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

Should low-quality evidence dominate high-level evidence? A systematic review and meta-analysis of systematic reviews of musculoskeletal physical therapy interventions

OBJECTIVES

To determine the: 1) quality of articles cited in systematic reviews (SRs); 2) methodological quality of the SRs; and 3) impact of quality on level 1A evidence.

METHODS

SRs related to musculoskeletal physical therapy interventions were identified. The methodological quality of the SRs and articles cited by the SRs were assessed by two blinded reviewers. Data analysis was performed by a third blinded researcher. Additional comparisons were made based on the Journal Impact Factor, spin, financial bias, and conflict of interest.

RESULTS

Twenty-four SRs were identified; 21/24 SRs had 'critically low' quality on the AMSTAR 2. Thirty-four percent of included studies were 'low quality,' and 58% of SRs included studies that had unreported external validity. One-half of the SRs represented 'spin,' and one-third of the SRs generated conclusions based on low-quality clinical trials.

DISCUSSION

The 'critically low' SRs methodological quality was exacerbated by low-quality research inclusion. Most SRs failed to follow best practices, including prospective registration and integration of professional librarians in the search process. Based on the high proportion of SRs that include low-quality trials and overall low methodological quality, further discussion regarding practice recommendations on level vs. quality of evidence is warranted.

LEVEL OF EVIDENCE

1a.

Overcoming Overuse Part 2: Defining and Quantifying Health Care Overuse for Musculoskeletal Conditions

In this series on "Overcoming Overuse," we explore the issue of health care overuse and how it may be identified in musculoskeletal physical therapy. In part 2, we frame health care overuse as a continuum from overuse to appropriate care, and consider how to measure overuse. We describe how overuse can be defined within a framework of care that is ineffective, inefficient, and misaligned, depending on the perspective of the person delivering or receiving care-the clinician, society, or patient. To ensure that musculoskeletal health care is of high value and sustainable, we encourage physical therapists to reflect on their practice. J Orthop Sports Phys Ther 2020;50(11):588-591. doi:10.2519/jospt.2020.0109.

Introduction of a psychologically informed educational intervention for pre-licensure physical therapists in a classroom setting

BACKGROUND

There is an increasing need for physical therapists to address psychosocial aspects of musculoskeletal pain. Psychologically informed practice is one way to deliver this type of care through the integration of biopsychosocial interventions into patient management. An important component of psychologically informed practice is patient centered communication. However, there is little research on how to effectively implement patient centered communication into pre-licensure training for physical therapists.

METHODS

Thirty Doctor of Physical Therapy (DPT) students took part in an educational intervention that consisted of one 4-h didactic teaching session and three 1-h experiential learning sessions. Prior to the first session, students performed an examination of a standardized patient with chronic low back pain and were assessed on psychologically informed physical therapy (PIPT) adherent behaviors via a rating scale. Students also completed the Pain Attitudes and Beliefs Scale (PABS-PT). After the last experiential session, students evaluated another standardized patient and were reassessed on PIPT adherent behaviors. Students retook the PABS-PT and qualitative data was also collected.

RESULTS

After the educational intervention, students had positive changes in their pain attitudes and belief scores indicating a stronger orientation toward a psychosocial approach to patient care (p < 0.05). Additionally, after the intervention, students showed improvements in their adherence to using PIPT behaviors in their simulated patient interactions (p < 0.05). Qualitatively, students reported a high acceptability of the educational intervention with common themes indicating improved confidence with treating and communicating with complex patients.

CONCLUSION

Students had attitudes and beliefs shift towards a more psychosocial orientation and demonstrated improved PIPT behaviors in simulated patient interactions after a brief educational intervention. Future research should investigate best practices for implementation of psychologically informed physical therapy for licensed clinicians.

