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Advancing evidence-based practice in primary care physiotherapy: Guideline implementation, clinical practice, and patient preferences
Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Medicine and Health Sciences.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Research on physiotherapy treatment interventions has increased dramatically in the past 25 years and it is a challenge to transfer research findings into clinical practice, so that patients benefit from effective treatment. Development of clinical practice guidelines is a potentially useful strategy to implement research evidence into practice. However, the impact of guideline implementation in Swedish primary care physiotherapy is unknown. To achieve evidence-based practice (EBP), research evidence should be integrated with clinical expertise and patient preferences, but knowledge is limited about these factors in Swedish primary care physiotherapy.

The overall aim of this thesis was to increase understanding of factors of importance for the implementation of EBP in Swedish primary care physiotherapy. Specific aims were: to translate and adapt a questionnaire for the measurement of EBP and guidelines; to investigate physiotherapists’ attitudes, knowledge and behaviour related to EBP and guidelines; to examine clinical practice patterns; to evaluate the effects of a tailored guideline implementation strategy; and to explore patients’ preferences for physiotherapy.

The thesis comprises four studies (A-D), reported in five papers. In Study A, a questionnaire for the measurement of EBP and guidelines was translated, cross-culturally adapted, and tested for validity (n=10) and reliability (n=42). Study B was a cross-sectional study in which this questionnaire was used to survey primary care physiotherapists in the county council Region Västra Götaland (n=271). In Study C, a strategy for the implementation of guidelines was developed and evaluated, using the same questionnaire (n=271 at baseline, n=256 at follow-up), in a prospective controlled trial. The strategy was based on an implementation model, was tailored to address the determinants of guideline use identified in Study B, and comprised several components including an educational seminar. Study D was an exploratory qualitative study of patients with musculoskeletal disorders (n=20), using qualitative content analysis.

The validity and reliability of the questionnaire was found to be satisfactory. Most physiotherapists have a positive regard for EBP and guidelines, although these attitudes are not fully reflected in the reported use of guidelines. The most important determinants of  guideline use were considering guidelines important to facilitate practice and knowing how to integrate patient preferences with guidelines. The tailored, multi-component guideline implementation significantly affected awareness of, knowledge of, and access to guidelines. Use of guidelines was significantly affected among those who attended an implementation seminar. Clinical practice for common musculoskeletal conditions included interventions supported by evidence of various strengths as well as interventions with insufficient research evidence. The most frequently reported interventions were advice and exercise therapy. The interviewed patients expressed trust and confidence in the professionalism of physiotherapists and in the therapists’ ability to choose appropriate treatment, rendering treatment preferences subordinate. This trust seemed to foster active engagement in their physiotherapy.

In conclusion: The adapted questionnaire can be used to reliably measure EBP in physiotherapy. The positive attitudes found do not necessarily translate to guideline use, due to several perceived barriers. The tailored guideline implementation strategy used can be effective to reduce barriers and contribute to increased use of guidelines. The clinical practice patterns identified suggest that physiotherapists rely both on research evidence and their clinical expertise when choosing treatment methods. Patients’ trust in their physiotherapist’s competence and preference for active engagement in their therapy need to be embraced by the clinician and, together with the therapist’s clinical expertise, integrated with guideline use in the clinical decision making. Further research is needed on how the EBP components and different knowledge sources can be integrated in physiotherapy practice, as well as on implementation effects on patient outcomes.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2015. , 105 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1486
National Category
Physiotherapy Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:liu:diva-122558DOI: 10.3384/diss.diva-122558ISBN: 978-91-7685-935-3 (print)OAI: oai:DiVA.org:liu-122558DiVA: diva2:868036
Public defence
2015-12-09, Berzeliussalen, Campus US, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2015-11-09 Created: 2015-11-09 Last updated: 2015-11-30Bibliographically approved
List of papers
1. Measuring Evidence-Based Practice in Physical Therapy: Translation, Adaptation, Further Development, Validation, and Reliability Test of a Questionnaire
Open this publication in new window or tab >>Measuring Evidence-Based Practice in Physical Therapy: Translation, Adaptation, Further Development, Validation, and Reliability Test of a Questionnaire
2013 (English)In: Physical Therapy, ISSN 0031-9023, E-ISSN 1538-6724, Vol. 93, no 6, 819-832 p.Article in journal (Refereed) Published
Abstract [en]

