title: Evidence for physiotherapy practice: a survey of the Physiotherapy Evidence Database (PEDro). 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 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. Adherence to physiotherapy clinical guideline acute ankle injury and determinants of adherence: a cohort study Evaluating two implementation strategies for whiplash guidelines in physiotherapy: a cluster randomised trial. Testing the effectiveness of an innovative information package on practitioner reported behaviour and beliefs: The UK Chiropractors, Osteopaths and Musculoskeletal Physiotherapists Low back pain ManagemENT (COMPLeMENT) trial [ISRCTN77245761] Compliance with the guidelines for acute ankle sprain for physiotherapists is moderate in the Netherlands: an observational study. Does physiotherapy management of low back pain change as a result of an evidence-based educational programme? Prognostic Factors for Low Back Pain in Patients Referred for Physiotherapy: Comparing Outcomes and Varying Modeling Techniques
abstract: Evidence -based practice involves the use of evidence from systematic review s and r and omised controlled trials , but the extent of this evidence in physiotherapy has not previously been surveyed . The aim of this survey is to describe the quantity and quality of r and omised controlled trials and the quantity of systematic review s relevant to physiotherapy . The Physiotherapy Evidence Data base ( PEDro ) was search ed . The quality of trials was assessed with the PEDro scale . The search identified a total of 2,376 r and omised controlled trials and 332 systematic review s. The first trial was published in 1955 and the first review was published in 1982 . Since that time , the number of trials and review s has grown exponentially . The mean PEDro quality score has increased from 2.8 in trials published between 1955 and 1959 to 5.0 for trials published between 1995 and 1999 . There is a substantial body of evidence about the effects of physiotherapy . However , there remains scope for improvements in the quality of the conduct and reporting of clinical trials 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 r and omised controlled trial comparing an active strategy with st and ard dissemination . Setting : Primary care physiotherapy practice s. Participants : 113 physiotherapists were r and omly 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 BACKGROUND AND PURPOSE An active strategy was developed for the implementation of the clinical guidelines on physical therapy for patients with low back pain . The effect of this strategy on patients ' physical functioning , coping strategy , and beliefs regarding their low back pain was studied . SUBJECTS One hundred thirteen primary care physical therapists treated a total of 500 patients . METHODS The physical therapists were r and omly assigned to 1 of 2 groups . The control group received the guidelines by mail ( st and ard passive method of dissemination ) . The intervention group , in contrast , received an additional active training strategy consisting of 2 sessions with education , group discussion , role playing , feedback , and reminders .  Patients with low back pain , treated by the participating therapists , completed question naires on physical functioning , pain , sick leave , coping , and beliefs . RESULTS Physical functioning and pain in the 2 groups improved substantially in the first 12 weeks . Multilevel longitudinal analysis showed no differences between the 2 groups on any outcome measure during follow-up . DISCUSSION AND CONCLUSION The authors found no additional benefit to applying an active strategy to implement the physical therapy guidelines for patients with low back pain . Active implementation strategies are not recommended if patient outcomes are to be improved Background Clinical guidelines are considered important instruments to improve quality in health care . In physiotherapy , insight in adherence to guidelines is limited . Knowledge of adherence is important to identify barriers and to enhance implementation . Purpose of this study is to investigate the ability to adherence to recommendations of the guideline Acute ankle injury , and to identify patient characteristics that determine adherence to the guideline . Methods Twenty-two physiotherapists collected data of 174 patients in a prospect i ve cohort study , in which the course of treatment was systematic ally registered . Indicators were used to investigate adherence to recommendations . Patient characteristics were used to identify prognostic factors that may determine adherence to the guideline . Correlation between patient characteristics and adherence to outcome -indicators ( treatment sessions , functioning of patient , accomplished goals ) was calculated using univariate logistic regression . To calculate explained variance of combined patient characteristics , multivariate analysis was performed . Results Adherence to individual recommendations varied from 71 % to 100 % . In 99 patients ( 57 % ) the physiotherapists showed adherence to all indicators . Adherence to preset maximum of six treatment sessions for patients with severe ankle injury was 81 % ( 132 patients ) .The odds to receive more than six sessions were statistically significant for three patient characteristics : females ( OR:3.89 ; 95%CI : 1.41–10.72 ) , recurrent sprain ( OR : 6.90 ; 95%CI : 2.34 – 20.37 ) , co-morbidity ( OR : 25.92 ; 95 % CI : 6.79 – 98.93 ) . All factors together explained 40 % of the variance . Inclusion of physiotherapist characteristics in the regression model showed that work-experience reduced the odds to receive more than six sessions ( OR : 0.2 ; 95%CI : 0.06 – 0.77 ) , and increased explained variance to 