Implementing models of care for musculoskeletal conditions in health systems to support value-based care

Models of Care (MoCs), and their local Models of Service Delivery, for people with musculoskeletal conditions are becoming an acceptable way of supporting effective implementation of value-based care. MoCs can support the quadruple aim of value-based care through providing people with musculoskeletal disease improved access to health services, better health outcomes and satisfactory experience of their healthcare; ensure the health professionals involved are experiencing satisfaction in delivering such care and health system resources are better utilised. Implementation of MoCs is relevant at the levels of clinical practice (micro), service delivery organisations (meso) and health system (macro) levels. The development, implementation and evaluation of MoCs has evolved over the last decade to more purposively engage people with lived experience of their condition, to operationalise the Chronic Care Model and to employ innovative solutions. This paper explores how MoCs have evolved and are supporting the delivery of value-based care in health systems.

Physiotherapists may improve management of knee osteoarthritis through greater psychosocial focus, being proactive with advice, and offering longer-term reviews: a qualitative study

QUESTIONS

What are the experiences of physiotherapists delivering care for people with knee osteoarthritis? How do these experiences align with the national Clinical Care Standard?

DESIGN

A qualitative study using individual interviews.

PARTICIPANTS

Twenty-two Australian physiotherapists (mean age 34 years, 50% female) with experience in providing care for people with knee osteoarthritis.

METHODS

Physiotherapists participated in semi-structured individual telephone interviews. Questions were informed by seven quality statements from the national Knee Osteoarthritis Clinical Care Standard. Thematic analysis was undertaken, with themes/subthemes inductively derived. Interview data were also deductively analysed according to the Clinical Care Standard.

RESULTS

Five themes emerged. First, physiotherapists focused on biomedical assessment with little psychosocial consideration. They managed 'mechanical' aspects of knee osteoarthritis, aiming to restore functional ability. Second, physiotherapists' perceived their role as primarily providing goal-orientated personalised exercise via short-term episodic care. Knee surgery was considered a last option, but physiotherapists 'prepped' patients who decided on surgery. Third, clinical challenges included patient comorbidity, unsatisfactory patient adherence and a patient's desire for a 'quick fix'. The other two themes were: physiotherapists described a mismatch between what they know and what they do regarding imaging, weight management and manual therapy; and physiotherapists viewed weight loss, medication and surgical advice as outside of their professional role.

CONCLUSION

Physiotherapists' reported experiences of delivering care for people with knee osteoarthritis were mostly consistent with the quality care standard. Care may be improved by increasing the focus on psychosocial aspects of care, offering longer-term reviews, and being more proactive with advice and/or referral regarding weight loss, pain medications and knee surgery. By describing the potential benefits and harms of common osteoarthritis medications and surgical interventions, physiotherapists will ensure that their patients are fully informed about all their treatment options.

The Active with OsteoArthritis (AktivA) Physiotherapy Implementation Model: A Patient Education, Supervised Exercise and Self-Management Program for Patients with Mild to Moderate Osteoarthritis of the Knee or Hip Joint. A National Register Study with a Two-Year Follow-Up

BACKGROUND

Recent systematic reviews and international guidelines recommend patient education, exercises, and weight control (if overweight) as first-line treatment for patients with hip or knee osteoarthritis (OA). The Active with osteoArthritis (AktivA) program is a physiotherapy model for the implementation of these guidelines into clinical primary care practice. The purpose of the present study was to evaluate the long-term effects of and adherence to the AktivA program for patients with mild to moderate knee or hip OA.

METHODS

The AktivA program includes three modules: a physiotherapy certification course, a patient education and exercise program and an electronic quality register. An electronic questionnaire including questions about, pain, quality of life, physical activity, self-efficacy and satisfaction with the AktivA program are sent to the participants at inclusion and after 3, 12 and 24 months. A linear mixed model for repeated measurements was used to assess the difference between the follow-up times.

RESULTS

Until January 2020, 6245 patients were included in the register. The response rates were 98%, 86% and 63% at 3, 12 and 24 months, respectively. After participating in the AktivA program, the patients reported decreased pain and increased health-related and disease-specific quality of life at three months and the positive effect was maintained up to two years after inclusion. The proportion of patients reporting to be inactive or having a low physical activity level was reduced from 43% to 22%. After two years, more than 80% of the participants reported to use what they have learned from the AktivA program at least once a week.