Background. Evidence-based practice (EBP) and evidence-based clinical practice guidelines are becoming increasingly important in physical therapy. For the purpose of meeting the goals of designing, implementing, and evaluating strategies to facilitate the development of more EBP in primary care physical therapy, a valid and reliable questionnaire for measuring attitudes, knowledge, behavior, prerequisites, and barriers related to EBP and guidelines is needed. less thanbrgreater than less thanbrgreater thanObjective. The 3 objectives of this study were: (1) to translate and cross-culturally adapt a questionnaire to a Swedish primary care context for the purpose of measuring various aspects of EBP and guidelines in physical therapy, (2) to further develop the questionnaire to examine more aspects of guidelines, and (3) to test the validity and reliability of the adapted Swedish questionnaire. less thanbrgreater than less thanbrgreater thanDesign. This was an instrument development study with validity and reliability testing. less thanbrgreater than less thanbrgreater thanMethods. A previously used questionnaire about EBP was translated and cross-culturally adapted to a Swedish primary care physical therapy context. Additional items were constructed. A draft version was pilot tested for content validity (n=10), and a revised version was tested for test-retest reliability (n=42). The percentage of agreement between the 2 tests was analyzed. less thanbrgreater than less thanbrgreater thanResults. The development process resulted in a first questionnaire draft containing 48 items. The validation process resulted in a second draft with acceptable content validity and consisting of 38 items. The test-retest analysis showed that the median percentage of agreement was 67% (range=41%-81%). After removal or revision of items with poor agreement, the final questionnaire included 31 items. less thanbrgreater than less thanbrgreater thanLimitations. Only face validity and content validity were tested. less thanbrgreater than less thanbrgreater thanConclusions. The final translated and adapted questionnaire was determined to have good face and content validity and acceptable reliability for measuring self-reported attitudes, knowledge, behavior, prerequisites, and barriers related to EBP and guidelines among physical therapists in primary care settings.

Place, publisher, year, edition, pages
American Physical Therapy Association (APTA), 2013
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-95503 (URN)10.2522/ptj.20120270 (DOI)000319546800010 ()
Available from: 2013-07-05 Created: 2013-07-05 Last updated: 2017-12-06
2. Determinants of Guideline Use in Primary Care Physical Therapy: A Cross-Sectional Survey of Attitudes, Knowledge, and Behavior
Open this publication in new window or tab >>Determinants of Guideline Use in Primary Care Physical Therapy: A Cross-Sectional Survey of Attitudes, Knowledge, and Behavior
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2014 (English)In: Physical Therapy, ISSN 0031-9023, E-ISSN 1538-6724, Vol. 94, no 3, 343-354 p.Article in journal (Refereed) Published
Abstract [en]

Background. Understanding of attitudes, knowledge, and behavior related to evidence-based practice (ESP) and use of evidence-based clinical practice guidelines in primary care physical therapy is limited. Objectives. The objectives of this study were: (1) to investigate self-reported attitudes, knowledge, behavior, prerequisites, and barriers related to EBP and guideline use among physical therapists in primary care and (2) to explore associations of self-reported use of guidelines with these social cognitive factors along with demographic and workplace characteristics. Design. This was a cross-sectional survey. Methods. A web-based survey of 419 physical therapists in primary care in western Sweden was performed. Multiple logistic regression analysis was performed to examine factors associated with guideline use. Results. The response rate was 64.7%. Most respondents had positive attitudes toward EBP and guidelines: 90% considered EBP necessary, and 96% considered guidelines important. Approximately two thirds reported confidence in finding and using evidence. One third reported being aware of guidelines. Thirteen percent knew where to find guidelines, and only 9% reported having easy access to guidelines. Fewer than half reported using guidelines frequently. The most important barriers to using guidelines were lack of time, poor availability, and limited access to guidelines. Young age and brief work experience were associated with positive attitudes toward EBP. A postgraduate degree was associated with higher application of EBP. Positive attitudes, awareness of guidelines, considering guidelines to facilitate practice, and knowing how to integrate patient preferences with guideline use were associated with frequent use of guidelines. Limitations. Data were self-reported, which may have increased the risk of social.desirability bias. Conclusions. Use of guidelines was not as frequent as could be expected in view of the positive attitudes toward EBP and guidelines among physical therapists. Awareness of and perceived access to guidelines were limited. The identified determinants can be addressed when developing guideline implementation strategies.