45 % . Conclusion Adherence to the clinical guideline Acute ankle sprain showed that the guideline is applicable in daily practice . Adherence to the guideline , even in a group of physiotherapists familiar with the guideline , showed possibilities for improvement . The necessity to exceed the expected number of treatment sessions may be explained by co-morbidity and recurrent sprains . It is not clear why female patients were treated with more sessions . Experience of the physiotherapist reduced the number of treatment sessions . Quality indicators may be used for audit and feedback as part of the implementation strategy QUESTION Are implementation strategies involving education any more effective than mere dissemination of clinical practice guidelines in changing physiotherapy practice and reducing patient disability after acute whiplash ? DESIGN Cluster-r and omised trial . PARTICIPANTS Twenty-seven physiotherapists from different private physiotherapy clinics and the 103 patients ( 4 dropouts ) who presented to them with acute whiplash . INTERVENTION The implementation group of physiotherapists underwent education by opinion leaders about whiplash guidelines and the dissemination group had the guidelines mailed to them . OUTCOME MEASURES The primary outcome was patient disability , measured using the Functional Rating Index , collected on admission to the trial and at 1.5 , 3 , 6 and 12 months . Physiotherapist knowledge about the guidelines was measured using a custom-made question naire . Physiotherapist practice and cost of care were measured by audit of patient notes . RESULTS There were no significant differences between groups for any of the patient outcomes at any time . The implementation patients had 0.6 points ( 95 % CI -7.8 to 6.6 ) less disability than the dissemination patients at 12 months ; 44 % more physiotherapists in the implementation group reported that they prescribed two out of the five guideline -recommended treatments ; and 32 % more physiotherapists actually prescribed them . The cost of care for patients in the implementation group was $ 255 ( 95 % CI -1505 to 996 ) less than for patients in the dissemination group . CONCLUSION Although the active implementation program increased guideline -consistent practice , patient outcomes and cost of care were not affected Background Low back pain ( LBP ) is a common and costly problem . Initiatives design ed to assist practitioner and patient decisions about appropriate healthcare for LBP include printed evidence -based clinical guidelines . The three professional groups of chiropractic , osteopathy and musculoskeletal physiotherapy in the UK share common ground with their approaches to managing LBP and are amongst those targeted by LBP guidelines . Even so , many seem unaware that such guidelines exist . Furthermore , the behaviour of at least some of these practitioners differs from that recommended in these guidelines .Few r and omised controlled trials evaluating printed information as an intervention to change practitioner behaviour have utilised a no-intervention control . All these trials have used a cluster design and most have method ological flaws . None specifically focus upon practitioner behaviour towards LBP patients . Studies that have investigated other strategies to change practitioner behaviour with LBP patients have produced conflicting results . Although numerous LBP guidelines have been developed worldwide , there is a paucity of data on whether their dissemination actually changes practitioner behaviour . Primarily because of its low unit cost , sending printed information to large numbers of practitioners is an attractive dissemination and implementation strategy . The effect size of such a strategy , at an individual practitioner level , is likely to be small . However , if large numbers of practitioners are targeted , this strategy might achieve meaningful changes at a population level . Methods The primary aim of this prospect i ve , pragmatic r and omised controlled trial is to test the short-term effectiveness ( six-months following intervention ) of a directly-posted information package on the reported clinical behaviour ( primary outcome ) , attitudes and beliefs of UK chiropractors , osteopaths and musculoskeletal physiotherapists . We sought to r and omly allocate a combined sample of 1,800 consenting practitioners to receive either the information package ( intervention arm ) or no information above that gained during normal practice ( control arm ) . We collected question naire data at baseline and six-months post-intervention . The analysis of the primary outcome will assess between-arm differences of proportions of responses to questions on recommendations about activity , work and bed-rest , that fall within categories previously defined by an expert consensus exercise as either ' guideline -consistent ' and ' guideline -inconsistent ' QUESTION What is the compliance with guidelines for acute ankle sprain for physiotherapists ? DESIGN Survey of r and om sample of physiotherapists . PARTICIPANTS 400 physiotherapists working in extramural health care in the Netherl and s. OUTCOME MEASURES Questions covered attitude towards guidelines in general , familiarity with the guidelines for acute ankle sprain , compliance with the guidelines , advantages and disadvantages of the guidelines , and factors relating to compliance with the guidelines . RESULTS The majority of the physiotherapists were familiar with the content of the guidelines to some degree and 66%applied it to more than half of their patients with acute ankle sprain . The recommendations to determine both the prognosis and the necessity of treatment by using the function score were the least followed . Some physiotherapists