CONCLUSIONS

Two years after inclusion in the AktivA physiotherapy program, the patients still report reduced pain, increased quality of life and higher activity levels.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPACT

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

What Interventions Do Physical Therapists Provide for Patients With Cardiorespiratory Conditions, Neurological Conditions, and Conditions Requiring Acute Hospital Care? A Systematic Review

OBJECTIVE

The aim of this systematic review was to determine what percentages of physical therapists provide interventions that are of high value, low value, or unknown value for cardiorespiratory conditions, neurological conditions, or conditions requiring acute hospital care. Whether an intervention was considered high or low value was determined by reference to guidelines or systematic reviews.

METHODS

Searches of numerous databases were performed by combining terms synonymous with "practice patterns" and "physical therapy" until April 2018. Studies that investigated what interventions physical therapists provide for any cardiorespiratory condition, neurological condition, or condition requiring acute hospital care through surveys and audits of clinical notes were included. Through the use of medians and interquartile ranges, the percentages of physical therapists who provided interventions that were of high value, low value, or unknown value were summarized.

RESULTS

Twenty-six studies were included. The median percentages of physical therapists who provided interventions of high, low, and unknown value for chronic obstructive pulmonary disease ranged from 78% to 96%, 67% to 100%, and 56% to 91%, respectively. These percentages ranged from 61% to 97%, 87% to 98%, and 83% to 98% for adults who were critically ill in intensive care units; 70% to 93%, 38% to 50%, and 8% to 95% before or after cardiac/thoracic surgery; 25% to 96%, 23% to 84%, and 96% for acute stroke; and 11% (high value) and 13% (unknown value) for Parkinson disease, respectively.

CONCLUSIONS

This review found patterns of physical therapist practice for cardiorespiratory conditions, neurological conditions, and conditions requiring acute hospital care that were both evidence based and not evidence based. A concern is that a substantial percentage of physical therapists provided interventions that were of low or unknown value despite the availability of high-value interventions.

IMPACT

This systematic review is the first, to our knowledge, to summarize the percentage of physical therapist treatment choices that were high versus low value for cardiorespiratory conditions, neurological conditions, and conditions requiring acute hospital care. The findings highlight areas of practice where low-value care could be replaced with high-value care-such as in the management of patients who have chronic obstructive pulmonary disease or who are in intensive care-and identify an urgent need to develop and test strategies to ensure that patients with these conditions receive the interventions most likely to improve their outcomes.

"It's disappointing and it's pretty frustrating, because it feels like it's something that will never go away." A qualitative study exploring individuals' beliefs and experiences of Achilles tendinopathy

Background

Achilles tendinopathy (AT) is a common and often persistent musculoskeletal disorder affecting both athletic and non-athletic populations. Despite the relatively high incidence there is little insight into the impact and perceptions of tendinopathy from the individual’s perspective. Increased awareness of the impact and perceptions around individuals’ experiences with Achilles tendinopathy may provide crucial insights for the management of what is often a complex, persistent, and disabling MSK disorder.

Purpose

To qualitatively explore the lived experiences of individuals with AT.

Design

A qualitative, interpretive description design was performed using semi-structured telephone interviews.

Methods

Semi-structured interviews were conducted on 15 participants (8 male and 7 female) with AT. Thematic analysis was performed using the guidelines laid out by Braun and Clarke. The study has been reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) checklist.

Results

Four main themes were identified from the data: 1) beliefs and perceptions surrounding AT: “If I'm over training or something, I don't really know”, 2) the biopsychosocial impact of AT: “I think it restricts me in a lot of things that I would be able to do”, 3) individuals’ experiences with the management process: “You want it to happen now. You're doing all this stuff and it's just very slow progress”, and 4) future prognosis and outlook in individuals with AT: “I see myself better”.

