Determinants of clinical practice guidelines' utilization for the management of musculoskeletal disorders: a scoping review

Patients' expectations of physiotherapists before and after an intensive chronic low back pain rehabilitation programme: a qualitative study based on semi-structured interviews and observations

PURPOSE

To investigate the expectations regarding physiotherapists of patients attending an interdisciplinary CLBP rehabilitation programme and the response to these expectations.

MATERIALS AND METHODS

A thematic analysis was conducted, based on interviews of working-age patients with CLBP and without significant comorbidities.

RESULTS

Twenty patients participated (9 male, 11 female, aged 21-58 years; symptoms duration 4.3 ± 3.0 years; pain VAS 53 ± 21 mm). Patients expected to learn pain and activity management. Expected outcomes were a reduction of pain, increased well-being and a return to normality. A collaborative approach involving therapeutic and relational adaptation was expected. Despite divergences concerning emotional aspects, patients expected a large range of applied psychosocial skills.The programme met the expectations of most patients, especially when its goals matched those reported by the individuals. For most participants, the pain relief was below expectations. Active therapies were valued. After the programme, patients felt more ready to take responsibility for their back.

CONCLUSION

The expectation of developing self-management skills was prevalent. Expected treatments were mostly compatible with recommendations. Expectations to resume activities and decrease pain were in line with the rehabilitation goals, although the expected reduction in pain was overestimated. Relational expectations converged towards patient-centred care.

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

Objective

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

Methods

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

Results

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

Conclusions

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

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

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47834.

Canadian Registered Dietitians' Utilization of the 2018 Diabetes Canada Nutrition Therapy Clinical Practice Guidelines: A Cross-sectional Study

OBJECTIVES

Our aim in this work was to ascertain Canadian registered dietitians' (RDs) use of the 2018 Diabetes Canada nutrition therapy (NT) recommendations and to identify the degree of agreement with facilitator-to-use statements.

METHODS

A national 28-item anonymous cross-sectional survey of RDs who counsel people with diabetes was conducted.

RESULTS

Three hundred sixty RDs responded to the survey, but some questions had fewer responses. Mean age of respondents was 36.8±10.1 years and 51.3% were certified diabetes educators (CDEs). Energy/macronutrient recommendations used most were regular timing/spacing of meals (85%), 30 to 50 g/day dietary fibre intake (71%), and maintaining a low glycemic index (65%). Mediterranean and Dietary Approaches to Stop Hypertension (DASH) dietary patterns had similar utilization rates as macronutrient distribution ranges, at 50% to 60%. Specific food recommendations were used most often, with the emphasis on fruits/vegetables and whole grains at 92% and 86%, respectively. Of the special considerations for people on insulin, regular meals/meal spacing was the recommendation used most often (88%). The statements "I trust the content …" and "I understand the scientific basis …" of the NT chapter were the internal facilitators most agreed with, at 86% each. The least agreed upon external facilitators were "my workplace encourages me to use the NT chapter," at 54%, and "I learned about the NT chapter in my formal education," at 44%. CDEs had significantly higher agreement on 12 of the 21 facilitator statements compared with non-CDEs.

CONCLUSIONS

Canadian RDs are utilizing the NT guidelines, including the new dietary patterns. Simple, easy-to-implement recommendations, such as specific foods and timing/spacing of meals, were used most frequently. Opportunities for increased use could include encouraging dietetic training programs and worksites to promote utilization of CPGs in practice.

Barriers, facilitators and implementation strategies for guideline-adherence in physiotherapy: a scoping review protocol

INTRODUCTION

Guideline-adherent physiotherapy can improve patient outcomes and reduce costs in the healthcare system. However, although there are numerous guidelines for physiotherapy practice, services are not consistently based on clinical practice guidelines. While various systematic and scoping reviews have highlighted barriers, facilitators and implementation strategies for guideline-adherent practice in other health professions, this scoping review aims to explore the barriers and facilitators for guideline-adherent physiotherapy and summarises the strategies used to implement such practice.

METHODS AND ANALYSIS

This scoping review will be based on Arksey and O'Malley's scoping review methodology and the methodological guidance for conducting scoping reviews published by Joanna Briggs Institute. Relevant publications will be first searched from the beginning of June 2023 on the MEDLINE and CINAHL databases before we expand the search to other databases such as EMBASE, the Cochrane Library and PEDro at the end of June 2023. Two reviewers will independently screen the titles and abstracts of all retrieved citations for inclusion against the eligibility criteria before conducting an independent full-text screening. The criteria will be tested on a sample of abstracts before beginning the abstract review to ensure that they are robust enough to capture any articles that may relate. The extracted data will finally be collated and charted to summarise key findings regarding our research question.

