audiences, reflecting the importance of a whole-of-system approach to musculoskeletal health. We proposed a worked example on how to operationalise the framework and apply the BCTs. Evidence-informed strategies are recommended to empower healthcare professionals to assess, identify and analyse biopsychosocial factors, as well as targeted interventions relevant to various stakeholders. These strategies can help to strengthen a whole-of-system adoption of a biopsychosocial approach to pain care.

"My Back is Fit for Movement": A Qualitative Study Alongside a Randomized Controlled Trial for Chronic Low Back Pain

A new wave of treatments has emerged to target nervous system alterations and maladaptive conceptualizations about pain for chronic low back pain. The acceptability of these treatments is still uncertain. We conducted a qualitative study alongside a randomized controlled trial to identify perceptions of facilitators or barriers to participation in a non-pharmacological intervention that resulted in clinically meaningful reductions across 12 months for disability compared to a sham intervention. We conducted semi-structured interviews with participants from the trial's active arm after they completed the 12-week program. We included a purposeful sample (baseline and clinical characteristics) (n = 20). We used reflexive thematic analysis informed by the Theoretical Framework of Acceptability for health care interventions. We identified positive and negative emotional/cognitive responses associated with treatment acceptability and potential efficacy, including emotional support, cognitive empowerment, readiness for self-management, and acceptance of face-to-face and online components designed to target the brain. These findings suggest the importance of psychoeducation and behavior change techniques to create a positive attitude towards movement and increase the perception of pain control; systematic approaches to monitor and target misconceptions about the interventions during treatment; and psychoeducation and behavior change techniques to maintain the improvements after the cessation of formal care. PERSPECTIVE: This article presents the experiences of people with chronic low back pain participating in a new non-pharmacological brain-targeted treatment that includes face-to-face and self-directed approaches. The facilitators and barriers of the interventions could potentially inform adaptations and optimization of treatments designed to target the brain to treat chronic low back pain.

A Guideline-Implementation Intervention to Improve the Management of Low Back Pain in Primary Care: A Difference-in-Difference-in-Differences Analysis

BACKGROUND

Real-world adherence to clinical practice guidelines is often poor, resulting in sub-standard patient care and unnecessary healthcare costs. This study evaluates the effect of a guideline-implementation intervention for the management of low back pain (LBP) in general practice-the Fear Reduction Exercised Early (FREE) approach-on LBP-related injury insurance claims, healthcare utilisation, and costs of treatment.

DESIGN

Data were extracted from comprehensive nationwide New Zealand injury insurance claims records. Data were analysed using a 'triple-difference' (difference-in-difference-in-differences) method to isolate the causal effect of FREE training on LBP claims activity, comparing the difference in general practitioner (GP) LBP claims and associated activity before and after training with their non-musculoskeletal injury claims for the same periods (assumed to be unaffected by training), relative to the same comparisons for GPs not trained in the FREE approach.

RESULTS

Training GPs in the FREE approach resulted in significant reductions in the number of LBP injury claims lodged (- 19%, 95% CI -34 to -5), the use of physiotherapy (-30%, 95% CI - 42 to - 18) and imaging (- 27%, 95% CI - 46 to - 8%), and the healthcare costs (- 21%, 95% CI - 41 to - 1) of LBP injury. Changes in claims for earnings' compensation (- 10%, 95% CI - 34 to 13) were not significant.

CONCLUSIONS

A brief guideline-implementation intervention following best-practice LBP management and guideline-implementation strategies achieved significant reductions, persisting over at least 6 to18 months, in healthcare utilisation consistent with improved delivery of guideline-concordant care.

Low-value care in musculoskeletal health care: Is there a way forward?

BACKGROUND

Low-value care that wastes resources and harms patients is prevalent in health systems everywhere.

METHODS

As part of an invited keynote presentation at the Pain in Motion IV conference held in Maastricht, Holland, in May 2022, we reviewed evidence for low-value care in musculoskeletal conditions and discussed possible solutions.

RESULTS

Drivers of low-value care are diverse and affect patients, clinicians, and health systems everywhere. We show that low-value care for back pian, neck pain, and osteoarthritis is prevalent in all professional groups involved in caring for people who seek care for these conditions. Implementation efforts that aim to reverse low-value care seem to work better if designed using established conceptual and theoretical frameworks.

CONCLUSION

Low-value care is prevalent in the care of people with musculoskeletal conditions. Reducing low-value care requires behaviour change among patients and clinicians as well as in health systems. There is evidence that behaviour change can be facilitated through good conceptual and theoretical frameworks but not convincing evidence that it changes patient outcomes.

Implementation initiatives to improve low back pain care in Australia: a scoping review

OBJECTIVE

This scoping review aimed to comprehensively review strategies for implementation of low back pain (LBP) guidelines, policies and models of care in the Australian healthcare system.

METHODS

A literature search was conducted in MEDLINE, EMBASE, CINAHL, Amed and Web of Science to identify studies that aimed to implement or integrate evidence-based interventions/practices to improve LBP care within Australian settings.

RESULTS

Twenty-five studies met the inclusion criteria. Most studies targeted primary care settings (n = 13). Other settings included tertiary care (n = 4), community (n = 4), pharmacies (n = 3). One study targeted both primary and tertiary care settings (n = 1). Only 40% of the included studies reported an underpinning framework, model or theory. Implementation strategies most frequently used were evaluative and iterative strategies (n = 14, 56%) and train and educate stakeholders (n = 13, 52%), followed by engage consumers (n = 6, 24%), develop stakeholder relationships (n = 4, 16%), change in infrastructure (n = 4, 16%) and support clinicians (n = 3, 12%). The most common implementation outcomes considered were acceptability (n = 11, 44%) and adoption (n = 10, 40%), followed by appropriateness (n = 7, 28%), cost (n = 3, 12%), feasibility (n = 1, 4%) and fidelity (n = 1, 4%). Barriers included time constraints, funding, and teamwork availability. Facilitators included funding and collaboration between stakeholders.

CONCLUSIONS

Implementation research targeting LBP appears to be a young field, mostly focusing on training and educating stakeholders in primary care. Outcomes on sustainability and penetration of evidence-based interventions are lacking. There is a need for implementation research guided by established frameworks that consider interrelationships between organisational and system contexts beyond the clinician-patient dyad.

Does the implementation of clinical practice guidelines for low back and neck pain by physical therapists improve patient outcomes? A systematic review

BACKGROUND

Physical therapy for neck and low back pain is highly variable despite the availability of clinical practice guidelines (CPG). This review aimed to determine the impact of CPG implementation on patient-level outcomes for spinal pain. Implementation strategies were also examined to determine prevalence and potential impact.

METHODS

Multiple databases were searched through April 2021 for studies assessing CPG implementation in physical therapy for neck and low back pain. Articles were screened for eligibility. The Modified Downs and Black checklist was utilized to determine study quality. Due to the heterogeneity between studies, a meta-analysis was not performed.

RESULTS

Twenty-one studies were included in this review. Implementation strategies were significantly varied between studies. Outcomes pertaining to healthcare utilization, pain, and physical functioning were assessed in relation to the implementation of CPGs. Multiple implementation strategies were identified, with Managing Quality as the most frequently utilized key implementation process. Findings indicate CPG implementation decreased healthcare utilization, but inconsistent results were found with physical functioning and pain outcomes.

CONCLUSIONS

CPG implementation appears to have a beneficial effect on healthcare utilization outcomes, but may not impact pain and physical functioning outcomes. Effective CPG implementation strategies remain unknown, though utilizing implementation framework may improve outcomes. More research is needed to determine the most effective implementation strategies and effects on pain and physical function outcomes.

The impact of ergonomic-educational interventions on reduction of musculoskeletal symptoms among employees of oil and gas installations in Iran

BACKGROUND: Musculoskeletal disorders can cause increased absenteeism, costs, and injuries. OBJECTIVE: The present study was aimed to investigate the impact of ergonomic-educational interventions on the reduction of musculoskeletal symptoms among employees of oil and gas installations. METHODS: This interventional study was conducted on 1243 male workers of oil and gas installations in the south of Iran. The Nordic questionnaire and quick exposure check (QEC) method were used to evaluate the risk of developing musculoskeletal disorders in the participants. Then, the educational interventions via training sessions, designed educational booklets and leaflets, and prepared educational film were performed. Data were collected at the times of two months before and six months after the interventions. RESULTS: The prevalence of musculoskeletal symptoms, at least in one of the body areas, was equal to 71.28%. The results showed that the prevalence of these symptoms significantly decreased in all body areas after the educational interventions (P <0.028). The highest reduction rate occurred in the regions of wrists and hands (52.77%), knees (47.17%), and waist (47.13%), respectively. Moreover, the results indicated that the mean value of the total score of quick exposure check (QEC) had a meaningful decrease from 0.92 to 0.54 after the educational interventions (P <0.0001). CONCLUSION: The planned educational interventions efficiently reduced the prevalence of musculoskeletal symptoms and the ergonomic risk levels estimated by QEC in the research population.

