Professional barriers and facilitators to using stratified care approaches for managing non-specific low back pain: a qualitative study with Canadian physiotherapists and chiropractors

Perspectives from clinicians and managers: facilitators and barriers to the uptake of rehabilitation guidance for children with arthrogryposis

PURPOSE

To identify the perceived facilitators and barriers among clinicians and managers about the uptake of expert guidance for rehabilitation of children with arthrogryposis multiplex congenita (AMC) in practice.

METHODS

Qualitative study using individual interviews, guided by the Theoretical Domains Framework (TDF), to explore beliefs and to identify facilitators and barriers to guidance uptake. Interviews were conducted with a convenience sample of 15 clinicians working with children with AMC and four pediatric clinical managers using Microsoft Teams©. Interviews were then transcribed verbatim and analyzed by four independent reviewers using deductive and inductive coding.

RESULTS

The TDF domains of Environmental Context and Resources, Behavioural Regulation, Reinforcement, Beliefs about Consequences, and Social Influences were shared amongst clinicians and clinical managers across North America and Europe as being relevant and influential on the target behaviour of using rehabilitation expert guidance to manage pediatric patients. Among clinicians only, the domain Memory, Attention, and Decision-Making Processes was also found relevant. Among managers only, the domain Social/Professional Role and Identity was found relevant.

CONCLUSIONS

Coupling shared relevant domains amongst clinicians and managers with individual supports and barriers helps to map out what is needed to promote the uptake of rehabilitation guidance at multiple levels.

Barriers and facilitators of integrating physiotherapy into primary health care settings: A systematic scoping review of qualitative research

Purpose

This scoping review investigated the barriers and facilitators to integrating physiotherapy into primary health care (PHC).

Materials and methods

PubMed, Scopus, Web of Science, Embase, ProQuest, and REHABDATA were searched. Two independent reviewers were involved in screening, selecting, and extracting data. Data were synthesized using thematic analysis.

Results

Of the 483 screened documents, 44 qualitative studies, primarily from high-income countries, were included. All of the studies had good methodological quality. Barriers and facilitators of integrating physiotherapy into PHC were extracted within the WHO six building blocks framework. In total, 41 items were identified as barriers to the integration process. The studies included 49 recommendations to facilitate integrating physiotherapy services into PHC.

Conclusion

Integrating physiotherapy services into PHC faces many barriers. The most commonly suggested potential barriers are poor knowledge of physicians about physiotherapy, ineffective teamwork, physiotherapists' time constraints/workload, a lack of clarity over the role and knowledge of physiotherapists, unawareness of physiotherapy users about these services, and lack of intra- and inter-professional collaborations. The most commonly suggested recommendations to facilitate the integration process include: Clarifying the role of involved professionals, strengthening teamwork, improving intra- and inter-professional collaborations, and providing comprehensive training programs for physiotherapists.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

Descriptive qualitative design.

METHODS

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

RESULTS

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

CONCLUSION

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

Physiotherapists Using the Biopsychosocial Model for Chronic Pain: Barriers and Facilitators-A Scoping Review

The use of the biopsychosocial model in primary care physiotherapy for chronic pain is far from the recommendations given in research and current guidelines. To understand why physiotherapists have difficulty implementing a biopsychosocial approach, more insight is needed on the barriers and facilitators. This scoping review aimed to investigate and map these barriers and facilitators that physiotherapists working in primary care reportedly face when treating patients with chronic musculoskeletal pain from a biopsychosocial perspective. Four electronic databases (PubMed, Embase, CINAHL and ERIC) and the grey literature were searched. Studies were included if they investigated the experiences of physiotherapists in the treatment of chronic pain from a biopsychosocial perspective in primary care. Extracted data were discussed and sub grouped in themes following a qualitative content analysis approach. To align with current use of theories on behavior change, the resulting themes were compared to the Theoretical Domains Framework. After screening, twenty-four studies were included. Eight groups of barriers and facilitators were identified, thematically clustered in six themes: knowledge, skills, and attitudes; environmental context and resources; role clarity; confidence; therapeutic alliance; and patient expectations. The results of this review can be used to inform the development of implementation programs.

Translation and cross-cultural adaptation of the low back pain treatment belief questionnaire and its clinimetric properties

BACKGROUND

The Low Back Pain Treatment Beliefs Questionnaire (LBP-TBQ) was developed to systematically measure patients' preferences about common treatments for low back pain (LBP). However, the questionnaire is not available in the Arabic language.

OBJECTIVE

To translate and cross-culturally adapt the LBP-TBQ to the Arabic language and assess its clinimetric properties.

METHODS

The LBP-TBQ was translated into Arabic version according to published guidelines. In pilot testing, the face and content validity of the translated questionnaire was assessed. Two hundred and fifty patients with LBP completed the translated LBP-TBQ for five common LBP treatments. In addition, a subgroup of 51 participants completed the questionnaire on two consecutive occasions to examine the test-retest reliability.

