Management of low back pain by physical therapists in quebec: how are we doing?

The influence of low back pain-related attitudes and beliefs on the clinical decision making of physical therapists

BACKGROUND

The LBP-related attitudes and beliefs of clinicians may impact the experience of patients by influencing clinician decision-making and by shaping the attitudes, beliefs, and actions of patients. The purpose of this study was to identify the specific LBP-related attitudes and beliefs of US-based physical therapists and determine if those beliefs correlate with clinical decision-making.

METHODS

An electronic survey was sent to US-based physical therapists. Attitudes and beliefs were measured using the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) and the Pain and Impairment Relationship Scale for Physiotherapists (PABS-PT). The survey also included 2 patient vignettes that collected information about clinical decision-making.

RESULTS

Complete survey responses were recorded from 420 physical therapists. Eleven of the 27 attitude and beliefs questions were answered in a more biomedically oriented way by at least 20% of respondents. Physical therapist low back pain-related attitudes and beliefs were associated with activity and management strategies for both vignettes in the expected direction. Higher scores on HC-PAIRS and PABS-BM were associated with more restrictive work and activity recommendations, lower-intensity exercise choices, biomechanical rationale for manual therapy and motor control exercises, pathoanatomical-focused education, and use of modalities.

CONCLUSION

Some physical therapists hold biomedically oriented beliefs about the connection between pain and physical activity. Clinician beliefs were associated with activity and work recommendations, and treatment choices. Physical therapists with more biomedically oriented beliefs were more likely to limit physical activity and work, and less likely to incorporate psychologically informed interventions.

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.

Improved Outcomes Following a Care Guideline Implementation: Part 1 of an Analysis of 12 355 Patients After Total Knee Arthroplasty

OBJECTIVE: To describe the application and examine the influence of a continuous quality improvement intervention, which had a goal of standardizing care to reduce the proportion of patients who do not have a meaningful improvement in patient-reported outcomes following total knee arthroplasty (TKA). DESIGN: Continuous quality improvement. METHODS: A physical therapy (PT) care guideline was initiated in 2013 for patients following TKA. The Knee Outcome Survey - Activities of Daily Living (KOS-ADL) was measured at every visit, and scores were extracted from a clinical outcomes database to calculate the proportion of patients who did not achieve a minimal clinically important difference. Based on logistic regression analysis, we compared the proportion of patients who did not progress on the KOS-ADL in a non-care guideline group (2008-2012) to a care guideline (CG) group (2014-2019). RESULTS: This study included 12 355 patients (aged 18-92 years) following TKA incurring at least 3 PT visits from 2008 to 2019. The percentage of patients who did not progress in the non-care guideline group was 25.8% and in the care guideline group 14.3% (P<0.001). The relationship between care guideline adherence and lack of progression on the KOS-ADL was statistically significant, X2 (df = 1) = 148.7, P<.001. CONCLUSION: The percentage of patients who did not achieve meaningful progress on the KOS-ADL declined significantly in the 6 years after implementing a TKA care guideline without an increase in the number of clinical visits. The standardized care guideline was associated with meaningful improvements for patients following TKA when applied in conjunction with PT access to outcome data, feedback through audits, performance goals, and financial incentives. J Orthop Sports Phys Ther 2023;53(3):143-150. Epub: 12 December 2022. doi:10.2519/jospt.2022.11369.

A study protocol for the validation of a prognostic model with an emphasis on modifiable factors to predict chronic pain after a new episode of acute- or subacute nonspecific idiopathic, non-traumatic neck pain presenting in primary care

BACKGROUND

The primary objective of this study is to identify which modifiable and non-modifiable factors are independent predictors of the development of chronic pain in patients with acute- or subacute nonspecific idiopathic, non-traumatic neck pain, and secondly, to combine these to develop and internally validate a prognostic prediction model.