Evaluation of a guidelines implementation intervention to reduce work disability and sick leaves related to chronic musculoskeletal pain: a theory-informed qualitative study in occupational health care

Background

Guidelines for pain management and sick leave prescription were formulated and implemented in an occupational health services (OHS) in Finland to reduce work disability and sick leaves related to musculoskeletal pain. We investigated how the guidelines implementation intervention may have produced its effects, how the number of prescribed sick leave days varied before and after the launch of the guidelines, and which factors beyond physician behaviour were seen to influence sick leaves.

Methods

Seventeen physicians, two occupational physiotherapists and one occupational health care nurse were interviewed. Qualitative content analysis using both inductive and deductive approaches was performed, informed by Behaviour Change Wheel and Theoretical Domains Framework. Employees’ sick leave days related to musculoskeletal disorders in 2015–2019 were drawn from the employer’s register.

Results

Physicians’ guidelines adherence was facilitated by psychological capability (e.g., having relevant knowledge, remembering to engage in recommended behaviours), reflective motivation (e.g., guidelines-related behaviours regarded as central part of one’s professional role; beliefs in the positive consequences of recommended behaviours to employees and employers), and physical and social opportunities (e.g., adequate physical resources, culture of social support). Some physicians also described barriers to recommended behaviours (e.g., lack of knowledge or non-pharmacological pain treatment tools). The guidelines had served as sources of new knowledge, reminders of recommended practices and means of self-assessment. Considerable declining trend of prescribed sick leave days was detected, especially during the first years after the intervention, levelling off somewhat thereafter. OHS policies and structures were seen to enable professionals’ focusing on preventing pain-related disability and prolonged sick leaves. The decline of sickness absences was also attributed to the municipal client organization’s commitment and the employees’ positive attitudes towards the alternatives to full-time sick leave.

Conclusions

The guidelines implementation intervention was found successful. The study showed the importance of social and organizational environment supporting physicians’ engagement in recommended practices.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05234-8.

Improved adherence to clinical guidelines for low back pain after implementation of the BetterBack model of care: A stepped cluster randomized controlled trial within a hybrid type 2 trial

BACKGROUND

The BetterBack model of care (MoC) for low back pain (LBP) was recently developed in Swedish physiotherapy (PT) primary care.

OBJECTIVE

To evaluate if PTs' adherence to LBP clinical practice guidelines (CPGs) improves after implementation of the BetterBack MoC (intervention).

METHODS

This was a stepped, single-blinded cluster randomized controlled trial. Patients nested in the three clusters were allocated to routine care (n = 222) or intervention (n = 278). The primary outcome was referral to specialist consultation. This was among five best practice recommendations divided into an assessment quality index (no referral to specialist consultation and no medical imaging) and a treatment quality index (use of educational interventions; use of exercise interventions; no use of non-evidence-based physiotherapy). For overall adherence, patients had to be treated with all five recommendations fulfilled. Logistic regression was used for between-group comparisons.

RESULTS

The proportion of patients receiving referral to specialist consultation during the PT treatment period was low in both groups with no between-group differences. However, patients in the intervention group showed significantly higher assessment quality index, treatment quality index and overall adherence compared to routine care. Adherence to the separate recommendations showed improved stratified number of visits, use of exercise was maintained high, patient educational intervention increased and use of non-evidence-based physiotherapy decreased. A reduction of medical imaging during the physiotherapy treatment period was also observed.

CONCLUSIONS

The adoption of CPGs could be substantially improved by introducing a MoC through PT training and supportive materials.

Improving adherence to acute low back pain guideline recommendations with chiropractors and physiotherapists: the ALIGN cluster randomised controlled trial

Background

Acute low back pain is a common condition, has high burden, and there are evidence-to-practice gaps in the chiropractic and physiotherapy setting for imaging and giving advice to stay active. The aim of this cluster randomised trial was to estimate the effects of a theory- and evidence-based implementation intervention to increase chiropractors’ and physiotherapists’ adherence to a guideline for acute low back pain compared with the comparator (passive dissemination of the guideline). In particular, the primary aim of the intervention was to reduce inappropriate imaging referral and improve patient low back pain outcomes, and to determine whether this intervention was cost-effective.

Methods

Physiotherapy and chiropractic practices in the state of Victoria, Australia, comprising at least one practising clinician who provided care to patients with acute low back pain, were invited to participate. Patients attending these practices were included if they had acute non-specific low back pain (duration less than 3 months), were 18 years of age or older, and were able to understand and read English. Practices were randomly assigned either to a tailored, multi-faceted intervention based on the guideline (interactive educational symposium plus academic detailing) or passive dissemination of the guideline (comparator). A statistician independent of the study team undertook stratified randomisation using computer-generated random numbers; four strata were defined by professional group and the rural or metropolitan location of the practice. Investigators not involved in intervention delivery were blinded to allocation. Primary outcomes were X-ray referral self-reported by clinicians using a checklist and patient low back pain-specific disability (at 3 months).

Results

A total of 104 practices (43 chiropractors, 85 physiotherapists; 755 patients) were assigned to the intervention and 106 practices (45 chiropractors, 97 physiotherapists; 603 patients) to the comparator; 449 patients were available for the patient-level primary outcome. There was no important difference in the odds of patients being referred for X-ray (adjusted (Adj) OR: 1.40; 95% CI 0.51, 3.87; Adj risk difference (RD): 0.01; 95% CI − 0.02, 0.04) or patient low back pain-specific disability (Adj mean difference: 0.37; 95% CI − 0.48, 1.21, scale 0–24). The intervention did lead to improvement for some key secondary outcomes, including giving advice to stay active (Adj OR: 1.96; 95% CI 1.20, 3.22; Adj RD: 0.10; 95% CI 0.01, 0.19) and intending to adhere to the guideline recommendations (e.g. intention to refer for X-ray: Adj OR: 0.27; 95% CI 0.17, 0.44; intention to give advice to stay active: Adj OR: 2.37; 95% CI 1.51, 3.74).

Conclusions

Intervention group clinicians were more likely to give advice to stay active and to intend to adhere to the guideline recommendations about X-ray referral. The intervention did not change the primary study outcomes, with no important differences in X-ray referral and patient disability between groups, implying that hypothesised reductions in health service utilisation and/or productivity gains are unlikely to offset the direct costs of the intervention. We report these results with the caveat that we enrolled less patients into the trial than our determined sample size. We cannot recommend this intervention as a cost-effective use of resources.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12609001022257. Retrospectively registered on 25 November 2009

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06053-x.

American Physical Therapy Association Clinical Practice Guideline Implementation for Neck and Low Back Pain in Outpatient Physical Therapy: A Nonrandomized, Cross-sectional Stepped-Wedge Pilot Study

OBJECTIVE

To determine whether a multifaceted implementation strategy for American Physical Therapy Association neck and low back pain clinical practice guidelines (CPGs) was associated with changes in clinician and patient outcomes.

DESIGN

Cross-sectional stepped-wedge pilot study.

METHODS

Physical therapy clinics (n = 9) were allocated to 1 of 4 clusters that varied by CPG implementation timing. Clinics crossed over from usual care (control) to CPG implementation (intervention) every 8 weeks and ended with a 24-week follow-up period. Implementation outcomes were measured at the clinician (perspectives and behaviors) and patient (pain and disability outcomes) levels. Descriptive statistics were used to summarize clinician perspectives and behaviors. Generalized linear mixed models were used to analyze patient-level outcomes data (pain and disability) and total number of physical therapy visits.

RESULTS

Improvements in several clinician perspectives about CPGs were observed 8 weeks after training and sustained at 16 weeks (P<.05), although it is unclear whether these changes were meaningful. Training on CPGs was relevant to physical therapists and more acceptable at 16 weeks (P<.05). In a random sample (n = 764/1994, 38.3%), the overall rate of CPG classification was 65.0% (n = 497/764), and CPG intervention concordance was 71.2% (n = 354/497). Implementation of a CPG was not associated with final pain and disability scores (P>.05) but was associated with an approximate increase of 8% in total visits.

CONCLUSION

Our multifaceted implementation strategy was associated with statistical changes in clinician perspectives and behaviors, but not in patient outcomes. J Orthop Sports Phys Ther 2022;52(2):113-123. doi:10.2519/jospt.2022.10545.

The relationship between psychosocial factors and reported disability: the role of pain self-efficacy

BACKGROUND

Chronic pain and the accompanying level of disability is a healthcare crisis that reaches epidemic proportions and is now considered a world level crisis. Chronic non-specific low back pain (CNLBP) contributes a significant proportion to the chronic pain population. CNLBP occurs with overlapping psychosocial factors. This study was design to investigate specific psychosocial factors and their influence on reported disability in a population with CNLBP.