Place, publisher, year, edition, pages
American Physical Therapy Association (APTA), 2014
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-106033 (URN)10.2522/ptj.20130147 (DOI)000332351300008 ()
Available from: 2014-04-17 Created: 2014-04-17 Last updated: 2017-12-05
3. Evaluation of a tailored, multi-component intervention for implementation of evidence-based clinical practice guidelines in primary care physical therapy: a non-randomized controlled trial.
Open this publication in new window or tab >>Evaluation of a tailored, multi-component intervention for implementation of evidence-based clinical practice guidelines in primary care physical therapy: a non-randomized controlled trial.
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2014 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, no 1, 105- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:

Clinical practice guidelines are important for transmitting research findings into practice and facilitating the application of evidence-based practice (EBP). There is a paucity of knowledge about the impact of guideline implementation strategies in primary care physical therapy. The aim of this study was to evaluate the effect of a guideline implementation intervention in primary care physical therapy in western Sweden.

METHODS:

An implementation strategy based on theory and current evidence was developed. A tailored, multi-component implementation intervention, addressing earlier identified determinants, was carried out in three areas comprising 28 physical therapy practices including 277 physical therapists (PTs) (intervention group). In two adjacent areas, 171 PTs at 32 practices received no intervention (control group). The core component of the intervention was an implementation seminar with group discussions. Among other components were a website and email reminders. Data were collected at baseline and follow-up with a web-based questionnaire. Primary outcomes were the self-reported awareness of, knowledge of, access to, and use of guidelines. Secondary outcomes were self-reported attitudes toward EBP and guidelines. Analyses were performed using Pearson's χ2 test and approximative z-test.

RESULTS:

168 PTs (60.6%) in the intervention group and 88 PTs (51.5%) in the control group responded to the follow-up questionnaire. 186/277 PTs (67.1%) participated in the implementation seminars, of which 97 (52.2%) responded. The proportions of PTs reporting awareness of (absolute difference in change 20.6%, p = 0.023), knowledge where to find (20.4%, p = 0.007), access to (21.7%, p < 0.001), and frequent use of (9.5%, NS) guidelines increased more in the intervention group than in the control group. The proportion of PTs reporting frequent guideline use after participation in the implementation seminar was 15.2% (p = 0.043) higher than the proportion in the control group. A higher proportion considered EBP helpful in decision making (p = 0.018). There were no other significant differences in secondary outcomes.

CONCLUSIONS:

A tailored, theory- and evidence-informed, multi-component intervention for the implementation of clinical practice guidelines had a modest, positive effect on awareness of, knowledge of, access to, and use of guidelines, among PTs in primary care in western Sweden. In general, attitudes to EBP and guidelines were not affected.

Place, publisher, year, edition, pages
BioMed Central, 2014
Keyword
Implementation; Physical therapy; Evidence-based practice; Practice guidelines
National Category
Physiotherapy
Identifiers
urn:nbn:se:liu:diva-105610 (URN)10.1186/1472-6963-14-105 (DOI)000333535400002 ()24589291 (PubMedID)
Available from: 2014-03-28 Created: 2014-03-28 Last updated: 2017-12-05
4. Clinical practice in line with evidence?: A survey among primary care physiotherapists in western Sweden
Open this publication in new window or tab >>Clinical practice in line with evidence?: A survey among primary care physiotherapists in western Sweden
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2015 (English)In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 21, no 6, 1169-1177 p.Article in journal (Refereed) Published
Abstract [en]

Rationale, aims and objectives

Evidence-based practice is becoming increasingly important in primary care physiotherapy. Clinical practice needs to reflect current best evidence and be concordant with evidence-based clinical guidelines. There is limited knowledge about therapeutic interventions used in primary care physiotherapy in Sweden. The objectives were to examine preferred treatment interventions reported by publicly employed physiotherapists in primary care for three common musculoskeletal disorders (low back pain, neck pain and subacromial pain), the extent to which these interventions were supported by evidence, and associations with demographic variables.