METHODS

A prospective cohort study will be conducted by physiotherapists in 30 primary physiotherapy practices between January 26, 2020, and August 31, 2022, with a 6-month follow-up until March 17, 2023. Patients who consult a physiotherapist with a new episode of acute- (0 to 3 weeks) or subacute neck pain (4 to 12 weeks) will complete a baseline questionnaire. After their first appointment, candidate prognostic variables will be collected from participants regarding their neck pain symptoms, prior conditions, work-related factors, general factors, psychological and behavioral factors. Follow-up assessments will be conducted at six weeks, three months, and six months after the initial assessment. The primary outcome measure is the Numeric Pain Rating Scale (NPRS) to examine the presence of chronic pain. If the pain is present at six weeks, three months, and six months with a score of NPRS ≥3, it is classified as chronic pain. An initial exploratory analysis will use univariate logistic regression to assess the relationship between candidate prognostic factors at baseline and outcome. Multiple logistic regression analyses will be conducted. The discriminative ability of the prognostic model will be determined based on the Area Under the receiver operating characteristic Curve (AUC), calibration will be assessed using a calibration plot and formally tested using the Hosmer and Lemeshow goodness-of-fit test, and model fit will be quantified as Nagelkerke's R2. Internal validation will be performed using bootstrapping-resampling to yield a measure of overfitting and the optimism-corrected AUC.

DISCUSSION

The results of this study will improve the understanding of prognostic and potential protective factors, which will help clinicians guide their clinical decision making, develop an individualized treatment approach, and predict chronic neck pain more accurately.

Physical therapists demonstrate clinical behaviors consistent with established clinical practice guidelines in managing individuals following amputation

BACKGROUND AND PURPOSE

Investigating physical therapy in amputation management offers insights into clinical practice. This study explores the self-reported clinical practice of physical therapists in amputation management and compares it to established clinical practice guidelines to determine whether physical therapists are delivering care that is considered recommended clinical practice.

METHOD

An online survey of Australian physical therapists with limited or extensive experience in managing individuals following amputation.

RESULTS

A total of 110 responses were received. The majority of Australian physical therapists (83%) reported their skills were adequate however, reported a lack of professional development opportunities. Physical therapists reported coordinating care with other health and medical professionals across all phases of care. They report providing comprehensive care in the following areas: residual limb management, pain management, falls prevention, education, counselling, psychological and peer support, and discharge planning. The majority of physical therapists were not aware if a comprehensive care plan was in place following a transition of care from a previous health service.

DISCUSSION

Overall, physical therapists displayed clinical practice meeting the guidelines across most areas of amputation management. Future research into alternate data collection of clinical practice, and the development of physical therapy-specific clinical practice guidelines is needed.

Factors associated with the low back pain-related attitudes and beliefs of physical therapists

BACKGROUND

Clinicians who believe in a strong connection between pain and disability, and who have biomedically oriented beliefs recommend less physical activity, more time off work, and promote unhelpful beliefs in patients. Understanding how these beliefs develop may assist in identifying ways to reduce unhelpful beliefs in clinicians.

OBJECTIVE

To identify factors that are associated with the LBP-related attitudes and beliefs of US-based physical therapists.

DESIGN

Cross-sectional design METHOD: An electronic survey was sent to US-based physical therapists. Attitudes and beliefs were measured using the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) and the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT), pain science knowledge was measured using the Neurophysiology of Pain Questionnaire (NPQ), and professional and demographic information were collected.

RESULTS

Completed surveys were obtained from 420 physical therapists. More helpful attitudes and beliefs were associated with board certification in orthopedics or sports, higher NPQ scores, and working in a hospital-based clinic. Less helpful attitudes and beliefs were associated with working in private practice and a personal history of LBP that had a minimum or significant impact on life. The factors included in this study explained 16.8% of the variability in HC-PAIRS scores (p < .001), 13% of the variability in PABS-BM scores (p < .001), and 8.3% of the variability in PABS-BPS scores (p < .001).

CONCLUSION

Several modifiable and non-modifiable factors are associated with the LBP-related attitudes and beliefs of US physical therapists.

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.

Attitudes and Beliefs of Primary Care Physicians Working in Saudi Arabia Regarding the Management of Low Back Pain: A Cross-Sectional Study

Introduction

Healthcare professionals’ beliefs and attitudes towards low back pain management play a significant role during treatment. This is a crucial aspect of primary care physicians working as a first point of contact for people seeking healthcare for low back pain.

Aim

To identify the beliefs and behaviors of frontline healthcare professionals (primary care physicians) working in the Riyadh region with regard to low back pain management.

Methods

A cross-sectional design was implemented, in which the Pain Attitude and Beliefs Scale (PABS) questionnaire was used along with a low back pain clinical vignette with some questions. The PABS assesses healthcare provider orientations toward low back pain with two subscales: biomedical and behavioral. In total, 400 primary care physicians working in the Riyadh region of Saudi Arabia were invited to participate.