ETHICS AND DISSEMINATION

This scoping review will provide an extensive overview of the barriers, facilitators and implementation strategies for guideline-adherent physiotherapy. As scoping reviews are a form of secondary data analysis, ethical review is not required. Results will be disseminated through a peer-reviewed publication and stakeholder meetings.

TRIAL REGISTRATION NUMBER

This scoping review has been registered on 3 April 2023 on the Open Science Framework under https://doi.org/10.17605/OSF.IO/SEUW6.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Telerehabilitation Implementation: Perspectives from Physiotherapists Working in Complex Care

Purpose:

The COVID-19 pandemic resulted in a rapid change in ways clinicians deliver physiotherapy services, leading to an important uprise in telerehabilitation implementation. Sharing the experiences of physiotherapists in clinically adopting this technology during this initial wave of the pandemic can influence future implementation. This mixed-method study aimed to identify the barriers and new facilitators of telerehabilitation clinical implementation.

Methods:

Canadian physiotherapists with and without telerehabilitation experience, working in various clinical settings, were recruited during the first wave of the COVID-19 pandemic. Participants completed the Assessing Determinants of Prospective Uptake of Virtual Reality instrument (ADOPT-VR) adapted for telerehabilitation and participated in online focus groups to explore their experiences with telerehabilitation implementation. Demographic data and ADOPT-VR responses were analyzed descriptively. Qualitative data were analyzed using content analysis.

Results:

Sixteen physiotherapists completed the study. Scores on the Likert scale showed that physiotherapists enjoyed telerehabilitation (7.5/10) and perceived it as being useful (7.3/10). Physiotherapists disagreed with the necessity to use only minimal mental efforts (4.4/10) and feeling familiar with the evidence (4.7/10). Limited access to telerehabilitation implementation evidence, a reduced hands-on approach, and a lack of validated remote assessments were reported as barriers.

Discussion:

Clinical practice guidelines, validated remote neurological assessments, changes in physiotherapy curriculum and policymaking are critical to improving telerehabilitation implementation within physiotherapy practices.

Conclusion:

Participants positively experienced the quick use of telerehabilitation from the beginning of the COVID-19 pandemic, but some important barriers remain.

Do chiropractic interns use clinical practice guidelines when managing patients with neck pain in France? A feasibility study

BACKGROUND

In France, we lack knowledge about factors influencing chiropractors' use of French guideline for managing neck pain and associated disorders (NAD). In particular, we know little about how chiropractic interns use clinical practice guidelines during their training.

OBJECTIVES

We aimed to determine the feasibility of conducting a cross-sectional study of chiropractic interns to determine their utilization and conformity with clinical practice guidelines when managing patients with NAD in France.

METHOD

We developed a web-based questionnaire which included 3 sections: (1) clinical vignettes; (2) determinants of practice and (3) socio-demographic and current practice information. The study was conducted in two phases. The first phase included 2 groups: chiropractors and students (interns). Ten chiropractors reviewed and made recommendations on content (especially clinical vignettes), readability, and flow of the survey. Fifteen interns were invited to pretest the proposed recruitment strategy and determine time needed to survey completion, assess completeness of data collection, and evaluate its readability and flow in students. Due to the low participation of students during the first phase, 20 additional interns were invited to participate and pilot the revised recruitment strategy during the second phase. A group of 20 interns were invited to participate and pilot the revised recruitment strategy during the second phase. Qualitative feedbacks about the recruitment strategy, the content of the questionnaire and the survey process were collected by phone to improve all these steps if necessary.

RESULTS

We collected data from November 2020 to February 2021. In phase 1, 70% of chiropractors (7/10) reviewed the survey and one intern responded (7% participation rate). A revised recruitment strategy was designed and 70% of interns agreed to participate in phase 2. Time to complete the questionnaire was on average 48 m:22 s. Interns evaluated survey content as relevant, comprehensive, covering the range of 4 grades of NAD, and adapted to an intern sample. Five main modifications were recommended by (1) Adjusting survey support; (2) Enhancing communication strategy; (3) Considering interns' comments about the length of the questionnaire; (4) Modifying 2 determinants not adapted to a French context; (5) Adding a proposal when determinants deal with multidisciplinary management.