Methods

419 physiotherapists in primary care in western Sweden were surveyed using a validated web-based questionnaire.

Results

The survey was completed by 271 respondents (65%). Median number of interventions reported was 7 (range 1–16). The most common treatment interventions across the three conditions were advice on posture (reported by 82–94%), advice to stay active (86–92%), and different types of exercise (65–92%). Most of these interventions were supported by evidence. However, interventions with insufficient evidence, such as advice on posture, TENS and aquatic exercise, were also used by 29–96%. Modalities such as laser therapy and ultrasound were sparingly used (<5%), which is in line with evidence. For neck pain, use of evidence-based interventions was associated with gender and for subacromial pain, with work experience.

Conclusions

Advice and exercise therapy were the interventions most frequently reported across the three diagnoses, illustrating an active treatment strategy. While most reported interventions are supported by evidence, interventions with unclear or no evidence of effect were also used to a high extent.

Place, publisher, year, edition, pages
John Wiley & Sons, 2015
Keyword
clinical practice, evidence, evidence-based practice, interventions, physical therapy, treatment
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Family Medicine
Identifiers
urn:nbn:se:liu:diva-122555 (URN)10.1111/jep.12380 (DOI)000371414500032 ()25988993 (PubMedID)
Note

Funding agencies: local Research and Development Board for Gothenburg and Sodra Bohuslan; Linkoping University

Available from: 2015-11-09 Created: 2015-11-09 Last updated: 2017-12-01Bibliographically approved
5. “In the physio we trust”: A qualitative study on patients’ preferences for physiotherapy
Open this publication in new window or tab >>“In the physio we trust”: A qualitative study on patients’ preferences for physiotherapy
2017 (English)In: Physiotherapy Theory and Practice, ISSN 0959-3985, E-ISSN 1532-5040, Vol. 33, no 7, 535-549 p.Article in journal (Refereed) Published
Abstract [en]

Background: Patient preferences are suggested to be incorporated in clinical decision making, but little is known about preferences for physiotherapy treatment of patients with musculoskeletal pain. This study aimed to explore preferences regarding physiotherapy treatment and participation in decision making, of patients who seek primary care physiotherapy for pain in the back, neck or shoulder.

Methods: A qualitative study set in an urban physiotherapy clinic in Sweden. Individual, semi-structured interviews were conducted with a purposeful sample of 20 individuals who sought physiotherapy for back, neck or shoulder pain. The interviews were digitally recorded, transcribed verbatim and analysed with qualitative content analysis.

Results: An overarching theme, embracing six categories, was conceptualised: Trust in the physiotherapist fosters active engagement in therapy. Most informants preferred active treatment strategies such as exercise and advice for self-management, allowing them to actively engage in their therapy. Some preferred passive treatments, primarily acupuncture (because they had heard that it works well) or massage therapy (because “it feels good”). Preferences were consistent across the three musculoskeletal conditions. Key influencers on treatment preferences were previous experiences and media. All informants wanted to be involved in the clinical decision making, but to varying extents. Some expressed a preference for an active role and wanting to share decisions while others were content with a passive role. Expectations for a professional management were reflected in trust and confidence in physiotherapists’ skills and competence, expectations for good outcomes, and believing that treatment methods should be evidence-based.

Conclusions: Trust in the physiotherapist’s ability to choose appropriate treatment and confidence in the professional skills and competence of physiotherapists, as well as a desire to participate in clinical decision making, fostered active engagement in physiotherapy. Preferences for particular interventions were subordinate, although a preference for active treatments dominated. Preferences for active engagement need to be embraced by the physiotherapist. Awareness of these preferences can facilitate clinical decision making and contribute to increased quality of care for patients with musculoskeletal pain.

Place, publisher, year, edition, pages
Taylor & Francis, 2017
Keyword
Physical therapy, patient preferences, shared decision making, primary care, guidelines
National Category
Physiotherapy Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:liu:diva-122556 (URN)10.1080/09593985.2017.1328720 (DOI)000403937700003 ()
Note

Funding agencies: Local Research and Development Board for Gothenburg; Local Research and Development Board for Sodra Bohuslan

Previous status of this publication was Manuscript

Available from: 2015-11-09 Created: 2015-11-09 Last updated: 2017-07-07Bibliographically approved

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