Results

The responding primary care physicians (n = 72, response rate = 18%) provided an average score on the behavioral subscale (mean = 31.5±7.1) that was lower than that on the biomedical subscale (36.5±7.8) of the PABS. The lower scores in the biomedical subscale are associated with the using of clinical guidelines for low back pain management (χ² (1) = 4.7, p = 0.03). Moreover, providing guideline-based advices regarding activity and work was more likely to come from those scoring above the mean in the behavioral subscale.

Conclusion

The results of this study show that Saudi Arabian primary care physicians manage their patients within a biomedical framework; there is some compliance to the current low back pain clinical guidelines among these physicians, with under/post-graduate education being needed for these professionals to adopt a more biopsychosocial framework during low back pain management.

Profile, attitudes and beliefs of physiotherapists in the management of chronic nonspecific low back pain

Abstract Introduction: About 84% of the population have had some low back symptom during their lifetime; where 23% of cases become chronic pain. It is observed that in around 85% of cases of chronic low back pain, there is no specific cause or diagnosis, where it is referred to as chronic nonspecific low back pain. Given its disabling potential, the comprehensive assessment, attitudes and beliefs of the physiotherapist in clinical management become essential to the prognosis. Objective: To evaluate the relationship between sociodemographic/socioeducational and work profile and the attitudes and beliefs of physiotherapists in the management of chronic nonspecific low back pain treatment. Methods: This was a cross-sectional quantitative study. For data collection, two questionnaires were used, one referring to the sociodemographic/socioeducational profile information and the other referring to attitudes and beliefs determined by the Pain Attitudes and Beliefs Scale for Physiotherapists. Data were analyzed using the BioEstat 5.0 program using descriptive statistics, t-test and Pearson correlation (p < 0.05). Results: Fifty-seven physical therapists were analyzed, where most were women (61.4%), had specialization (56.2%), worked in private clinics (63.2%) and used specific methods in the management of chronic nonspecific low back pain (84.2%). Biomedical belief was predominant (70.2%) and showed a significant relationship with age (p = 0.0006). Conclusion: The biomedical model is still predominantly used, which is related to the age of the professionals surveyed.

Limited evidence exists on determinants of physiotherapists' adherence to high value interventions in nonspecific low back pain management: A scoping review

BACKGROUND

Examining the emerging body of evidence investigating what drives physiotherapist's clinical decisions in the management of low back pain can guide future research into identifying barriers and facilitators of their adherence to evidence recommended interventions.

OBJECTIVE

To establish the body of evidence regarding factors that improve or hinder physiotherapists' adherence to high-value interventions on the management of non-specific low back pain.

DESIGN

Scoping review.

METHODS

We conducted a Scoping review by searching MEDLINE, CINAHL, and SPORTDiscus databases on 13 February 2021. Two reviewers independently screened the retrieved literature and selected articles for inclusion. We included quantitative research that investigated an association between physiotherapists' personal characteristics or setting related characteristics with their clinical management of patients with non-specific low back pain.

RESULTS

Twelve studies reported in 13 publications were included. The majority of the studies were conducted in high-income countries including, the United States, Canada and UK. Twenty-six factors were investigated as potentially influencing physiotherapists' adherence to high value interventions in low back pain management. The most commonly examined physiotherapists' attributes were educational qualification that is postgraduate or certification course (58%, N = 7 studies), years of experience (41%, N = 5 studies), and beliefs and attitude about low back pain (41%, N = 5 studies). Work setting (N = 4) and workload (N = 3) were frequently investigated setting related factors.

CONCLUSION

Currently, there is limited evidence available to understand determinants controlling practice behaviours of physiotherapists' management of nonspecific low back pain. Future researches conceptualized within contemporary theories of clinician behaviour change and models of knowledge translation are needed.

Cross-cultural adaptation, validation and psychometric evaluation of the attitudes to back pain scale in musculoskeletal practitioners - Hebrew version

BACKGROUND

Research suggests that clinician's attitudes and beliefs towards low back pain (LBP) management may affect their patients' treatment course and outcomes. Attitudes to Back pain Scale in musculoskeletal practitioners (ABS-mp) is a questionnaire developed to assess musculoskeletal clinicians' attitudes and beliefs regarding LBP.

OBJECTIVE

This study aimed to translate, culturally adapt, and evaluate the psychometric properties of the Hebrew version of the ABS-mp questionnaire.

DESIGN

Cross-sectional study with nested prospective sub-sample.

METHODS

The translation was performed in several steps following the cross-cultural adaptation process. Test-retest and internal consistency reliability of the scales were evaluated along with convergent validity exploration between the ABS-mp and the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS). A convenience sample of 177 physical therapists were requested to participate in the study, out of which 132 have completed the survey, providing a 74% participation rate.