METHODS

The specific psychosocial factors examined included fear, catastrophizing, depression, and pain self-efficacy. This cross-sectional correlational study investigated the mediating role between pain self-efficacy, the specific psychosocial factors, and reported disability. The study recruited 61 female and 29 male participants from physical therapy clinics. The participants were between 20-to-60 years of age and diagnosed with CNLBP. All participants completed the Fear Avoidance Belief Questionnaire, The Pain Catastrophizing Scale, The Patient Health Questionnaire-9, The Pain Self-Efficacy Questionnaire, and The Lumbar Oswestry Disability Index. The battery of questionnaires measured fear of physical activity, pain catastrophizing, depression, pain self-efficacy, and reported disability. Multivariate regression and mediation analyses was used to analyse the data.

RESULTS

The principal finding was a strong inverse relationship between pain self-efficacy and reported disability with a p-value < 0.001. Further, pain self-efficacy was considered a statistical mediator with consistent p-value < 0.001 for the specific psychosocial factors investigated within this data set. Pain self-efficacy was considered to have a mediating role between reported fear of physical activity and disability, reported pain catastrophizing and disability, and reported depression and disability. Additionally, age and reported pain levels proved to be statistically significant. Adjustments for age and pain level did not alter the role of pain self-efficacy.

CONCLUSION

The results identified a mediating role for pain self-efficacy between the specific psychosocial factors (fear, catastrophizing, and depression) and reported disability. Pain self-efficacy plays a more significant role in the relationships between these specific psychosocial factors and reported disability with CNLBP than previously considered.

Involving practice nurse and other assistant clinical staff members in the management of low back pain: A qualitative interview study from Danish general practice

Objectives

Involving practice nurse and other assistant clinical staff members in providing information and education to patients with low back pain at follow-up appointments may release more time and improve care in general practice. However, this requires a shift in the division of tasks, and general practitioners' barriers and facilitators for this are currently unknown. The objectives were to explore general practitioners' experiences and perceptions of including assistant clinical staff members in the management of low back pain.

Methods

This is a semi-structured interview study in Danish general practice. General practitioners with a variation in demographics and experience with task-delegation to clinical staff were recruited for in-depth interviews. We used a phenomenological approach to guide the data collection and the analysis in order to gain insight into the subjective experiences of the general practitioners and to understand the phenomenon of 'delegating tasks to practice staff' from the perspective of the general practitioners' lifeworld. Analysis was conducted using an inductive descriptive method. The sample size was guided by information power.

Results

We conducted five interviews with general practitioners. All general practitioners had experience with task delegation, but there was a variation in which tasks the general practitioners delegated and to which types of clinical staff members. The following themes were derived from the analysis: general practice organisation, delegating to clinical staff members, doctor-patient relationship, exercise instruction, clinical pathway for patients and external support.

Conclusion

General practitioners consider patients with low back pain to be a heterogeneous group with a variety of treatment needs and a patient group without any predetermined content or frequency of consultations; this can be a barrier for delegating these patients to clinical staff members.

Training of Physical Therapists to Deliver Individualized Biopsychosocial Interventions to Treat Musculoskeletal Pain Conditions: A Scoping Review

OBJECTIVE

Current guidelines recommend management of musculoskeletal pain conditions from a biopsychosocial approach; however, biopsychosocial interventions delivered by physical therapists vary considerably in effectiveness. It is unknown whether the differences are explained by the intervention itself, the training and/or competency of physical therapists delivering the intervention, or fidelity of the intervention. The aim was to investigate and map the training, competency assessments, and fidelity checking of individualized biopsychosocial interventions delivered by physical therapists to treat musculoskeletal pain conditions.

METHODS

A scoping review methodology was employed, using Arksey and O'Malley's framework. Seven electronic databases were searched between January and March 2019, with a bridge search completed in January 2020. Full-text peer-reviewed articles, with an individualized biopsychosocial intervention were considered, and 35 studies were included.

RESULTS

Reporting overall was sparse and highly variable. There was a broad spectrum of training. More sophisticated training involved workshops combining didactic and experiential learning over longer durations with supervision and feedback. Less sophisticated training was brief, involving lectures or seminars, with no supervision or feedback. Competency assessments and fidelity testing were underperformed.

CONCLUSIONS

Training in some interventions might not have facilitated the implementation of skills or techniques to enable the paradigm shift and behavior change required for physical therapists to effectively deliver a biopsychosocial intervention. Lack of competency assessments and fidelity checking could have impacted the methodological quality of biopsychosocial interventions.

IMPACT

This study highlighted problematic reporting, training, assessment of competency, and fidelity checking of physical therapist-delivered individualized biopsychosocial interventions. Findings here highlight why previous interventions could have shown small effect sizes and point to areas for improvement in future interventions. These findings can help inform future research and facilitate more widespread implementation of physical therapist-delivered biopsychosocial interventions for people with musculoskeletal pain and thereby improve their quality of life.

Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical Practice Guideline

Lumbar spinal stenosis (LSS) causing neurogenic claudication (NC) is increasingly common with an aging population and can be associated with significant symptoms and functional limitations. We developed this guideline to present the evidence and provide clinical recommendations on nonsurgical management of patients with LSS causing NC. Using the GRADE approach, a multidisciplinary guidelines panel based recommendations on evidence from a systematic review of randomized controlled trials and systematic reviews published through June 2019, or expert consensus. The literature monitored up to October 2020. Clinical outcomes evaluated included pain, disability, quality of life, and walking capacity. The target audience for this guideline includes all clinicians, and the target patient population includes adults with LSS (congenital and/or acquired, lateral recess or central canal, with or without low back pain, with or without spondylolisthesis) causing NC. The guidelines panel developed 6 recommendations based on randomized controlled trials and 5 others based on professional consensus, summarized in 3 overarching recommendations: (Grade: statements are all conditional/weak recommendations) Recommendation 1. For patients with LSS causing NC, clinicians and patients may initially select multimodal care nonpharmacological therapies with education, advice and lifestyle changes, behavioral change techniques in conjunction with home exercise, manual therapy, and/or rehabilitation (moderate-quality evidence), traditional acupuncture on a trial basis (very low-quality evidence), and postoperative rehabilitation (supervised program of exercises and/or educational materials encouraging activity) with cognitive-behavioral therapy 12 weeks postsurgery (low-quality evidence). Recommendation 2. In patients LSS causing NC, clinicians and patients may consider a trial of serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants. (very low-quality evidence). Recommendation 3. For patients LSS causing NC, we recommend against the use of the following pharmacological therapies: nonsteroidal anti-inflammatory drugs, methylcobalamin, calcitonin, paracetamol, opioids, muscle relaxants, pregabalin (consensus-based), gabapentin (very low-quality), and epidural steroidal injections (high-quality evidence). PERSPECTIVE: This guideline, on the basis of a systematic review of the evidence on the nonsurgical management of lumbar spine stenosis, provides recommendations developed by a multidisciplinary expert panel. Safe and effective non-surgical management of lumbar spine stenosis should be on the basis of a plan of care tailored to the individual and the type of treatment involved, and multimodal care is recommended in most situations.

Implementation of evidence-based, non-pharmacological interventions addressing behavior and psychological symptoms of dementia: a systematic review focused on implementation strategies

OBJECTIVE

This study aimed to identify the nature and effects of implementation strategies to increase the use of evidence-based, non-pharmacological interventions designed to reduce the frequency and/or severity of behavioral and psychological symptoms associated with dementia, for people living in the community.

DESIGN

This was a systematic review of implementation studies. We searched six databases (in January 2019) and hand-searched reference lists of reports. Studies were included if they used quantitative methods evaluating the use of implementation strategies to increase the use of non-pharmacological interventions. These interventions had to have been tested in a randomized controlled trial (RCT) and found to reduce behavioral and psychological symptoms of dementia, for those living in the community. Studies needed to report the effect of the implementation on clinical practice, for example, a change in practice or the adoption of the intervention in community settings.

RESULTS

Twelve studies were included: 11 one-group pre-post design studies and 1 cluster RCT. All studies reported practice change - the majority implementing a new intervention, with six different types of interventions implemented. All studies reported including using partnerships, new funding, educational strategies, and ongoing support and consultation. Seven implementation studies reported positive outcomes for clients on some aspect of behavior or depression for the person with dementia.

CONCLUSIONS

Implementation studies using multiple implementation strategies to increase the use of non-pharmacological interventions have demonstrated improvements in behavioral and psychological symptoms common in people with dementia, when provided by clinicians as part of their everyday work routines.

What behaviour change techniques have been used to improve adherence to evidence-based low back pain imaging?

Background

Despite international guideline recommendations, low back pain (LBP) imaging rates have been increasing over the last 20 years. Previous systematic reviews report limited effectiveness of implementation interventions aimed at reducing unnecessary LBP imaging. No previous reviews have analysed these implementation interventions to ascertain what behaviour change techniques (BCTs) have been used in this field. Understanding what techniques have been implemented in this field is an essential first step before exploring intervention effectiveness.

