American Physical Therapy Association Clinical Practice Guideline Implementation for Neck and Low Back Pain in Outpatient Physical Therapy: A Nonrandomized, Cross-sectional Stepped-Wedge Pilot Study

Adherence to neck and low back pain clinical practice guidelines based on clinical specialization: a survey of physical therapists

OBJECTIVE

To investigate physical therapist adherence to the Academy of Orthopaedic Physical Therapy's (AOPT) clinical practice guidelines (CPGs) for the management of neck and low back pain (LBP) and to compare adherence among varying clinical specializations.

DESIGN

Electronic cross-sectional survey.

METHODS

The survey was sent to 17,348 AOPT members and 7,000 American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) members. Participants selected the best diagnosis and intervention(s) for six case vignettes based on the current AOPT CPGs for neck and LBP. Diagnostic and intervention adherence rates were reported as total percentages and delineated by the highest level of clinical specialization - fellowship training (PTFs), orthopedic residency training (PTRs), Board Certified Clinical Specialist in Orthopaedic Physical Therapy (PTSs), orthopedic background without clinical specialization (PTOs). Binary logistic regression analyses were performed to determine the effects of clinical specialization (PTFs, PTRs, or PTSs) compared to PTOs on the likelihood of guideline adherence for all six cases.

RESULTS

Of the 159 participants who responded to the survey, 152 were eligible and 145 completed demographic data. Participant responses declined as the survey progressed from 125 completing case one to 106 completing case six. The odds ratio from binary logistic regression analyses were not significant for any specialization in all six cases (OR = 0.16; 95% CI: 0.02, 1.11; p = 0.064).

CONCLUSIONS

The results of this manuscript demonstrated variable adherence rates across subgroups of patients with neck and LBP with no significant association between clinical specialization and adherence. Adherence to CPGs is dependent on the clinical presentation of various patient cohorts.

Differences in content of care and outcomes between a clinical practice guideline adherent program and usual care for patellofemoral pain: A retrospective pilot study

BACKGROUND

Patellofemoral pain (PFP) is a common knee condition in young and active individuals that is managed with highly variable treatment strategies.

OBJECTIVE

To determine whether the length, number of visits, and content of physical therapy care for patients with PFP differ between a Clinical Practice Guidelines (CPG) adherent program and usual care. Additionally, the percentage of patients reporting clinically important improvements in patient-reported outcomes in each group was evaluated as an exploratory aim.

DESIGN

Retrospective analysis of clinical data.

SETTING

Military outpatient physical therapy clinics.

PATIENTS

Thirty-two patients who received CPG-adherent care and 46 patients who received usual care.

INTERVENTIONS

Patients in the CPG-adherent group were classified into overuse/overload, movement coordination deficits, muscle performance deficits, or mobility impairments subcategories based on CPG-recommended examination procedures and received the CPG-recommended interventions. Patients in the usual care group received interventions based on clinical expertise and organizational practice standards.

MAIN OUTCOMES MEASURES

Length of care, number of visits, and intervention content were used as primary outcomes. The Anterior Knee Pain Scale (AKPS), Defense and Veterans Pain Rating Scale (DVPRS), and Global Rating of Change (GROC) scores were used as secondary outcomes. These scores were extracted from routinely collected health data available in medical records; as a result, not all patients completed these outcomes during the follow-up time points because they were optional.

RESULTS

The number of physical therapy visits and percentage of patients receiving knee-targeted exercises, soft tissue mobility interventions, neuromuscular reeducation, patient education, patellar taping, and foot orthoses were greater in the CPG-adherent group compared to usual care (p < .05). Additionally, most patients in the CPG-adherent group reported clinically meaningful improvements in secondary outcomes: AKPS (1 month: 13/23; 3 months: 11/16), DVPRS (1 month: 11/20; 3 months: 8/14), and GROC (1 month: 14/22; 3 months: 11/16). In contrast, fewer than half of the patients in the usual care group reached clinically meaningful thresholds: AKPS (1 month: 1/17; 3 months: 3/8), DVPRS (1 month: 3/15; 3 months: 3/7), and GROC (1 month: 2/12; 3 months: 2/7).

CONCLUSION

The content of the CPG-adherent care was significantly different versus usual care and associated with meaningful changes in outcomes. Several CPG-recommended interventions appeared to be underused in usual care, underscoring the value of further CPG adoption.