Conclusions

This study offers a unique insight into the profound impact and consequences of Achilles tendinopathy in a mixed sample of both athletic and non-athletic individuals. The findings of this study have important clinical implications. Specifically, it highlights the need for clinicians to recognize and adopt treatment approaches to embrace a more biopsychosocial approach for the management of tendinopathy.

Development and Usability Testing of a Web-Based and Therapist-Assisted Coping Skills Program for Managing Psychosocial Problems in Individuals With Hand and Upper Limb Injuries: Mixed Methods Study

Background

Ineffective coping has been linked to prolonged pain, distress, anxiety, and depression after a hand and upper limb injury. Evidence shows that interventions based on cognitive behavioral therapy (CBT) may be effective in improving treatment outcomes, but traditional psychological interventions are resource intensive and unrealistic in busy hand therapy practices. Developing web-based, evidence-based psychological interventions specifically for hand therapy may be feasible in clinical practice and at home with reduced training and travel costs. Hand Therapy Online Coping Skills (HOCOS) is a program developed to supplement traditional hand therapy with therapist-assisted coping skills training based on principles from CBT and the Technology Acceptance Model.

Objective

This study aimed to describe the development and assess the usability of HOCOS to support hand therapists in the management of psychosocial problems.

Methods

The ADDIE model (Analysis, Design, Development, Implementation, and Evaluation) of system design was applied to create HOCOS. The usability testing of HOCOS involved a 2-stage process. In the first step, heuristic testing with information and communications technology (ICT) experts was completed using two sets of heuristics: Monkman heuristics and the Health Literacy Online (HLO) checklist. The second step involved user testing with hand therapists performing a series of online and face-to-face activities, completing 12 tasks on the website using the think-aloud protocol, completing the system usability scale (SUS) questionnaire, and a semistructured feedback interview in 2 iterative cycles. Descriptive statistics and content analyses were used to organize the data.

Results

In total, 4 ICT experts and 12 therapists completed usability testing. The heuristic evaluation revealed 15 of 35 violations on the HLO checklist and 5 of 11 violations on the Monkman heuristics. Initially, hand therapists found 5 tasks to be difficult but were able to complete all 12 tasks after the second cycle of testing. The cognitive interview findings were organized into 6 themes: task performance, navigation, design esthetics, content, functionality and features, and desire for future use. Usability issues identified were addressed in two iterative cycles. There was good agreement on all items of the SUS. Overall, therapists found that HOCOS was a detailed and helpful learning resource for therapists and patients.

Conclusions

We describe the development and usability testing of HOCOS; a new web-based psychosocial intervention for individuals with a hand and upper limb injuries. HOCOS targets psychosocial problems linked to prolonged pain and disability by increasing access to therapist-guided coping skills training. We actively involved target users in the development and usability evaluation of the website. The final website was modified to meet the needs and preferences of the participants.

Has physical therapists' management of musculoskeletal conditions improved over time?

BACKGROUND

Our 2019 systematic review found that up to 63% of physical therapists provided recommended care for musculoskeletal conditions, up to 43% provided non-recommended care, and up to 81% provided care of unknown value. We included studies published as early as 1993 and as recent as 2017.

OBJECTIVE

To determine whether physical therapists' treatment choices for musculoskeletal conditions have improved over time.

METHODS

For the original review, we included studies (until April 2018) that quantified physical therapy treatment choices for musculoskeletal conditions through surveys of physical therapists, audits of clinical notes, and other methods (e.g. clinical observation). Using medians and interquartile ranges, we summarised the percentage of physical therapists who provided treatments that were recommended, not recommended, and of unknown value. For this analysis, we stratified the findings from the above systematic review by decade (1990-1999, 2000-2009, 2010-2018).

RESULTS

The median percentage of physical therapists who provided recommended treatments (40% from 1990 to 1999, 50% from 2000 to 2009, and 35% from 2010 to 2018) and non-recommended treatments (41%, 28%, and 39% respectively) has not changed over time. However, more physical therapists seem to be providing treatments of unknown value (41% from 1990 to 1999, 55% from 2000 to 2009, and 70% from 2010 to 2018).

