Effect on the process of care of an active strategy to implement clinical guidelines on physiotherapy for low back pain: a cluster randomised controlled trial

Abstract

Objectives: To evaluate the effect on the process of care of an active strategy to implement clinical guidelines on physiotherapy for low back pain. Design: A cluster randomised controlled trial comparing an active strategy with standard dissemination. Setting: Primary care physiotherapy practices. Participants: 113 physiotherapists were randomly allocated to receive the guidelines by mail (control group) or to receive an additional active strategy (intervention group) which consisted of a multifaceted programme including education, discussion, role playing, feedback, and reminders. Main outcome measures: Adherence to the guidelines was measured by means of individual patients' forms recording the treatment completed by the physiotherapist. The forms were assessed using an algorithm based on the number of treatment sessions, treatment goals, interventions, and patient education. Results: Physiotherapists in the intervention group more often correctly limited the number of treatment sessions for patients with a normal course of back pain (OR 2.39; 95% CI 1.12 to 5.12), more often set functional treatment goals (OR 1.99; 95% CI 1.06 to 3.72), more often used mainly active interventions (OR 2.79; 95% CI 1.19 to 6.55), and more often gave adequate patient education (OR 3.59; 95% CI 1.35 to 9.55). They also adhered more to all four criteria (OR 2.05; 95% CI 1.15 to 3.65). Conclusions: The active strategy moderately improved adherence to the guidelines. Active strategies are recommended to implement the clinical guidelines on physiotherapy for low back pain.

Implementation of Clinical Guidelines on Physical Therapy for Patients With Low Back Pain: Randomized Trial Comparing Patient Outcomes After a Standard and Active Implementation Strategy

“…Each item is scored on a 4-point scale ranging from 1 ("seldom or never") to 4 ("very often"). Reversed items were recoded and separate sum scores were calculated for 3 active coping strategy subscales (transforming [4 -16], relaxation [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20], and lowering demands [3][4][5][6][7][8][9][10][11][12]) and for 3 passive coping strategy subscales (withdrawing , catastrophizing [9 -36], and resting [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]). A higher score refers to the use of more active and passive coping strategies for active and passive subscales, respectively.…”

“…Physical therapists in the intervention group more often gave 3 or fewer sessions to patients with a normal course of back pain (27% of patients in the intervention group and 13% of patients in the control group), set functional treatment goals (79% versus 71%), used mainly active interventions (77% versus 60%), and gave adequate patient education (96% versus 87%). 18 Based on these results, we expected that the active strategy would have beneficial effects on patient outcomes. First, we hypothesized that active implementation of the guidelines would improve physical functioning.…”

Advancing evidence-based practice in primary care physiotherapy : Guideline implementation, clinical practice, and patient preferences

“…Since most EBP implementation studies have been conducted in settings other than physiotherapy, the systematic reviews were scrutinised to identify studies set in this context. As can be seen in the Appendix 1 table, this overview revealed that only three RCTs [41,103,104] (included in six of the ten reviews) have been conducted in physiotherapy settings. Two of those three studies evaluated implementation using a guideline strategy and the third evaluated an educational program.…”

“…Because physiotherapists in Sweden are first-line practitioners and practice autonomously, without need for medical referral, guidelines can be expected to play an important role in clinical decision making. In an international perspective, only two studies were found on physiotherapy guideline implementation that used a controlled research design [103,104], indicating that knowledge is limited about the effectiveness of guideline implementation strategies in this context. Therefore, more research on this topic is needed, particularly in a Swedish primary care physiotherapy context.…”

Providing services for acute low-back pain: A survey of Australian physiotherapists

“…Many guidelines include generic advice regarding their implementation. Measuring and understanding current practice, and barriers and enablers to recommended practice, has a key role in the development of strategies to engage practitioners in adopting CPG recommendations [2].…”