RESULTS

The forward-backward translation process revealed minor discrepancies that were addressed by the expert panel. The test-retest reliability of the Hebrew ABS-mp was excellent (ICC = 0.906). Five items were found to be irrelevant for the Israeli physiotherapy health settings and were omitted. For internal consistency, the average inter-item correlation reached appropriate values for the Psychological, Biomedical, Re-activation, and Limitation on Sessions subscales (0.437, 0.265, 0.341, 0.197, respectively). For convergent validity, the ABS-mp's Biomedical subscale and the HC-PAIRS's total score were moderately correlated (0.535).

CONCLUSIONS

The Hebrew version of the ABS-mp has been validated and has demonstrated excellent test-retest reliability, good convergent validity and acceptable internal consistency.

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

Context

Many clinical practice guidelines have been developed for the management of musculoskeletal disorders (MSDs). However, there is a gap between evidence-based knowledge and clinical practice, and reasons are poorly understood. Understanding why healthcare providers use clinical practice guidelines is essential to improve their implementation, dissemination, and adherence.

Aim

To identify determinants of clinical practice guidelines’ utilization by health care providers involved in the assessment and management of MSDs.

Method

A scoping review of the literature was conducted. Three databases were searched from inception to March 2021. Article identification, study design, methodological quality, type of healthcare providers, MSDs, barriers and facilitators associated with guidelines’ utilization were extracted from selected articles.

RESULTS: 8671 citations were retrieved, and 43 articles were selected. 51% of studies were from Europe, and most were quantitative studies (64%) following a cross-sectional design (88%). Almost 80% of articles dealt with low back pain guidelines, and the most studied healthcare providers were general practitioners or physiotherapists. Five main barriers to guideline utilization were expressed by providers: 1) disagreement between recommendations and patient expectations; 2) guidelines not specific to individual patients; 3) unfamiliarity with “non-specific” term, or with the bio psychosocial model of MSDs; 4) time consuming; and 5) heterogeneity in guideline methods. Four main facilitators to guideline utilization were cited: 1) clinician’s interest in evidence-based practice; 2) perception from clinicians that the guideline will improve triage, diagnosis and management; 3) time efficiency; and 4) standardized language.

Conclusion

Identifying modifiable determinants is the first step in developing implementation strategies to improve guideline utilization in clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04204-w.

What does it take to facilitate the integration of clinical practice guidelines for the management of low back pain into practice? Part 1: A synthesis of recommendation

BACKGROUND

Despite the emergence of multiple clinical practice guidelines (CPGs) for the rehabilitation of low back pain (LBP) over the last decade, self-reported levels of disability in this population have not improved. This may be explained by the numerous implementation barriers, such as the complexity of information and sheer volumes of CPGs.

OBJECTIVES

The purpose of this study was to summarize the evidence and recommendations from the most recent and high-quality CPGs on the rehabilitation management of LBP by developing an infographic summarizing the recommendations to facilitate dissemination into clinical practice.

METHODS

We performed a systematic review of high-quality CPGs with an emphasis on rehabilitation approaches. We searched major health-related research databases (e.g., PubMed, CINAHL, and PEDro). We performed quality assessment via the AGREE-II instrument. Contents of the CPGs were synthesized by extracting recommendations, which were then compared to one another to identify consistencies based on an iterative evaluation process.

RESULTS

We identified and assessed 5 recent high-quality CPGs. We synthesized 13 recommendations on the rehabilitation management of LBP (2 for screening procedures, 3 for assessment procedures, and 8 involving treatment approaches) and 2 underlying principles were highlighted. These results were then synthetized and illustrated in a concise infographic that serves as a conceptual roadmap that identifies the specific behavior changes (i.e., adoption of CPGs' recommendations) rehabilitation professionals should adopt in order to integrate an evidenced-based approach for the management of LBP.

CONCLUSIONS

We systematically reviewed the literature for CPGs' recommendations for the physical rehabilitation management of LBP and synthesized the information through an infographic.