Methods

We searched EMBASE, Ovid (Medline), CINAHL and Cochrane CENTRAL from inception to February 1, 2021, as well as and hand-searched 6 relevant systematic reviews and conducted citation tracking of included studies. Two authors independently screened titles, abstracts, and full texts for eligibility and extracted data on study and intervention characteristics. Study interventions were qualitatively analysed by three coders to identify BCTs, which were mapped to mechanisms of action from the theoretical domains framework (TDF) using the Theory and Techniques Tool.

Results

We identified 36 eligible studies from 1984 citations in our electronic search and a further 2 studies from hand-searching resulting in 38 studies that targeted physician behaviour to reduce unnecessary LBP imaging. The studies were conducted in 6 countries in primary (n = 31) or emergency care (n = 7) settings. Thirty-four studies were included in our BCT synthesis which found the most frequently used BCTs were ‘4.1 instruction on how to perform the behaviour’ (e.g. Active/passive guideline dissemination and/or educational seminars/workshops), followed by ‘9.1 credible source’, ‘2.2 feedback on behaviour’ (e.g. electronic feedback reports on physicians’ image ordering) and 7.1 prompts and cues (electronic decision support or hard-copy posters/booklets for the office). This review highlighted that the majority of studies used education and/or feedback on behaviour to target the domains of knowledge and in some cases also skills and beliefs about capabilities to bring about a change in LBP imaging behaviour. Additionally, we found there to be a growing use of electronic or hard copy reminders to target the domains of memory and environmental context and resources.

Conclusions

This is the first study to identify what BCTs have been used to target a reduction in physician image ordering behaviour. The majority of included studies lacked the use of theory to inform their intervention design and failed to target known physician-reported barriers to following LBP imaging guidelines.

Protocol Registation

PROSPERO CRD42017072518

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01136-w.

Sustainment of a patient flow intervention in an intensive care unit in a regional hospital in Australia: a mixed-method, 5-year follow-up study

OBJECTIVE

In 2014, an escalation plan and morning handover meetings were implemented in an intensive care unit (ICU) to reduce access block for post-operative care. In this study, the improvement intervention is revisited 5 years on with the objective to see if the changes are sustained and to understand factors contributing to sustainability.

DESIGN

A mixed-method approach was used, with quantitative analysis of ICU administrative data and qualitative analysis of interviews with hospital management and ICU staff.

SETTING

ICU with mixed surgical and non-surgical cases in a regional hospital in Australia.

PARTICIPANTS

Interview participants: ICU nurses (four), ICU doctors (four) and hospital management (four).

MAIN OUTCOME MEASURES

Monthly number of elective surgeries were cancelled due to unavailability of ICU beds. Staff perceptions of the interventions and factors contributed to sustainability.

RESULTS

After a decline in elective surgeries being cancelled in the first year after the intervention, there was an increase in cancellations in the following years (χ²=16.38, p=0.003). Lack of knowledge about the intervention and competitive interests in the management of patient flow were believed to be obstacles for sustained effects of the original intervention. So were communication deficiencies that were reported within the ICU and between ICU and other departments. There are discrepancies between how nurses and doctors use the escalation plan and regard the availability of ICU beds.

CONCLUSION

Improvement interventions in healthcare that appear initially to be successful are not necessarily sustained over time, as was the case in this study. In healthcare, there is no such thing as a 'fix and forget' solution for interventions. Management commitment to support communication within and between microsystems, and to support healthcare staff understanding of the underlying reasons for intervention, are important implications for change and change management across healthcare systems.

Physical therapy for patients with low back pain in Germany: a survey of current practice

Background

Low back pain (LBP) is one of the most common musculoskeletal disorders worldwide. The National Disease Management Guideline (NVL) “Non-specific LBP” is a practical decision-making aid for both physicians and non-medical professionals in Germany to improve quality of health care. Although LBP is the most frequent diagnosis resulting in physical therapy treatment, information on the current management of patients with LBP and guideline adherence is limited. The objective of this study was to evaluate the current physical therapy management of patients with LBP in Germany, and to explore guideline adherence to the NVL “Non-specific LBP” recommendations.

Methods

An online survey among physical therapists working in Germany was conducted based on the recommendations given in the NVL “Non-specific LBP”. Participants were recruited using a snowball sampling approach and invited to complete the questionnaire. Guideline adherence was evaluated by comparing the survey findings with the recommendations of the NVL.

Results

In total, 1361 physical therapists (41 years of age (SD 11); 839 female, 514 male; 16 years of clinical experience (SD 10)) completed the survey.

Fifty percent (n = 675) of our respondents adhered to the recommendations of the NVL on the therapeutic diagnostic process, and 72% (n = 973) to the recommendations concerning treatment. The guideline adherence across the entire management process (i.e., both diagnosis and treatment) of LBP was 38% (n = 513). German physical therapists predominantly provide active interventions, e.g., exercise therapy, but also use interventions with low or conflicting evidence, respectively. Massage and Kinesio Taping were frequently used despite being not recommended. Less than one third of study participants (n = 400, 29%) answered to know the NVL or had dealt with its recommendations.

Conclusions

In the management of LBP, overall guideline adherence among German physical therapists was 38% with higher adherence in the treatment section than in the physical therapeutic diagnostic process. Widespread employment of implementation strategies and removal of existing barriers against the application of evidence-based guidelines could facilitate the transfer of scientific evidence into clinical practice and contribute to optimize the quality of health care.

Trial registration

German Clinical Trials Register (DRKS00012607). Registered 04 October 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04422-2.

The Effectiveness of Matrix Rhythm Therapy in Patients with Chronic Low Back Pain

STUDY DESIGN

Randomized clinical study.

OBJECTIVE

Our study was planned to determine the effect of matrix rhythm therapy (MRT) on pain, level of disability, and quality of life in chronic low back pain.

SUMMARY OF BACKGROUND DATA

Low back pain is a complex and heterogeneous disorder. Different therapy options can be applied in the treatment of low back pain. In the literature, there are very few studies showing the effect of MRT in patients with chronic low back pain.

METHODS

A total of 32 participants with a mean age of 36.41 ± 8.91 years were randomly divided into two groups (intervention group and control group). Each participant was treated with ten sessions a combined physiotherapy program (hot pack, transcutaneous electrical nerve stimulation, therapeutic ultrasound, home exercise and patient education program). Additionally, intervention group received six sessions of MRT. Pain (McGill Pain Questionnaire), level of disability (Oswestry Disability Index) and quality of life (Short Form-36) were measured before and after the treatment programme.

RESULTS

When pre- and post-treatment results were compared in the intervention group, a statistically significant difference was found in total pain level, disability level, and all subdimensions except the "Emotional Role" subdimension of Short Form-36 (SF-36) and total SF-36 scores (P ≤ 0.05). In the control group, statistically significant differences were found in disability level, the "Vitality" and "Bodily Pain" subdimensions of SF-36 and total SF-36 scores (P ≤ 0.05). When the delta values were compared between groups, there was a statistically significant difference only in the "general health perceptions" subdimension of SF-36 (P ≤ 0.05) in favor of the intervention group.

CONCLUSION

It was determined that both the combined physiotherapy program and the MRT application in addition to the combined physiotherapy program have a positive effect on pain, disability level, and quality of life in patients with chronic low back pain.Level of Evidence: 2.

Mind the gap - Evaluation of the promotion initiatives for implementation of the GLA:D® back clinician courses

BACKGROUND

Translation of research into practice is a methodological challenge. The GLA:D® Back program was initiated to implement evidence-based care for people with low back pain inspired by GLA:D® (Good Life with osteoArthritis in Denmark) that has succeeded in implementing evidence-based care for knee and hip osteoarthritis. This study evaluates the spread and reach of promotion initiatives for GLA:D® Back clinician courses, and the adoption of the GLA:D® Back intervention in clinical practice.

METHODS

Pre-defined success criteria addressed; i) spread; achievement of intended promotion activities (e.g. social media), ii) reach; recruitment of clinicians with certain profiles (e.g. gender balance). Adoption was defined as patient enrollment in the GLA:D® Back registry by course participants. Univariate and multivariate logistic regression was used to investigate associations between adoption and clinician characteristics.

RESULTS

Most clinicians signed up based on information from colleagues (22%). Pre-defined goals for reach, except one, was obtained. 23% (140) of clinicians initiated the GLA:D® Back program in clinical practice within <90 days of course participation; mainly physiotherapists (p < 0.001). The odds ratio for starting GLA:D® Back patient care in a chiropractic setting was 7.4 [2.5; 21.4], indicating that physiotherapists employed by chiropractors mostly handled the intervention.