CONCLUSION

Conducting a web-based cross-sectional study of chiropractic interns to assess their utilization and conformity to clinical practice guideline is feasible.

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 utilisation of regulated standardised care packages by Danish chiropractors: a mixed methods study

Background

In Denmark, chiropractors in primary care work as independent private contractors regulated by the Danish National Health Authorities. The regulation includes partial reimbursement intended for standardised care packages for lumbar and cervical radiculopathy and lumbar spinal stenosis. Random checks have shown lower use than expected. This study aimed to describe and explore the utilisation of standardised chiropractic care packages and identify barriers to uptake.

Methods

A convergent mixed-method design was conceptualised. The use of standardised care packages was collected by register data. Potential determinants of difference in utilisation were assessed using a modified version of the Determinants of Implementation Behaviour Questionnaire (DIBQ) divided into 13 domains and sent to chiropractors in private clinics in Denmark in 2019. An open-ended question was added to the questionnaire, and thematic content analysis was applied. Qualitative findings were used to expand on the DIBQ data providing further insight into the clinicians’ perspective on standardised care packages. 

Results

Registry data of 244 included chiropractic clinics showed limited and inconsistent use of the standardised chiropractic care packages. A total of 269 chiropractors (44%) answered the DIBQ, and 45 provided data for the qualitative analyses. At least 60% of the clinicians answered ‘Strongly agree’ or ‘Agree’ in 10 out of 13 DIBQ domains suggesting a positive attitude towards using the standardised care packages. Three domains were identified as ‘problematic’ as more than 20% of clinicians disagreed or strongly disagreed: ‘Socio-political context’, ‘Goals’ and ‘Innovation’. Qualitative findings indicated that lack of usage of the standardised care packages was mainly related to the practical organization of standardised care, the chiropractor’s role when managing patients, and the patient population of interest to the clinic (e.g., children, athletes).

Conclusion

In general, Danish chiropractors displayed positive attitudes towards standardised packages of care. However, considerable variation in the use of the standardised care programs was observed. Low utilisation seemed mainly related to logistics, the chiropractor’s role, collaboration with GPs, and the patient population of interest to the clinic. These findings should be further explored in more extensive qualitative studies to inform implementation initiatives to increase and rectify utility.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-022-00423-7.

Learning from the past to plan for the future: A scoping review of musculoskeletal clinical research in Sweden 2010-2020

BACKGROUND

The aims of this study are to 1) determine the scope of musculoskeletal (MSK)-related clinical research in Sweden; 2) collate the amount of first-tier funding received; 3) discuss strategies and infrastructure supporting future MSK clinical trials in Sweden.

METHODS

A systematic scoping review protocol was applied in PubMed, Scopus, and SweCRIS databases. The articles were examined, and data were extracted in multiple stages by three blinded authors.

RESULTS

The search strategy resulted in 3,025 publications from 479 Swedish-affiliated authors. Primary health care was the basis for 14% of the publications, 84% from secondary health care, and 2% from occupational health care with a similar proportional distribution of first-tier research grant financing. Approximately one in six publications were randomized controlled trials (RCTs), while the majority were of observational cohort design. The majority of publications in primary and occupational health care were related to pain disorders (51 and 67%, respectively), especially diagnosis, prognosis, and healthcare organizational-related interventions (34%) and rehabilitation (15%) with similar proportional distribution of first-tier research grant financing. In secondary health care, rheumatic inflammatory disorder-related publications were most prevalent (30%), most frequently concerning diagnosis, prognosis, and healthcare organizational-related interventions (20%), attracting approximately half of all first-tier funding. Publications related to degenerative joint disorders (25%), fractures (16%), and joint, tendon, and muscle injuries (13%) frequently concerned surgical and other orthopedic-related interventions (16, 6, and 8%, respectively). Pain disorder-related publications (10%) as well as bone health and osteoporosis-related publications (4%) most frequently concerned diagnosis, prognosis, and healthcare organizational-related interventions (5 and 3%, respectively).

CONCLUSIONS

Swedish-affiliated MSK disorder research 2010-2020 was predominantly observational cohort rather than RCT based. There was skewed first-tier funding allocation considering prevalence/incidence and burden of disease. Use of infrastructure supporting register-based RCTs, placebo-controlled RCTs, and hybrid effectiveness-implementation studies on prevention and clinical intervention is important strategies for the future in all healthcare sectors.