What does it take to facilitate the integration of clinical practice guidelines for the management of low back pain into practice? Part 2: A strategic plan to activate dissemination

Low back pain (LBP) is the leading cause of disability worldwide among all musculoskeletal disorders despite an intense focus in research efforts. Researchers and decision makers have produced multiple clinical practice guidelines for the rehabilitation of LBP, which contain specific recommendations for clinicians. Adherence to these recommendations may have several benefits, such as improving the quality of care for patients living with LBP, by ensuring that the best evidence-based care is being delivered. However, clinicians' adherence to recommendations from these guidelines is low and numerous implementation barriers and challenges, such as complexity of information and sheer volume of guidelines have been documented. In a previous paper, we performed a systematic review of the literature to identify high-quality clinical practice guidelines on the management of LBP, and developed a concise yet comprehensive infographic that summarizes the recommendations from these guidelines. Considering the wealth of scientific evidence, passive dissemination alone of this research knowledge is likely to have limitations to help clinicians implement these recommendations into routine practice. Thus, an active and engaging dissemination strategy, aimed at improving the implementation and integration of specific recommendations into practice is warranted. In this paper, we argue that a conceptual framework, such as the theoretical domains framework, could facilitate the implementation of these recommendations into clinical practice. Specifically, we present a systematic approach that could serve to guide the development of a theory-informed knowledge translation intervention as a means to overcome implementation challenges in rehabilitation of LBP.

Ontario Musculoskeletal Physiotherapists' Attitudes toward and Beliefs about Managing Chronic Low Back Pain

Purpose: The purpose of this study was to explore Ontario musculoskeletal physiotherapists' attitudes toward and beliefs about managing chronic low back pain (CLBP), and their biomedical (BM) and bio-psychosocial (BPS) treatment orientation. Method: Through a link in the Ontario Physiotherapy Association newsletter, we administered an electronic survey to registered physiotherapists via SurveyMonkey. We used a modified three-step Dillman approach to encourage participation. The questionnaire included the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) measure, and demographic-practice items. Results: A total of 99 physiotherapists met the eligibility criteria and completed the PABS-PT (72.7% women; mean 17 years of experience). Respondents scored a mean of 26.98 (SD 7.69) on the BM sub-scale and 34.43 (SD 4.84) on the BPS sub-scale. Physiotherapists in public practice had a stronger BPS orientation (mean 36.52) than those in private practice (33.80; p = 0.01). Less experienced physiotherapists (<10 y) had a higher BM sub-scale score (mean 29.33) than more experienced physiotherapists (25.24, p = 0.013), and 78.8% of physiotherapists reported an awareness of clinical practice guidelines. Conclusions: Our preliminary findings suggest that Ontario physiotherapists' attitudes and beliefs align with a BPS orientation. Future studies should explore the impact of education that promotes a BPS approach to the management of CLBP.

Adherence to key domains in low back pain guidelines: A cross-sectional study of Danish physiotherapists

OBJECTIVE

The aim of the study was threefold: Firstly, to investigate the adherence to clinical practice guidelines for low back pain (LBP) among Danish physiotherapists with regard to three key domains: (a) activity, (b) work and (c) psychosocial risk factors. Secondly, to investigate whether adherence differed between physiotherapists working in private clinics (private physiotherapists) and physiotherapists working at public healthcare centres (public physiotherapists). Thirdly, to describe the physiotherapists' treatment modalities for patients with LBP.

METHODS

A cross-sectional online survey was conducted with 817 physiotherapists working in the Central Denmark Region. Adherence to the guideline domains was assessed using two vignettes. The difference in adherence between the groups was assessed using the Chi-squared test. Treatment modalities were reported using descriptive statistics.

RESULTS

A total of 234 physiotherapists responded, hereof 163 private physiotherapists and 71 public physiotherapists (response rate 29%). The proportions of physiotherapists managing the patients strictly in line with the guideline domains were 32% (activity), 16% (work) and 82% (psychosocial risk factors) for Vignette 1 and 6% (activity), 53% (work) and 60% (psychosocial risk factors) for Vignette 2. Public physiotherapists were more likely to manage patients strictly in line with guidelines for assessing the psychosocial risk factors compared to private physiotherapist (Vignette 1: 92% vs. 77% p = .030; Vignette 2:70% vs. 55% p = .035). Regarding the other two domains, there was no significant difference between the two groups in terms of adherence (p > .05). Concerning treatment modalities, the majority of physiotherapists instructed the patients in adopting an exercise program or informed the patients about the benign nature and prognosis of LBP.

CONCLUSION

Overall, the participating Danish physiotherapists strictly adhered to only one out of three key domains. This underlines the importance of bringing focus on implementing the current guidelines' recommendations in clinical practice.

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.

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

OBJECTIVES

Physicians often refer patients with musculoskeletal conditions to physical therapy. However, it is unclear to what extent physical therapists' treatment choices align with the evidence. The aim of this systematic review was to determine what percentage of physical therapy treatment choices for musculoskeletal conditions agree with management recommendations in evidence-based guidelines and systematic reviews.