CONCLUSION

Future promotion strategies should recognize the influence of colleagues and professional networks. Converting clinician courses into patient care was mostly adopted physiotherapists. Although, evaluation processes were less useful in this study, future evaluation of health care processes has potential to inform the implementation of new models in future studies.

Clinical guidelines and care pathway for management of low back pain with or without radicular pain

OBJECTIVE

To develop guidelines for low back pain management according to previous international guidelines and the updated literature.

METHODS

A report was compiled from a review of systematic reviews of guidelines published between 2013 and 2018 and meta-analysis of the management of low back pain published between 2015 and 2018. This report summarized the state-of-the-art scientific knowledge for each predefined area of the guidelines from a critical review of selected literature. A multidisciplinary panel of experts including 17 health professionals involved in low back pain management and 2 patient representatives formulated preliminary guidelines based on the compilation report and a care pathway. The compilation report and preliminary guidelines were submitted to 25 academic institutions and stakeholders for the consultation phase. From responses of academic institutions and stakeholders, the final guidelines were developed. For each area of the guidelines, agreement between experts was assessed by the RAND/UCLA method.

RESULTS

The expert panel drafted 32 preliminary recommendations including a care pathway, which was amended after academic institution and stakeholder consultation. The consensus of the multidisciplinary expert panel was assessed for each final guideline: 32 recommendations were assessed as appropriate; none was assessed as uncertain or inappropriate. Strong approval was obtained for 27 recommendations and weak for 5.

CONCLUSION

These new guidelines introduce several concepts, including the need to early identify low back pain at risk of chronicity to provide quicker intensive and multidisciplinary management if necessary.

Factors influencing implementation of the GLA: D Back, an educational/exercise intervention for low back pain: a mixed-methods study

Introduction and aims:

Guidelines for low back pain (LBP) management recommend patient education and exercises. GLA:D Back, a structured group-based patient-education exercise program for LBP, facilitates evidence-based care implementation. This study aimed to inform on the implementation processes, assessing clinician-related factors. Objectives were to describe profiles of implementers and nonimplementers by demographics, and responses to the tailored version of the Determinants of Implementation Behaviour Questionnaire (DIBQ-t) qualitatively explore clinician perspectives on implementation, and compare the results of the DIBQ-t with the interview data to evaluate their fit of integration for facilitators, barriers, and new insights.

Methods:

A mixed-methods parallel design study was conducted. Physiotherapists and chiropractors, educated in the GLA:D Back program, were asked to complete the DIBQ-t (measuring theoretical determinants of implementation) 6 months after their training. Implementers and nonimplementers of the program were selected for interviews. Qualitative data were used to understand clinicians’ viewpoints on implementation, providing a broader perspective on the quantitative data and exploring new aspects.

Results:

More physiotherapists than chiropractors implemented the program. Implementers responded more positively on most domains of the DIBQ-t. The interviews revealed three themes important for implementation: personal gain, practicalities, and buying-in on the program. Clinicians’ attitudes to the program appeared additionally as relevant to implementation.

Conclusion:

The profession of the clinician was associated with implementation behavior. Implementers and nonimplementers identified the same themes but perceived them as either positive or negative. Both groups reported high levels of knowledge and skills, indicating that training alone is insufficient for implementation.

What is known about factors improving physiotherapists' adherence to high value interventions in nonspecific low back pain? A scoping review protocol

INTRODUCTION

Despite multiple guidelines providing best practice treatment recommendations for managing low back pain (LBP), current evidence suggests that physiotherapists across the world often provide costly, ineffective, unnecessary, even harmful care. The purpose of this scoping review is to establish the body of evidence regarding factors that improve or hinder physiotherapist's adherence to high-value interventions in the management of non-specific LBP.

METHODS

This scoping review will be conducted based on the methodological framework for scoping review recommended by Arksey & O'Malley's and Levac. Three electronic databases will be searched: MEDLINE, CINAHL and SPORTDiscus. A search of grey literature will also be performed. The search will cover studies published in English from the inception of each database to the present date. The reference lists of all included reports and articles will be hand-searched for additional results. Two independent reviewers will screen titles and abstracts for assessment against the eligibility criteria. Data will be extracted and presented in tabular form and a narrative summary that aligns with the review's aim.

ETHICS AND DISSEMINATION

This scoping review does not require ethics approval. Results of this scoping review will be disseminated via conference presentation and/or publication in a scientific journal. We will also disseminate the results as part of stakeholder meetings with physiotherapists including clinicians, academicians, researchers and administrators managing non-specific LBP. A summary of the key results will be shared across social networking sites in the form of infographics.

Impact on radiological practice of active guideline implementation of musculoskeletal guideline, as measured over a 12-month period

Background

An ever-increasing technological development in the field of radiology urges a need for guidelines to provide predictable and just health services. A musculoskeletal guideline was developed in Norway in 2014, without active implementation.

Purpose

To investigate the impact of active guideline implementation on the use of musculoskeletal diagnostic imaging most frequently encountered in general practice (pain in the neck, shoulders, lower back, and knees).

Material and Methods

The total number of outpatient radiological examinations across modalities registered at the Norwegian Health Economics Administration between January 2013 and February 2019 was assessed using an interrupted time series design.

Results

A 12% reduction in the total examination of Magnetic Resonance Imaging shoulder and knee, and x-ray lower back and shoulder was found at a significant level (p = 0.05). Stratified analysis (Magnetic Resonance Imaging examination as one group and x-ray examinations as the other) showed that this reduction mainly was due to the reduction in the use of Magnetic Resonance Imaging examinations (shoulder and knee) which was reduced by 24% at a significant level (p = 0.002), while x-ray examinations had no significant level change (p = 0.71). No other statistically significant changes were found.

Conclusion

The impact of the implementation on the use of imaging of the neck, shoulder, lower back, and knee is uncertain. Significant reductions were demonstrated in the use of some examinations in the intervention county, but similar effects were not seen when including a control group in the analysis. This indicates a diffusion of the implementation, or other interventions or events that affected both counties and occurred in the intervention period.

Effectiveness and Quality of Implementing a Best Practice Model of Care for Low Back Pain (BetterBack) Compared with Routine Care in Physiotherapy: A Hybrid Type 2 Trial

Low back pain (LBP) occurs in all ages and first-line treatment by physiotherapists is common. The main aim of the current study was to evaluate the effectiveness of implementing a best practice model of care for LBP (intervention group—BetterBack☺ MoC) compared to routine physiotherapy care (control group) regarding longitudinal patient reported outcomes. The BetterBack☺ MoC contains clinical guideline recommendations and support tools to facilitate clinician adherence to guidelines. A secondary exploratory aim was to compare patient outcomes based on the fidelity of fulfilling a clinical practice quality index regarding physiotherapist care. A stepped cluster randomized design nested patients with LBP in the three clusters which were allocated to control (n = 203) or intervention (n = 264). Patient reported measures were collected at baseline, 3, 6 and 12 months and analyzed with mixed model regression. The primary outcome was between-group changes from baseline to 3 months for pain intensity and disability. Implementation of the BetterBack☺ MoC did not show any between-group differences in the primary outcomes compared with routine care. However, the intervention group showed significantly higher satisfaction at 3 months and clinically meaningful greater improvement in LBP illness perception at 3 months and quality of life at 3 and 6 months but not in patient enablement and global impression of change compared with the control group. Physiotherapists’ care that adhered to all clinical practice quality indices resulted in an improvement of most patient reported outcomes with a clinically meaningful greater improved LBP illness perception at 3 months and quality of life at 3 and 6 months, significantly greater improvement in LBP illness perception, pain and satisfaction at 3 and 6 months and significantly better enablement at all time points as well as better global improvement outcomes at 3 months compared with non-adherent care. This highlights the importance of clinical guideline based primary care for improving patient reported LBP outcomes.