RESULTS

Confirmatory factor analysis results showed that the Arabic version of LBP-TBQ has three factors: (1) "credibility", (2) "effectiveness and fitness", and (3) "concerns", and this 3-factors model had the best fit for the data for all the five treatments. Cronbach's α of the total items ranged from 0.812 to 0.899, while the sub-scores ranged from 0.557 to 0.837, indicating moderate to high internal consistency. The ICC(2,1) ranged from 0.626 to 0.909, which shows acceptable to good test-retest reliability. Correlation with other LBP questionnaires was < 0.3, demonstrating acceptable discriminant validity. Finally, the questionnaire showed acceptable criterion validity for all the subscales and the general questionnaire.

CONCLUSIONS

The Arabic version of LBP-TBQ is reliable, valid, and appropriate to use in clinical and research settings.

Adherence to evidence-based practice across healthcare professionals in Germany: results from a cross-sectional, nationwide survey

Background

Adherence to evidence-based practice (EBP) is considered a key competence to improve healthcare quality. In this study, we aimed to describe the EBP adherence of healthcare professionals working in Germany and to explore barriers and facilitators regarding the implementation of EBP in clinical practice.

Methods

A nationwide online survey was performed among healthcare professionals in Germany from January to April 2018 using the German version of the Evidence-based Practice Inventory (EBPI) questionnaire for a comprehensive assessment of adherence to EBP. Univariate logistic regression analyses were performed to explore the association between demographic and professional determinants and each EBPI dimension.

Results

We analysed data of 889 participants, including 318 physical therapists, 154 occupational therapists, 137 midwifes and 280 participants of six other healthcare professions. Approximately 70% of the participants generally demonstrated a positive attitude towards EBP and believed that EBP was useful in clinical practice. Broadly, 80% of the respondents evaluated themselves as being able to enact EBP behaviour in clinical practice. In contrast, less than 70% preferred to use quantitative information instead of their intuition to inform their habitual clinical behaviour. Still, 20 to 30% reported that EBP did not sufficiently account for their clinical experience and differences between patients.

The strongest facilitators to EBP adherence across at least three dimensions of the EBPI were the availability of ≥ 60 min for scientific literature at work (OR: 9.67; 95% CI: 5.86; 16.30), followed by a master or higher academic degree (OR: 9.09, 95% CI: 5.86; 14.28) and the involvement in ≥ 1 scientific publication (OR: 7.06, 95% CI: 5.10; 9.85).

Conclusions

This study showed that healthcare professionals in Germany in general had a positive attitude towards EBP although they currently do not consider EBP principles in its entirety. The most important determinant positively influencing a healthcare professional’s decision to perform EBP was the time available for scientific literature at work. German healthcare professionals experience similar barriers towards the implementation of EBP in clinical practice compared to other international healthcare settings. These barriers should be targeted by future research.

Trial registration

German Clinical Trials Register (DRKS00013792). Registered 19 January 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08682-z.

Implementation of a biopsychosocial approach into physiotherapists' practice: a review of systematic reviews to map barriers and facilitators and identify specific behavior change techniques

PURPOSE

Our first objective was to map the barriers and facilitators to the implementation of a biopsychosocial approach into physiotherapists' practice within the Theoretical Domains Framework (TDF). Our second objective was to identify the specific behavior change techniques (BCT) that could facilitate this implementation.

MATERIALS AND METHODS

We conducted a review of systematic reviews to identify barriers and facilitators to the use of a biopsychosocial approach by physiotherapists and we mapped them within the TDF domains. We then analyzed these domains using the Theory and Techniques tool (TaTT) to identify the most appropriate BCTs for the implementation of a biopsychosocial approach into physiotherapists' practice.

RESULTS

The barriers and facilitators to the use of a biopsychosocial approach by physiotherapists were mapped to 10 domains of the TDF (Knowledge; skills; professional role; beliefs about capabilities; beliefs about consequences; intentions; memory, attention and decision processes; environmental context; social influences; emotion). The inclusion of these domains within the TaTT resulted in the identification of 33 BCTs that could foster the use of this approach by physiotherapists.

CONCLUSIONS

Investigating the implementation of a biopsychosocial approach into physiotherapists' practice from a behavior change perspective provides new strategies that can contribute to successfully implement this approach.Implications for RehabilitationThe implementation of a biopsychosocial approach into physiotherapists' practice is a complex process which involves behavior changes influenced by several barriers and facilitators.Barriers and facilitators reported by physiotherapists when implementing a biopsychosocial approach can be mapped within 10 domains of the Theoretical Domain Framework.Thirty-three behavior change techniques (e.g., verbal persuasion about capability, problem solving, restructuring the physical environment, etc.) were identified to foster the implementation of a biopsychosocial approach and specifically target barriers and facilitators.By using a behavior change perspective, this study highlights new strategies and avenues that can support current efforts to successfully implement the use of a biopsychosocial approach into physiotherapists' practice.