DESIGN

Systematic review.

SETTING

We performed searches in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine, Scopus and Web of Science combining terms synonymous with 'practice patterns' and 'physical therapy' from the earliest record to April 2018.

PARTICIPANTS

Studies that quantified physical therapy treatment choices for musculoskeletal conditions through surveys of physical therapists, audits of clinical notes and other methods (eg, audits of billing codes, clinical observation) were eligible for inclusion.

PRIMARY AND SECONDARY OUTCOMES

Using medians and IQRs, we summarised the percentage of physical therapists who chose treatments that were recommended, not recommended and had no recommendation, and summarised the percentage of physical therapy treatments provided for various musculoskeletal conditions within the categories of recommended, not recommended and no recommendation. Results were stratified by condition and how treatment choices were assessed (surveys of physical therapists vs audits of clinical notes).

RESULTS

We included 94 studies. For musculoskeletal conditions, the median percentage of physical therapists who chose recommended treatments was 54% (n=23 studies; surveys completed by physical therapists) and the median percentage of patients that received recommended physical therapy-delivered treatments was 63% (n=8 studies; audits of clinical notes). For treatments not recommended, these percentages were 43% (n=37; surveys) and 27% (n=20; audits). For treatments with no recommendation, these percentages were 81% (n=37; surveys) and 45% (n=31; audits).

CONCLUSIONS

Many physical therapists seem not to follow evidence-based guidelines when managing musculoskeletal conditions. There is considerable scope to increase use of recommended treatments and reduce use of treatments that are not recommended.

PROSPERO REGISTRATION NUMBER

CRD42018094979.

Aspects influencing clinical reasoning and decision-making when matching treatment to patients with low back pain in primary healthcare

BACKGROUND

It is unclear how physiotherapists match treatment to patients with low-back pain (LBP) in primary healthcare. A further exploration of physiotherapists' perspective of matching treatments to the individual patient in this setting is needed.

OBJECTIVE

The aim of this study was to explore and describe aspects influencing physiotherapists' clinical reasoning in the decision-making on individualized treatment of LBP in primary healthcare.

DESIGN

This was an explorative study using qualitative content analysis.

METHOD

Fifteen semi-structured individual interviews were conducted with physiotherapists, men and women, experienced and novice, working in primary healthcare settings in one sparsely populated region and in one larger city in Sweden.

FINDINGS

Two overarching themes were identified influencing decision-making for individualized treatment of LBP: 1) Matching requires differentiation and adaptation, with categories describing specific patient characteristics, assessment findings and treatment adaptations (classification of pain and bodily findings; patient physical capacity and emotions; patient awareness and motivation; treatment combinations and atypical treatment rationales): and 2) The tension between trust and barriers; with categories describing aspects of physiotherapists' convictions, constraints and working environment (confidence in treatments and oneself; physiotherapists' terms overrule patients' preferences; personal constraints and workplace approach and priorities).

CONCLUSION

This study describes aspects of the patients, the physiotherapists and their workplaces that influence decisions for individualized treatment of LBP. The findings underpin the need for clinician self-reflection, initiatives for skilled clinical competence and the weight clinician observations carry on the complex treatment selection process which need to be appreciated when implementing evidence-based recommendations in clinical practice.

Tratamento de pacientes com dor lombar crônica inespecífica por fisioterapeutas: um estudo transversal

RESUMO Estudos atuais têm investigado a orientação de tratamento que fisioterapeutas adotam no tratamento da dor lombar crônica inespecífica (DLCI) pela avaliação de suas atitudes e crenças. Porém, no Brasil, pouco se sabe sobre essa temática principalmente no contexto do Sistema Único de Saúde (SUS). O objetivo desse estudo foi descrever atitudes e crenças dos fisioterapeutas que atuam no SUS no tratamento de pacientes com DLCI e identificar a relação entre suas características demográficas e profissionais e as orientações de tratamento da DLCI. O estudo é de base populacional e transversal. Os dados foram coletados com um questionário demográfico e profissional e o questionário Pain Attitudes and Beliefs Scale for Physiotherapists. O estudo contou com 49 fisioterapeutas e os resultados evidenciaram maior concordância com crenças e atitudes relacionadas à orientação biomédica, sendo a pontuação nessa escala 15,5% maior que na comportamental, e uma correlação regular e positiva (p<0,05) entre o tempo de formação e a orientação de tratamento biopsicossocial. Concluí-se que houve predomínio de crenças biomédicas entre os fisioterapeutas que trataram a DLCI em pacientes do SUS. O estudo também demonstrou que os fisioterapeutas com maior tempo de formação foram aqueles que apresentaram maior influência da orientação biopsicossocial.