Rational Pharmacotherapy in Case of Exacerbation of the Primary Low Back Pain

Low back pain (LBP) is one of the most common causes of orthopedic disability in people under 45 years of age. Primary LBP accounts for more than 90 % of all cases. The main objectives of treatment are to slow the progression of the degenerative process, reduce the intensity of inflammation and pain, increase functional activity and quality of life of patients. The solution of the set tasks is impossible without effective complex influence on numerous links of pathogenesis of degenerative-dystrophic and inflammatory process and ensuring safety at treatment. The objective: to evaluate the clinical effectiveness of complex conservative treatment of primary LBP with the use of the drug Alsokam (meloxicam) in patients with uncomplicated forms of degenerative-dystrophic lesions of the spine in the period of exacerbation. Materials and methods. A non-randomized, prospective comparative clinical study in two parallel groups involved 30 patients with exacerbation of LBP on the background of uncomplicated forms of degenerative-dystrophic lesions of the spine (osteochondrosis, spondyloarthritis). The mean age of patients was 40±7,2 years. There were 12 (40 %) female patients and 18 (60 %) male patients. The main group consisted of 15 patients who were prescribed the drug Alsokam (meloxicam) at a dose of 15 mg 1 time per day intramuscularly for 7 days. The control group consisted of 15 patients who received diclofenac sodium at a traditional daily dose of 75 mg intramuscularly once daily for 7 days during the same treatment period. In both groups, tolperisone 150 mg 3 times a day and B vitamins were also used for 10 15 days. Outcome evaluation parameters included: Visual analog pain scale (VAS), Huskisson; assessment of the patient’s functional status on the Roland-Morris scale (RDQ-24); accounting for side effects and adverse events in the observation groups. Results. In both groups, a significant decrease in the intensity of the pain syndrome was observed in the assessment of pain by VAS, but no statistically significant difference was observed between the observation groups (p=0,312). The analysis of the results of the evaluation of RDQ-24 also showed an increase in functional capacity in both groups, but without a significant difference between the groups of clinical observation (p=0,302). Analysis of the number of undesirable side effects in the observation groups showed a significantly lower frequency in patients of the main group with a high statistical probability (p<0,01). Conclusions. The results of a clinical study showed the effectiveness of meloxicam (Alsokam) in the complex conservative treatment of patients with primary LBP in the period of exacerbation, which correlates with the effect of diclofenac sodium in the average daily dose. The nature and frequency of adverse reactions in the main and comparator groups showed that meloxicam in Alsocam has a significantly higher safety profile compared to diclofenac sodium, and its use in complex treatment regimens for patients with primary LBP syndrome reduces the risk of NSAIDs gastropathies.

How to Ensure Referral and Uptake for COPD Rehabilitation-Part 1: Disentangling Factors in the Cross-Sectorial Workflow of Patients with COPD to Understand why Most Patients are not Referred to Rehabilitation

Introduction:

Chronic obstructive lung disease (COPD) is one of the most serious and common chronic conditions. Patients having COPD can greatly benefit from rehabilitation initiatives. However, not all patients having COPD are referred to rehabilitation. Literature does not clearly explain why only some patients with COPD are referred to rehabilitation, and only very few successful solutions to address the complexity of cross-sectorial organisations are described. The overall objective of this research project is to ensure referral and uptake for COPD rehabilitation. We focus on detangling the processes in the cross-sectorial workflow of patients with COPD to understand why most patients are not referred to rehabilitation.

Methods:

Based on semi structured interviews and observations a FRAM analysis was conducted to map the referring routines from hospital to municipality.

Results:

We found that the hospital and the municipality have different understandings of what rehabilitation is, they use different words and hospital staff lack knowledge of offers at the municipality.

Conclusion:

The FRAM analysis was useful to detangle factors important to cross-sectorial collaboration and resulted in a series of focus areas that were disseminated at a workshop. The municipality and the hospital agreed to initiate activities to develop and coordinate the cross-sectorial relations.

Management of Low back pain in Saudi Arabia healthcare system. A Qualitative Study

Background

Patients with chronic low back pain can contribute to a global socioeconomic burden. Current international recommendations emphasize that low back pain management should occur at the primary-care level. However, there is a lack of essential services for low back pain management at the primary-care level in Saudi Arabia. We explored the current state of low back pain management in Saudi Arabia from the perspective of spine surgeons and physiotherapists.

Methods

A qualitative study with semi-structured interviews was conducted on spine surgeons and physiotherapists. A total of 17 healthcare workers, 8 spine surgeons (age range 28–49 years) and 9 physiotherapists (age range 30–49 years) participated in the study. Data were recorded and analyzed thematically.

Results

Three main themes were identified from the interview data that outlined current low back pain management in Saudi Arabia: clinical guideline availability and pathways of care, utilization of primary care services, and overutilization of secondary care resources.

Conclusions

This study suggests underutilization of primary care services and overutilization of secondary care services in Saudi Arabia. Therefore, the implementation of local clinical guidelines could improve patient care as well as reduce the cost of low back pain management.

Risk-stratified and stepped models of care for back pain and osteoarthritis: are we heading towards a common model?

Supplemental Digital Content is Available in the Text.

Substantial overlap between interventions and models of care for osteoarthritis and low back pain suggests potential for one common model, which may facilitate implementation.

The overall quality of care for musculoskeletal pain conditions is suboptimal, partly due to a considerable evidence-practice gap. In osteoarthritis and low back pain, structured models of care exist to help overcome that challenge. In osteoarthritis, focus is on stepped care models, where treatment decisions are guided by response to treatment, and increasingly comprehensive interventions are only offered to people with inadequate response to more simple care. In low back pain, the most widely known approach is based on risk stratification, where patients with higher predicted risk of poor outcome are offered more comprehensive care. For both conditions, the recommended interventions and models of care share many commonalities and there is no evidence that one model of care is more effective than the other. Limitations of existing models of care include a lack of integrated information on social factors, comorbid conditions, and previous treatment experience, and they do not support an interplay between health care, self-management, and community-based activities. Moving forwards, a common model across musculoskeletal conditions seems realistic, which points to an opportunity for reducing the complexity of implementation. We foresee this development will use big data sources and machine-learning methods to combine stepped and risk-stratified care and to integrate self-management support and patient-centred care to a greater extent in future models of care.

Effectiveness of Implementation Strategies to Improve Adherence of Physical Therapist Treatment Choices to Clinical Practice Guidelines for Musculoskeletal Conditions: Systematic Review

OBJECTIVE

The objective of this study was to evaluate the effectiveness of implementation strategies aimed at improving the adherence of physical therapists' treatment choices to clinical practice guidelines for a range of musculoskeletal conditions.

METHODS

For this review, searches were performed in several databases combining terms synonymous with "practice patterns" and "physical therapy" until August 2019. The review included randomized controlled trials that investigated any intervention to improve the adherence of physical therapists' treatment choices to clinical practice guidelines or research evidence. Treatment choices assessed by surveys, audits of clinical notes, and treatment recording forms were the primary measures of adherence. Self-reported guideline adherence was the secondary measure. Three reviewers independently assessed risk of bias. Because of heterogeneity across studies, only a narrative synthesis of the results was performed.

RESULTS

Nine studies were included. Four demonstrated a positive effect on at least 1 measure of treatment choices for low back pain and acute whiplash. One involved a comparison with no intervention, and 3 involved a comparison with another active intervention. The interventions that demonstrated a positive effect included dissemination of clinical practice guidelines, with additional elements including interactive educational meetings (3 studies), tailored interventions and monitoring of the performance of health care delivery (1 study), peer assessment (1 study), and local opinion leaders plus educational outreach visits (1 study).

CONCLUSIONS

Although this review revealed limited trials evaluating interventions to increase physical therapists' use of evidence-based treatments for musculoskeletal conditions compared with no intervention, it highlighted some interventions that may be effective.

IMPACT

Dissemination of clinical practice guidelines, interactive educational meetings, tailored interventions and monitoring the performance of health care delivery, peer assessment, and use of local opinion leaders plus educational outreach visits should be implemented to improve physical therapists' adherence to clinical practice guidelines for a range of musculoskeletal conditions.

Confidence, attitudes, beliefs and determinants of implementation behaviours among physiotherapists towards clinical management of low back pain before and after implementation of the BetterBack model of care

BACKGROUND

Implementing clinical guidelines is challenging. To facilitate uptake, we developed a model of care (BetterBack Model of Care) and an implementation strategy to support management of low back pain in primary care. The aim of this study was to evaluate physiotherapists´ confidence, attitudes and beliefs in managing patients with low back pain before and after a multifaceted implementation of the BetterBack Model of Care. A further aim was to evaluate determinants of implementation behaviours among physiotherapists.

METHODS

This clinical trial was an experimental before and after study within a hybrid type 2 effectiveness-implementation trial. The primary outcome was Practitioner Self-Confidence Scale (PCS), secondary outcomes were the Pain Attitude and Beliefs Scale for Physiotherapists (PABS-PT) and Determinants of Implementation Behaviour Questionnaire (DIBQ). Data was analysed using repeated measures ANOVA and pairwise comparisons.

RESULTS

One hundred sixteen physiotherapists answered a questionnaire before, directly after, as well as 3 and 12 months after implementation of the Model of Care. PCS improved over time with a large effect size post implementation (ηp2 = 0.197, p < 0.001). Changes in PABS-PT were only significant after 12 months with higher biopsychosocial orientation, (ηp2 = 0.071, p < 0.01) and lower biomedical orientation, (ηp2 = 0.136, p < 0.001). Directly after the workshop, after 3 and 12 months, physiotherapists had high ratings on all DIBQ domains, (scores > 50) implying that all were potential facilitators of the implementation. However, after 3 months, all domains had significantly decreased except for organisation, social influence and patient expectation domains. However, after 12 months, organisation and social influence domains had significantly decreased while domains such as knowledge, skills and beliefs about capabilities returned to initial levels.