Assessment and monitoring of Achilles tendinopathy in clinical practice: a qualitative descriptive exploration of the barriers clinicians face

Our primary objective was to explore the barriers preventing clinicians from implementing what they think is ideal practice as it relates to using tools to aid diagnosis and monitor progress in mid-portion Achilles tendinopathy. Our secondary objectives were to describe the assessments employed by clinicians in their own practice to aid with (a) diagnosis and (b) monitoring progress in Achilles tendinopathy and explore the outcome measure domains clinicians believe to be the most and least important when managing patients with Achilles tendinopathy. We employed a qualitative descriptive study design. Thirteen participants (eight female, five male) from across Australia, consisting of two junior physiotherapists, five senior physiotherapists working in private practice, four senior physiotherapists working within elite sports organisations and two sport and exercise medicine doctors, were included and one-on-one interviews were performed. Audio was transcribed then entered into NVivo for coding and analysis. Four main themes were perceived as barriers to implementing ideal practice of assessment and monitoring in people with Achilles tendinopathy: financial constraints, time constraints, access to equipment and patient symptom severity. Assessments related to function, pain on loading, pain over a specified time frame and palpation are commonly used to assist diagnosis. Assessments related to disability, pain on loading, pain over a specified time frame and physical function capacity are used to monitor progress over time. Furthermore, pain on loading and pain over a specified time frame were considered the most important outcome measure domains for assisting diagnosis whereas pain on loading, patient rating of the condition and physical function capacity were the most important outcome measure domains for monitoring progress. A number of barriers exist that prevent clinicians from implementing what they view as ideal assessment and monitoring for Achilles tendinopathy. These barriers should be considered when developing new assessments and in clinical practice recommendations.

Expert guidance for the rehabilitation of children with arthrogryposis: protocol using an integrated knowledge translation approach

BACKGROUND

Arthrogryposis multiplex congenita (AMC) is a group of rare congenital disorders characterized by multiple joint contractures present at birth. Contractures can affect different body areas and impact activities of daily living, mobility and participation. Although early rehabilitation is crucial to promote autonomy and participation in children with AMC, empirical evidence to inform best practice is scarce and clinical expertise hard to develop due to the rarity of AMC. Preliminary research involving stakeholders in AMC (youth with AMC, parents, and clinicians) identified priorities in pediatric rehabilitation. Scoping reviews on these priorities showed a lack of high quality evidence related to rehabilitation in AMC. The objective of this project is to provide rehabilitation expert guidance on the assessment and treatment of children with AMC in the areas of muscle and joint function, pain, mobility and self-care, participation and psychosocial wellbeing.

METHODS

An integrated knowledge translation approach will be used throughout the project. Current rehabilitation practices in AMC will be identified using a clinician survey. Using the Grading of Recommendations, Assessment, Development and Evaluations framework (GRADE) approach, a panel of interdisciplinary expert clinicians, patient and family representatives, and researchers will develop expert guidance on the assessment and treatment for pediatric AMC rehabilitation based on findings from the scoping reviews and survey results. Consensus on the guidance statements will be sought using a modified Delphi process with a wider panel of international AMC experts, and statements appraised using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Theoretical facilitators and barriers toward implementing clinical guidance into practice will be identified among rehabilitation clinicians and managers to inform the design of dissemination and implementation strategies.

DISCUSSION

This multi-phase project will provide healthcare users and providers with research-based, expert guidance for the rehabilitation of children with AMC and will contribute to family-centered practice.

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.

Patients' Views on the Implementation Potential of a Stratified Treatment Approach for Low Back Pain in Germany: A Qualitative Study

Stratified care for low back pain (LBP) has been shown to be clinically- and cost-effective in the UK, but its transferability to the German healthcare system is unknown. This study explores LBP patients’ perspectives regarding future implementation of stratified care, through in-depth interviews (n = 12). The STarT-Back-Tool was completed by participants prior to interviews. Interview data were analysed using Grounded Theory. The overarching theme identified from the data was ‘treatment-success’, with subthemes of ‘assessment and treatment planning’, ‘acceptance of the questionnaire’ and ‘contextual factors’. Patients identified the underlying cause of pain as being of great importance (whereas STarT-Back allocates treatment based on prognosis). The integration of the STarT-Back-Tool in consultations was considered helpful as long as it does not disrupt the therapeutic relationship, and was acceptable if tool results are handled confidentially. Results indicate that for patients to find STarT-Back acceptable, the shift from a focus on identifying a cause of pain and subsequent diagnosis, to prediction-orientated treatment planning, must be made clear. Patient ‘buy in’ is important for successful uptake of clinical interventions, and findings can help to inform future strategies for implementing STarT-Back in the Germany, as well as having potential implications for transferability to other similar healthcare systems.