Evaluation of the Application of Clinical Practice Guideline Recommendations on the Classification of Patients With Neck Pain

Background: Clinical practice guidelines (CPGs) are developed to synthesize evidence into recommendations for clinical practice. Minimal evidence exists on the evaluation practice of physical therapists in the treatment of patients with neck pain. Purpose: We sought to describe (1) the extent to which clinicians perform the Neck Pain CPG-recommended examination measures and (2) the percentage of patients properly classified. Methods: We retrospectively analyzed the electronic health records of 397 patients with neck pain at an ambulatory care setting in an academic medical center. The frequency of physical therapists' evaluation measures, subjective findings, positive examination results, and the percentage of patients properly classified into impairment-based categories (IBCs) were recorded. Descriptive statistics and χ2 tests were used to assess patient demographics and compare classification accuracy across IBCs. Results: Of the 397 patients, 56% were classified into an IBC. The most common IBC was neck pain with mobility deficits (24%), followed by neck pain with radiating pain (17%), neck pain with movement coordination impairments (NPMCIs) (8%), and neck pain with headache (6%). Neck pain with movement coordination impairment had the lowest percentage of proper classifications. Classification accuracy was highest when subjective and objective findings were combined and varied between IBCs. Conclusion: Our findings suggest that physical therapists evaluating patients with neck pain may have increased classification accuracy when subjective and objective findings are considered. Decreased classification accuracy was demonstrated in the NPMCI category, highlighting opportunities for further education and research.

Measuring guideline adherence in physiotherapy: A scoping review of methodological approaches

RATIONALE

Clinical practice guidelines summarise the existing evidence on specific health conditions and aim to optimise quality of care by providing evidence-based recommendations. Studies have reported a gap between research findings and clinical practice in physiotherapy. Guideline adherence is often used as a measure of agreement between therapeutic care and guideline recommendations. However, there is currently no standardised methodological approach for measuring guideline adherence.

AIMS AND OBJECTIVE

The objective of this scoping review was to summarise the methods and results of studies that assessed guideline adherence in physiotherapy.

METHODS

MEDLINE, EMBASE, PEDro and CENTRAL databases were searched for relevant literature up to December 2022. Published reports of observational studies and controlled clinical trials that provided information on the assessment of guideline adherence in physiotherapists were included. The selection process was performed independently by two reviewers. The methodological quality of the identified reports was not assessed. Results were summarised narratively.

RESULTS

From a total of 2560 potentially relevant records, 53 reports were included in the analysis. Physiotherapists' adherence to guidelines was primarily assessed in the context of musculoskeletal conditions, such as low back pain (n = 25, 47.2%) and osteoarthritis (n = 8, 15.1%). A wide range of measurement approaches were used with the majority of reports using web-based surveys (n = 21, 39.6%), followed by chart reviews (n = 17, 32.1%). Most reports (n = 21, 39.6%) provided information on the level of adherence in terms of frequency dichotomising (self-reported) clinical practice as adherent or non-adherent. Adherence rates varied widely between included reports.

CONCLUSIONS

Although the large number of included reports indicates a high level of interest in the topic of guideline adherence, there is considerable heterogeneity between studies regarding the methodological approaches used to assess guideline adherence in physiotherapists. This reduces the comparability of the study results.

TRIAL REGISTRATION

INPLASY (registration no. 202250081). Registered on 12th May 2022.

Developing a low back pain guideline implementation programme in collaboration with physiotherapists and chiropractors using the Behaviour Change Wheel: a theory-driven design study

BACKGROUND

Low back pain is still the leading cause of disability and societal burden, with 619 million prevalent cases worldwide in 2020. Most countries produce clinical guidelines to support healthcare professionals in evidence-based care regarding low back pain. However, several studies have identified relatively poor uptake of guidelines. Tailored strategies to facilitate the implementation of guidelines have been argued to increase uptake. This study aimed to develop a contextually tailored implementation programme to enhance evidence-based low back pain care among Danish physiotherapists and chiropractors in primary care.

METHODS

A theory-driven implementation programme development study was conducted using the Behaviour Change Wheel, with high healthcare professional involvement. Data collection included four workshops with seven physiotherapists and six chiropractors from primary care clinics. The development process consisted of [1] establishing a theoretical frame, [2] involving participants, [3] understanding the behaviour, [4] designing the implementation programme, and [5] final implementation programme.

RESULTS

The target behaviours selected (guideline recommendations) for the implementation programme were (i) screening of psychosocial risk factors and (ii) offering patient education. The barriers and facilitators for the selected behaviours were described and linked to intervention functions and behavioural techniques. Finally, the implementation programme comprised five strategies: webinars, e-learning videos, communication exercises, peer learning, and group dialogue meetings. In addition, the programme consisted of implementation support: champions, a physical material folder, a weekly email reminder, a specially designed website and a visit from an implementation consultant. An essential element of the overall programme was that it was designed as a step-by-step implementation process consisting of 16 h of education and training distributed over 16 weeks.