Working Together and Being Physically Active Are Not Enough to Advise Uniformly and Adequately Low Back Pain Patients: A Cross-Sectional Study

The profession of the health-care providers (HCPs) influences their recommendations to the patients. Conversely, interdisciplinarity seeks to challenge such differences, so that the patient receives one single and consistent therapeutic message. Some studies also suggest associations between HCPs life habits and recommendations. Our hypotheses were (1) that despite interdisciplinary work, the profession remains a predictor of recommendations and (2) that HCPs who are more physically active recommend more activity. Three clinical vignettes were presented to a group of experts of low back pain (LBP) (guidelines), and 20 physicians, 22 physiotherapists, and 23 nurses to assess how they evaluate the symptoms and pathologies of LBP patients and how much work and physical activity they recommend. Physical activity was assessed with accelerometers and questionnaires. Some interprofessional differences remained present within an interdisciplinary team. The nurses were more restrictive and further away from the guidelines. The physicians were the most in line with them. The physiotherapists recommend as much physical activity, but less work activity than the physicians. The level of physical activity of the HCPs is not associated with their recommendations. To ensure a clear and unique message, educational actions may be undertaken to promote the biopsychosocial model and clarify the guidelines.

Pain-related fear of (re-)injury in patients with low back pain: Estimation or measurement in manual therapy primary care practice? A pilot study

BACKGROUND

Manual physical therapists (MPTs) working in primary care get limited information about patient's courses of (chronic) low back pain (LBP). Identification of kinesiophobia is mostly based on clinical perception.

OBJECTIVE

The aim of this study was to evaluate the association between the scores with which manual physical therapists in a primary care setting identify kinesiophobia in patients with low back pain, and the patients' self-reported measures of kinesiophobia.

METHODS

The cross-sectional study comprised 104 patients with LBP and 17 MPTs. Patients first independently completed the Tampa Scale for Kinesiophobia (TSK-17). The therapists, blinded to the TSK-scores, rated their perception of a patient's kinesiophobia using the Visual Analogue Scale-Estimation (VAS-est) and the accuracy of their ratings using the Visual Analogue Scale-Accuracy (VAS-ac). Kendall's tau b was used to determine the level of correlation between scores on the TSK-17 and the VAS-est.

Physiotherapists' beliefs and attitudes influence clinical practice in chronic low back pain: a systematic review of quantitative and qualitative studies

QUESTION

What influence do physiotherapists' beliefs and attitudes about chronic low back pain have on their clinical management of people with chronic low back pain?

DESIGN

Systematic review with data from quantitative and qualitative studies. Quantitative and qualitative studies were included if they investigated an association between physiotherapists' attitudes and beliefs about chronic low back pain and their clinical management of people with chronic low back pain.

RESULTS

Five quantitative and five qualitative studies were included. Quantitative studies used measures of treatment orientation and fear avoidance to indicate physiotherapists' beliefs and attitudes about chronic low back pain. Quantitative studies showed that a higher biomedical orientation score (indicating a belief that pain and disability result from a specific structural impairment, and treatment is selected to address that impairment) was associated with: advice to delay return to work, advice to delay return to activity, and a belief that return to work or activity is a threat to the patient. Physiotherapists' fear avoidance scores were positively correlated with: increased certification of sick leave, advice to avoid return to work, and advice to avoid return to normal activity. Qualitative studies revealed two main themes attributed to beliefs and attitudes of physiotherapists who have a relationship to their management of chronic low back pain: treatment orientation and patient factors.

CONCLUSION

Both quantitative and qualitative studies showed a relationship between treatment orientation and clinical practice. The inclusion of qualitative studies captured the influence of patient factors in clinical practice in chronic low back pain. There is a need to recognise that both beliefs and attitudes regarding treatment orientation of physiotherapists, and therapist-patient factors need to be considered when introducing new clinical practice models, so that the adoption of new clinical practice is maximised. [Gardner T, Refshauge K, Smith L, McAuley J, Hübscher M, Goodall S (2017) Physiotherapists' beliefs and attitudes influence clinical practice in chronic low back pain: a systematic review of quantitative and qualitative studies. Journal of Physiotherapy 63: 132-143].