CONCLUSIONS

Physiotherapists´ confidence and biopsychosocial orientation increased after implementation and may have the potential to improve management of low back pain in primary care. The implementation behaviour showed mostly facilitating patterns but changed over time, pinpointing a need to repeatedly monitor these changes. This can inform the need for changes of implementation efforts in different phases and support sustainability strategies.

TRAIL REGISTRATION

ClinicalTrials.gov NCT03147300 3 May 2017, prospectivly registered.

An adventurous learning journey. Physiotherapists' conceptions of learning and integrating cognitive functional therapy into clinical practice

Background: Recent low back pain guidelines recommend a BPS approach to the management of disabling low back pain. However, the most effective way of teaching physiotherapists to implement these approaches remains unknown. The present qualitative study aimed to explore physiotherapists' conceptions of learning and integrating Cognitive Functional Therapy (CFT) into clinical practice in Finnish primary health care.Methods: We interviewed 22 physiotherapists, who participated in four to six days of CFT workshops. A phenomenographic approach was used to explore the variation in the physiotherapists' conceptions of this process.Results: Four themes emerged from the data: 1) membership of work community; 2) learning journey; 3) transition to new working methods; and 4) professional role as a physiotherapist. These themes varied in four categories of description: recognizing difference of the new approach, toward integrating the new approach, waking up to explore, commitment to new approach and expanding application of new approach. The critical aspects between the categories that enabled the integration of CFT into clinical practice were ability to overcome resistance and to change views, being shaken and ability to critically reflect on one's work, support from the work community and becoming convinced, creativity, multidisciplinary collaboration and continuous learning.Conclusion: The participants' responses to the training varied greatly, suggesting that for some, the training was insufficient to support adequate changes in their practice behavior; whereas for others, the training was a life changing experience.

A classification-based approach to low back pain in primary care - protocol for a benchmarking controlled trial

Background

Guidelines recommend a biopsychosocial framework for low back pain (LBP) management and the avoidance of inappropriate imaging. In clinical practice, care strategies are often inconsistent with evidence and guidelines, even though LBP is the most common disabling health condition worldwide. Unhelpful beliefs, attitudes and inappropriate imaging are common. LBP is understood to be a complex biopsychosocial phenomenon with many known multidimensional risk factors (symptom- and lifestyle-related, psychological and social) for persistent or prolonged disability, which should be identified and addressed by treatment. The STarT Back Tool (SBT) was developed for early identification of individual risk factors of LBP to enable targeted care. Stratified care according SBT has been shown to improve the effectiveness of care in a primary care setting. A biopsychosocially-oriented patient education booklet, which includes imaging guidelines and information, is one possible way to increase patients’ understanding of LBP and to reduce inappropriate imaging. Premeditated pathways, education of professionals, written material, and electronic patient registry support in health care organizations could help implement evidence-based care.

Methods

We will use a Benchmarking Controlled Trial (BCT) design in our study. We will prospectively collect data from three health care regions before and after the implementation of a classification-based approach to LBP in primary care. The primary outcome will be change in PROMIS (Patient-Reported Outcomes Measurement Information System) (short form 20a) over 12-month follow-up.

Discussion

The implementation of a classification-based biopsychosocial approach can potentially improve the care of LBP patients, reduce inappropriate imaging without increasing health-care costs, and decrease indirect costs by reducing work disability. Using the BCT we will be able to evaluate the effectiveness of the improvement strategy for the entire care pathway.

Trial registration

ISRCTN,ISRCTN13273552, retrospectively registered 13/05/2019.

A national intervention to reduce imaging for low back pain by general practitioners: a retrospective economic program evaluation using Medicare Benefits Schedule data

BACKGROUND

The overuse of diagnostic imaging for low back pain (LBP) in Australia results in unnecessary cost to the health system and, for patients, avoidable exposure to radiation. The 2013 NPS MedicineWise LBP program aimed to reduce unnecessary diagnostic imaging for non-specific acute LBP in the Australian primary care setting. The LBP program delivered referral pattern feedback, a decision support tool and patient information to 19,997 (60%) of registered Australian general practitioners (GPs). This study describes the findings from evaluation of the effectiveness of the 2013 LBP program at reducing X-ray and computed tomography (CT) scans of the lower back, and the financial costs and benefits of the program to the government funder.

METHODS

The effectiveness of the 2013 LBP program was evaluated using population-based time-series analysis of administrative claims data of Medicare Benefits Schedule (MBS) funded X-ray and CT scan services of the lower back. The CT scan referral trend of non-GP health professionals was used as an observational control group in a Bayesian structural time-series model. A retrospective cost-benefit analysis and cost-effectiveness analysis was conducted using program costs from organisational records and reimbursement data from the MBS.

RESULTS

The 2013 NPS MedicineWise LBP program was associated with a statistically significant 10.85% relative reduction in the volume of CT scans of the lumbosacral region, equating to a cost reduction to the MBS of AUD$11,600,898. The best available estimate of program costs was AUD$141,154. Every dollar of funding spent on the 2013 LBP program saved AUD$82 of funding to the MBS for CT scan reimbursements. Therefore, from the perspective of the Australian Government Department of Health, the 2013 LBP program was cost saving. The program cost AUD$2.82 per CT scan averted in comparison to the scenario of no program. No association between the 2013 NPS MedicineWise LBP program and the volume of X-ray items on the MBS was observed.

CONCLUSIONS

The 2013 NPS MedicineWise LBP program reduced CT scan referral by GPs, in line with the program's messages and clinical guidelines. Reducing this low-value care produced savings to the health system that exceeded the costs of program implementation.

The Fear Reduction Exercised Early (FREE) approach to management of low back pain in general practice: A pragmatic cluster-randomised controlled trial

BACKGROUND

Effective and cost-effective primary care treatments for low back pain (LBP) are required to reduce the burden of the world's most disabling condition. This study aimed to compare the clinical effectiveness and cost-effectiveness of the Fear Reduction Exercised Early (FREE) approach to LBP (intervention) with usual general practitioner (GP) care (control).

METHODS AND FINDINGS

This pragmatic, cluster-randomised controlled trial with process evaluation and parallel economic evaluation was conducted in the Hutt Valley, New Zealand. Eight general practices were randomly assigned (stratified by practice size) with a 1:1 ratio to intervention (4 practices; 34 GPs) or control group (4 practices; 29 GPs). Adults presenting to these GPs with LBP as their primary complaint were recruited. GPs in the intervention practices were trained in the FREE approach, and patients presenting to these practices received care based on the FREE approach. The FREE approach restructures LBP consultations to prioritise early identification and management of barriers to recovery. GPs in control practices did not receive specific training for this study, and patients presenting to these practices received usual care. Between 23 September 2016 and 31 July 2017, 140 eligible patients presented to intervention practices (126 enrolled) and 110 eligible patients presented to control practices (100 enrolled). Patient mean age was 46.1 years (SD 14.4), and 46% were female. The duration of LBP was less than 6 weeks in 88% of patients. Primary outcome was change from baseline in patient participant Roland Morris Disability Questionnaire (RMDQ) score at 6 months. Secondary patient outcomes included pain, satisfaction, and psychosocial indices. GP outcomes included attitudes, knowledge, confidence, and GP LBP management behaviour. There was active and passive surveillance of potential harms. Patients and outcome assessors were blind to group assignment. Analysis followed intention-to-treat principles. A total of 122 (97%) patients from 32 GPs in the intervention group and 99 (99%) patients from 25 GPs in the control group were included in the primary outcome analysis. At 6 months, the groups did not significantly differ on the primary outcome (adjusted mean RMDQ score difference 0.57, 95% CI -0.64 to 1.78; p = 0.354) or secondary patient outcomes. The RMDQ difference met the predefined criterion to indicate noninferiority. One control group participant experienced an activity-related gluteal tear, with no other adverse events recorded. Intervention group GPs had improvements in attitudes, knowledge, and confidence compared with control group GPs. Intervention group GP LBP management behaviour became more guideline concordant than the control group. In cost-effectiveness, the intervention dominated control with lower costs and higher Quality-Adjusted Life Year (QALY) gains. Limitations of this study were that although adequately powered for primary outcome assessment, the study was not powered for evaluating some employment, healthcare use, and economic outcomes. It was also not possible for research nurses (responsible for patient recruitment) to be masked on group allocation for practices.

CONCLUSIONS

Findings from this study suggest that the FREE approach improves GP concordance with LBP guideline recommendations but does not improve patient recovery outcomes compared with usual care. The FREE approach may reduce unnecessary healthcare use and produce economic benefits. Work participation or health resource use should be considered for primary outcome assessment in future trials of undifferentiated LBP.

TRIAL REGISTRATION

ACTRN12616000888460.

Does a tailored guideline implementation strategy have an impact on clinical physiotherapy practice? A nonrandomized controlled study

RATIONALE, AIMS, AND OBJECTIVES

Clinical practice guidelines are a common strategy for implementing research findings into practice and facilitating evidence-based practice in health care settings. There is a paucity of knowledge about the impact of different guideline implementation strategies on clinical practice in a physiotherapy context. The study aimed to assess the impact of a guideline implementation intervention on clinical physiotherapy practice.