CONCLUSIONS

A programme for implementing low back pain guideline recommendations was developed based on behaviour change theory and four co-design workshops involving healthcare professionals to overcome the contextually identified barriers. A theory-driven approach involving healthcare professionals was useful in identifying relevant target behaviours and tailoring the programme to consider contextual barriers and facilitators for implementation. The effectiveness of the final implementation programme will be evaluated in the project's next phase.

TRIAL REGISTRATION

Central Denmark Region, Registered November 11, 2021, act no. 1-16-02-93-19.

The Practice of Shared Decision-Making Among Physiotherapists and Patients with Musculoskeletal Conditions

Purpose

Shared decision-making (SDM) may be interpreted as a set of core values rather than as a consensus definition. This study aimed to explore how SDM between patients and physiotherapists may lead to patient satisfaction.

Patients and Methods

A cross-sectional study was conducted to examine the relationship between SDM and patient satisfaction. The study targeted physiotherapists and patients with musculoskeletal pain or disorders. A structured questionnaire (the nine-item Shared Decision-Making Questionnaire) was developed to show the extent to which patients felt involved in the process by scoring nine items from 0 to 5 on a six-point scale. t-tests were performed to estimate differences in SDM perceptions between patients and physiotherapists, and regression analyses were performed to estimate the best predictors of SDM.

Results

The questionnaire was completed by a total of 106 patients and nine physiotherapists. The demographic information of the samples was presented with frequency analysis. This study's findings demonstrate no variations in the final SDM perceptions between patients and physiotherapists, but when SDM was contrasted step-by-step (as items), many variances were discovered. These distinctions reinforce the notion that regardless of the end outcome, the process of reaching a consensus has a distinct profile depending on the type of medical care. Therapists emphasize the first steps, possibly because there is sufficient evidence to make a therapeutic decision. However, patients highlight the final steps, perhaps because the moment for a decision based on the consultation's nature is approaching.

Conclusion

This study demonstrates that SDM is a complex process that must be examined in multiple stages. However, in physiotherapy contexts, this process exhibits extremely different patterns, reflecting a significantly different perspective of the decision-making process.

Utilization of Clinical Practice Guideline Interventions in the Conservative Management of Mechanical Neck Pain: A Retrospective Analysis

INTRODUCTION

Neck pain is a common musculoskeletal condition frequently treated by physical therapists. The American Physical Therapy Association (APTA) published a clinical practice guideline (CPG) in 2008 with a revision in 2017 to improve the diagnosis and treatment of neck pain. One subset of neck pain in the CPG is "Neck Pain with Mobility Deficits," also called mechanical neck pain. Little data exists on the adherence of physical therapists to the CPG-recommended treatments for neck pain as well as the outcomes associated with the utilization of the CPG. The purpose of this study is to examine both CPG treatment adherence and associated outcomes in patients treated for mechanical neck pain by physical therapists in the outpatient setting.

METHODS

Retrospective chart review of patients (n=224) who received physical therapy for neck pain between 2018 and 2022. Data ranges were chosen due to the publication of the CPG revision in 2017. Six interventions for mechanical neck pain from the CPG were examined: thoracic manipulation, cervical mobilization, transcutaneous electrical stimulation (TENS), dry needling, advice to stay active, and scapular resistance exercises. The exclusion criteria were a history of cervical spine surgery. Other data collected included age, sex, characteristics of the evaluating physical therapist, and the number of visits.

RESULTS

For CPG treatment adherence, 4.5% of patients received thoracic manipulation, 47.8% of patients received cervical mobilization, 12.5% of patients received TENS, 22.8% of patients received dry needling, 99.1% of patients received advice to stay active, and 89.3% of patients received scapular resistance exercises. There was no significant improvement in pain, range of motion (ROM), and function based on a number of CPG interventions used during the bout of physical therapy (p=0.17 to p=0.74). Patients who were evaluated by a physical therapist who was an Orthopedic Certified Specialist (OCS) were more likely to receive more interventions recommended by the CPG (p<0.01).

CONCLUSION

CPG-recommended treatments are used with varying frequency by physical therapists when treating mechanical neck pain. Thoracic manipulation is rarely used while scapular resistance exercises are frequently used. There was no significant improvement in pain, ROM, or function based on the number of CPG-recommended treatments used during the bout of physical therapy.