CareTrack: Toward Appropriate Care for Low Back Pain

STUDY DESIGN

Retrospective medical record review to assess compliance with low back pain (LBP) care indicators.

OBJECTIVE

To establish baseline estimates of the appropriateness of LBP care in the general Australian population provided by a range of healthcare providers in various real-world settings.

SUMMARY OF BACKGROUND DATA

LBP is a costly condition and accounts for the greatest burden of disease worldwide, yet the care provided is often at variance with guidelines. No baseline estimates of performance are currently available in Australia across various aspects of LBP care, practitioners, and settings.

METHODS

A population-based sample of patients with 22 common conditions was recruited by telephone; consents were obtained to review their medical records against indicators ("CareTrack"). Care for LBP was reviewed against 10 indicators used in a previous study and ratified by experts as representing appropriate LBP care in Australia during 2009 and 2010.

RESULTS

Of the 22 CareTrack conditions, LBP had the highest number of eligible healthcare encounters (6588 of 35,573, 19%), 125 to 884 per indicator among 164 LBP patients. Overall compliance with LBP indicators was 72% (range 42%-98%). Allied health practitioners and hospitals were the most compliant (82%-83% respectively), followed by general practitioners (54%). Some aspects of care were poor, such as documenting a thorough neurological examination, screening for serious diseases such as infection and inappropriate use of drugs such as steroids and treatments such as traction.

CONCLUSION

Over a quarter of LBP care was not appropriate despite the availability of guidelines. There is a need for national and, potentially, international agreement on clinical standards, indicators and tools to guide, document and monitor the appropriateness of care for LBP, and for measures to increase their uptake, particularly where deficiencies have been identified.

LEVEL OF EVIDENCE

N /A.

The contribution of conceptual frameworks to knowledge translation interventions in physical therapy

There is growing recognition of the importance of knowledge translation activities in physical therapy to ensure that research findings are integrated into clinical practice, and increasing numbers of knowledge translation interventions are being conducted. Although various frameworks have been developed to guide and facilitate the process of translating knowledge into practice, these tools have been infrequently used in physical therapy knowledge translation studies to date. Knowledge translation in physical therapy implicates multiple stakeholders and environments and involves numerous steps. In light of this complexity, the use of explicit conceptual frameworks by clinicians and researchers conducting knowledge translation interventions is associated with a range of potential benefits. This perspective article argues that such frameworks are important resources to promote the uptake of new evidence in physical therapist practice settings. Four key benefits associated with the use of conceptual frameworks in designing and implementing knowledge translation interventions are identified, and limits related to their use are considered. A sample of 5 conceptual frameworks is evaluated, and how they address common barriers to knowledge translation in physical therapy is assessed. The goal of this analysis is to provide guidance to physical therapists seeking to identify a framework to support the design and implementation of a knowledge translation intervention. Finally, the use of a conceptual framework is illustrated through a case example. Increased use of conceptual frameworks can have a positive impact on the field of knowledge translation in physical therapy and support the development and implementation of robust and effective knowledge translation interventions that help span the research-practice gap.

Physiotherapy practice in the private sector: organizational characteristics and models

Background

Even if a large proportion of physiotherapists work in the private sector worldwide, very little is known of the organizations within which they practice. Such knowledge is important to help understand contexts of practice and how they influence the quality of services and patient outcomes. The purpose of this study was to: 1) describe characteristics of organizations where physiotherapists practice in the private sector, and 2) explore the existence of a taxonomy of organizational models.

Methods

This was a cross-sectional quantitative survey of 236 randomly-selected physiotherapists. Participants completed a purpose-designed questionnaire online or by telephone, covering organizational vision, resources, structures and practices. Organizational characteristics were analyzed descriptively, while organizational models were identified by multiple correspondence analyses.

Results

Most organizations were for-profit (93.2%), located in urban areas (91.5%), and within buildings containing multiple businesses/organizations (76.7%). The majority included multiple providers (89.8%) from diverse professions, mainly physiotherapy assistants (68.7%), massage therapists (67.3%) and osteopaths (50.2%). Four organizational models were identified: 1) solo practice, 2) middle-scale multiprovider, 3) large-scale multiprovider and 4) mixed.

Conclusions

The results of this study provide a detailed description of the organizations where physiotherapists practice, and highlight the importance of human resources in differentiating organizational models. Further research examining the influences of these organizational characteristics and models on outcomes such as physiotherapists’ professional practices and patient outcomes are needed.