CONCLUSION

Possible explanations for this trend include the growing need for clinical innovation, challenge of keeping up to date with evidence, increased exposure to treatments of unknown value, belief that evidence is not relevant to practice, and possible limitations of the data. Strategies to help physical therapists replace non-recommended care with recommended care are discussed.

Overcoming Overuse: Improving Musculoskeletal Health Care

This is the first article in a series on "Overcoming Overuse" in musculoskeletal health care. Overuse is the use of services that are unlikely to improve patient outcomes, result in more harm than benefit, and would not be desired by an informed patient. The Overcoming Overuse series explores the myriad ways diagnostic tests and treatments are overused in musculoskeletal health care, and proposes ways to ensure patients receive appropriate care. We focus on strategies to promote guideline-concordant care in rehabilitation practice and strategies to overcome overuse. J Orthop Sports Phys Ther 2020;50(3):113-115. doi:10.2519/jospt.2020.0102.

Clinical Characteristics and Patient-Reported Outcomes of Primary Care Physiotherapy in Patients with Whiplash-Associated Disorders: A Longitudinal Observational Study

BACKGROUND

Whiplash-associated disorders (WADs) constitute a state of health characterized by a wide diversity of symptoms as a result of impairments of functions, activity limitations, and participation restrictions. Patient-reported outcome measurements (PROMs) and patient-reported outcomes (PROs) seem appropriate when describing and evaluating the health status of patients with WAD.

AIM

To measure the use of PROMs and PROs as quality indicators in clinical reasoning, and to analyze and evaluate pre- and post-treatment 'pain intensity' and 'functioning', and for 'perceived improvement' in patients with WAD in primary care physiotherapy practice by year of referral, with the phase after accident and prognostic health profile embedded in the clinical reasoning process.

MATERIALS AND METHODS

Data were collected over a period of 10 years. Pain intensity, functioning, and perceived improvement were measured using the Visual Analogue Scale for Pain (VAS-P), the Neck Disability Index (NDI) and the Global Perceived Effect scale (GPE). Pre- and post-treatment mean differences were tested for statistical significance and compared to minimal clinically important differences (MCID). Effect sizes were expressed as Cohen's d. Multivariable regression analysis was performed to explore independent associations of year of referral, phase after the accident, and the patient's prognostic health profile with post-treatment pain intensity and functioning.

RESULTS

A consecutive sample of 523 patients was included. Pre- and post-treatment mean differences on VAS-P and NDI were statistically significant (P<0.000) and clinically relevant, with 'large' effect sizes for pain intensity and functioning. MCIDs were achieved by 80% for VAS-P and for 60% for NDI. Year of referral and phase after the accident were independently associated with worse post-treatment functioning. About half of the patients (n=241 [46.1%]) perceived themselves as improved.

CONCLUSION

The PROMs and PROs pain intensity, functioning and perceived improvement were integrated as quality indicators in the physiotherapy clinical reasoning process for patients with WAD. Significant differences in pain intensity and functioning were found but were unrelated to year of referral, phase after whiplash-related injury or prognostic health profile. The MCID VAS-P scores did not differ depending on experienced pain.

Family and Community Medicine and its role in preventing health overuse (preventive, diagnostic, therapeutic and rehabilitative)

In Medicine, it is critical "to offer 100% of what is needed and avoid 100% of what is not needed." Unfortunately, this primary issue is challenging, and generally, more than required is offered, and everything that is unnecessary is not avoided. This is a nonsystematic review with a teaching objective that reviews the general issue in primary care and suggests ways to avoid overuse and shortcomings concerning preventive, diagnostic, therapeutic, and rehabilitative interventions. Knowing not to do is science and art that is hardly taught and practiced less. The overuse that harm are an almost daily part of clinical practice in prevention, diagnosis, treatment, and rehabilitation. It is essential to promote "the art and science of not doing".