METHODS

A tailored, multicomponent guideline implementation was compared with usual practice. Clinical practice was evaluated in physiotherapy treatment methods used for 3 common musculoskeletal disorders. Data were collected with a validated web-based questionnaire.

RESULTS

Postimplementation data were collected from 168 physiotherapists in the intervention group and 88 in the control group. The most frequently reported treatment methods for low back pain were advice on posture (reported by 95% in the intervention group vs 90% in the control group), advice to stay active (93% vs 90%), and stabilization exercise (88% vs 80%). Differences between groups were not significant. Reported use of body awareness training (23% vs 6%, P = .023) and spinal manipulation (9% vs 23%, P = .044) differed between the groups. The most frequently used treatment methods for neck pain were advice on posture (95% vs 92%), advice to stay active (89% vs 87%), and ROM exercise (85% vs 71%) (no significant differences between groups). Reported use of body awareness training (24% vs 7%, P = .023) differed between the groups. The most frequently used treatment methods for subacromial pain were range of motion exercises (reported by 93% in both groups), advice on posture (90% vs 87%), home exercise (77% vs 74%), and stabilization exercise (69% vs 66%) (no significant difference between groups).

CONCLUSIONS

Treatment methods used were largely in line with evidence already before the guideline implementation, which may explain why the guideline implementation had only little impact on clinical practice.

An innovative method for clinical practice guideline contextualisation for chronic musculoskeletal pain in the South African context

BACKGROUND

Clinical guidelines produced in developed nations may not be appropriate in resource-constrained environments, due to differences in cultural, societal, economic and policy contexts. The purpose of this article is to describe an innovative and resource-efficient method to develop a clinical practice guideline (CPG), using the CPG contextualisation approach.

METHODS

The four phased contextualisation framework was applied to produce a contextualised, multidisciplinary CPG for the primary health care of adults with chronic musculoskeletal pain (CMSP) in the South African context. The four phases were: a contextual analysis, evidence synthesis, contextual integration and external evaluation. Qualitative methodology was used to investigate context factors influencing health care in this environment. A systematic review was conducted to identify current, high-quality CPGs on the topic, and to synthesise a core set of clinical recommendations from the CPGs. Consensus methods were used to integrate context information with recommendations. A multidisciplinary panel of local experts authenticated and contextualised recommendations. The resultant CPG was externally reviewed using a survey.

RESULTS

The results from the contextual analysis phase indicated a wide range of contextual factors that could influence the applicability and implementability of the recommendations, including: the personal characteristics of the patient and clinician, social and environmental circumstances, healthcare interventions available, and healthcare system factors. During phase two, six existent high quality CPGs were identified and a core set of multidisciplinary recommendations were sourced from them. The contextual integration phase produced the validated recommendations, accompanied by its underpinning body of evidence and context specific information. The outcome of phase four (external review) was that the recommendations were confirmed as relevant for the intended setting.

CONCLUSION

CPG contextualisation was found to be a practical approach to develop a contextualised multidisciplinary CPG for the primary health care of adults with CMSP in a South African setting. The contextualisation approach enhanced the integration of multiple stakeholder perspectives and highlighted the importance of considering clinical, social and economic complexities during CPG development. Attention to contextual information is advocated to enhance the uptake of CPG recommendations, particularly in resource constrained settings.

TRIAL REGISTRATION

Health Research Ethics Committee of Stellenbosch University, South Africa (S14/01/018); the review protocol was registered on PROSPERO (registration number CRD42015022098 ).

Adaptation and Implementation of the STarT Back Risk Stratification Strategy in a US Health Care Organization: A Process Evaluation

OBJECTIVE

To support implementation of effective treatments for back pain that can be delivered to a range of people, we summarize learnings from our process evaluation of the MATCH trial's implementation of an adaptation of the STarT Back risk-stratified care model.

DESIGN

Our logic model-driven evaluation focused primarily on qualitative data sources.

SETTING

This study took place in a US-based health care delivery system that had adapted and implemented the STarT Back stratified care approach. This was the first formal test of the strategy in a US setting.

METHODS

Data collection included observation of implementation activities, staff/provider interviews, and post-training evaluation questionnaires. Data were analyzed using thematic analysis of qualitative data and descriptive statistics for questionnaire data.

RESULTS

We found that both primary care teams and physical therapists at intervention clinics gave the training high scores on evaluation questionnaires and reported in the interviews that they found the training engaging and useful. However, there was significant variation in the extent to which the risk stratification strategy was incorporated into care. Some primary care providers reported that the intervention changed their conversations with patients and increased their confidence in working with patients with back pain. Providers using the STarT Back tool did not change referral rates for recommended matched treatments.

CONCLUSIONS

These insights provide guidance for future efforts to adapt and implement the STarT Back strategy and other complex practice change interventions. They emphasize the need for primary care-based interventions to minimize complexity and the need for ongoing monitoring and feedback.

GLA:D® Back: group-based patient education integrated with exercises to support self-management of persistent back pain - feasibility of implementing standardised care by a course for clinicians

BACKGROUND

Clinical guidelines for management of low back pain (LBP) are not routinely implemented in practice, and guidelines rarely offer tools for implementation. Therefore, we developed GLA:D® Back, a standardised intervention of patient education and supervised exercises. This pilot study tested the feasibility of implementing GLA:D Back in clinical practice in Denmark by delivering a course for physiotherapists and chiropractors. It should further inform the planning of an implementation-effectiveness study using a pre-post group design alongside nation-wide implementation.

METHODS

Thirty-one clinicians from nine clinics participated. Feasibility of implementation was evaluated in terms of adoption and through focus group interviews and a feedback meeting. Patient-level data, including pain, disability, and pain enablement, were collected from (1) LBP patients visiting the clinics during a pre-specified 2-week period 2 months prior to clinicians attending the GLA:D Back course (n = 84), (2) LBP patients consulting during a 2-week period 2 months after the course (n = 77), and (3) those enrolled in GLA:D Back during 4 months after implementation (n = 89). Patient data were collected at baseline and at 4 months.

RESULTS

Clinicians' evaluations of the course were positive and resulted in several modifications. The clinical intervention was adopted by all test sites. Most patient characteristics were similar across groups. Patients mainly had persistent LBP (73% > 3 months) and most had been treated for more than 4 weeks at inclusion. Patients in GLA:D Back were more often retired (30% vs. 16% before implementation) and at high risk of poor prognosis (25% vs. 13%). Procedures for data collection were feasible, and outcomes after implementation, especially with GLA:D Back, were as good as or better than before implementation. Recruiting patients and achieving comparable pre- and post-groups was difficult.

CONCLUSIONS

Implementation of the GLA:D Back clinical intervention in Danish primary care physiotherapy and chiropractic clinics was feasible through a 2-day clinician course. Both clinicians and patients were satisfied with the programme, and patient-reported outcomes were slightly better than outcomes in patients registered before implementation. It was not deemed possible to conduct an implementation-effectiveness trial as part of a nation-wide implementation.

A conceptual framework for increasing clinical staff member involvement in general practice: a proposed strategy to improve the management of low back pain

BACKGROUND

Low back pain affects about 80% of all adults, many of whom consult general practice. Providing management can be challenging, in part due to the scarcity of effective treatment methods. There is broad consensus in international clinical practice guidelines to provide patients with information about the nature of their pain and recommend them to stay active despite discomfort. Delivering this information is time-demanding and challenged by the limited available resources in general practice in many countries. Furthermore, general practice settings are highly variable in size and in their composition of clinical staff members - which presents difficulties, but also opportunities for developing alternative approaches to clinical management. Expanding the patient consultation time by involving clinical staff members (aside from the general practitioner) has been found feasible for other conditions. We propose that this approach is applied for non-specific low back pain. Consequently, we suggest the involvement of clinical staff members as part of a new strategy for managing low back pain in general practice.

MAIN TEXT

Multifaceted implementation strategies have the potential to effectively enable change in the clinical management of patients with low back pain in general practice if they are based on theory and are tailored to stake holders. Inspired by the Medical Research Council's guidance for complex interventions and the ChiPP (Change in professional performance) statement, we suggest applying the following two policy categories: organizational change (environmental/social planning) and service provision. This will involve attention to environmental restructuring, modelling, enabling, education, training, persuasion, and incentivising of general practices, with an over-arching strategy of involving clinical staff members in the management of low back pain.

CONCLUSION

This is a pre-clinical proposal of a multifaceted strategy to support the delivery of evidence-based treatment for patients with low back pain in general practice. As an original idea, we suggest it would be feasible to involve clinical staff members in the delivery of information and advice to patients, whilst the general practitioner remains responsible for diagnostic decision-making.