thought the function score was not completely clear , which may have been a barrier for implementation . Factors relating positively to compliance were a positive attitude towards guidelines in general , and having colleagues who implemented the guidelines for acute ankle sprain . CONCLUSION Although compliance with the guidelines for acute ankle sprain was fair/moderate , compliance may be enhanced by improving clarity of the function score , including it in the short version and improving the attitude of physiotherapists towards guidelines in general RATIONALE The concept of evidence -based medicine is important in providing efficient health care . The process uses research findings as the basis for clinical decision making . Evidence -based practice helps optimize current health care and enables the practitioners to be suitably accountable for the interventions they provide . Little work has been undertaken to examine how allied health professionals change their clinical practice in light of the latest evidence . The use of opinion leaders to disseminate new evidence around the management of low back pain into practice has been proposed . AIMS The aim of this study was to investigate if physiotherapists ' clinical management of patients with low back pain would change following an evidence -based education package , which utilized local opinion leaders and delivered the best evidence . METHOD Thirty musculoskeletal physiotherapists from a Community Trust in North Staffordshire were cluster r and omized by location of work , to two groups . The intervention group received an evidence -based programme on the management of low back pain , including advice regarding increasing activity levels and return to normal activity and challenging patients ' fears and beliefs about their pain . The control group received a st and ard in-service training package on the management of common knee pathologies . The physiotherapists ' clinical management of patients with low back pain was measured prior to training and 6 months post training . Outcome measures were based on physiotherapists completing ' discharge summary ' question naires , which included information relating to the use and importance of therapies for treating their low back pain patients . RESULTS There were few significant differences in treatment options between the intervention and control groups post training . Whilst there was some indication that physiotherapists were already utilizing aspects of psychosocial management for patients with low back pain , there was little change in what physiotherapists perceived to be important to patient recovery and actual clinical practice following the intervention . CONCLUSIONS Psychosocial factors have been identified as an important factor in the recovery of patients with low back pain . This project incorporated the latest evidence on the management of low back pain and utilized the theory of opinion leaders to disseminate this evidence into clinical practice . Whilst there were some limitations in the overall size of the study , the results help to give an insight into the challenges faced by the health care system and research ers alike to ensure quality evidence is actually utilized by practitioners for the benefits of patient care Study Design . Data were derived from a r and omized controlled trial on the ( cost- ) effectiveness of the implementation of the clinical guidelines on physiotherapy for low back pain in primary care . Objectives . To describe the course of low back pain in patients who are referred to physiotherapy  , to identify clinical ly important prognostic factors on different outcomes , and to evaluate the influence of different statistical techniques in developing a prognostic model . Summary of Background Data . Several studies have aim ed to identify prognostic factors for low back pain in primary care . These studies focused on different outcome measures and used various statistical techniques . Methods . Primary outcomes were perceived recovery , improvement in pain , improvement in functioning , and presence of disabling low back pain at 3 and 12 months follow-up . Multivariate logistic regression analyses were performed for each outcome variable . Two cut-off points were used to determine significance with respect to the univariate analysis , and two selection methods were used to build the final multivariate models . The result ing prognostic models were compared . Results . A total of 500 patients were included .  Pain and disability reduced considerably in the first 3 months , but further reduction was only modest . Prognostic factors varied for different outcomes , but the duration of the current episode was included in all models generated . Varying the statistical techniques also result ed in a different prognostic model with some change to the amount of variance explained . Conclusions . A substantial proportion of patients still experienced some pain and disability at 12 months follow-up . The most stable predictor of prognosis in low back pain was the duration of the current episode . The choice of statistical method influenced the final model ; however , changes in the explained variance were small
target: There was no evidence that patient health was improved or that the cost of care was reduced .
  This review shows that multifaceted interventions based on educational meetings to increase implementation of clinical guidelines may improve some outcomes of professional practice but do not improve patient health or reduce cost of care .
  These findings are comparable with results among other health professions
background: QUESTION What is the effectiveness of strategies to increase the implementation of physiotherapy clinical guidelines ?