A preplanned subgroup analysis of a randomized controlled trial. J Occup Environ Med. Were those subjects who were prepared to participate representative of the entire population from which they were recruited? Generating an ePub file may take a long time, please be patient. Trial Registration: Not applicable, because this article does not contain any clinical trials. Are the main outcomes to be measured clearly described in the Introduction or Methods section? Low Back Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Downloaded from www.jospt.org at on March 15, 2020. Patients that have fewer functional limitations may be more likely to follow the guideline of remaining active than those with greater functional limitations. Clinical practice guidelines in physical therapy may incorporate an active treatment approach for LBP management. The characteristics of the final included studies are presented in Table 1. Use of this and other APTA websites constitutes acceptance of our Terms & Conditions. Fritz et al8 reported that 23% of patients in the study experienced improvement in pain and disability with fewer visits, in a shorter time frame, and with lower charges when the patients received LBP treatment according to the clinical practice guidelines. Rutten et al17 also examined baseline and posttreatment scores of pain and disability using the QBPDS. Articles scored between 17 and 20 points based on a maximum total score of 26 on the modified Downs and Black checklist. A systematic review. Two did not report a country as they were conducted in global military health systems [16, 33]. Hoeijenbos M, Bekkering T, Lamers L, Hendriks E, van Tulder M, Koopmanschap M. Cost-effectiveness of an active implementation strategy for the Dutch physiotherapy guideline for low back pain. After duplicates were deleted, the titles and abstracts were screened by two reviewers (BR, RF), while one reviewer (KP) resolved any conflicts that arose between the two reviewers. Eighteen studies [16,17,18,19,20,21,22,23,24,25,26,27,28, 31, 33,34,35,36] assessed HCU as an outcome. In this study, the control group was the physiotherapist who only received information about the clinical guidelines for LBP treatment by the Royal Dutch Society for Physiotherapy via mail.13 The intervention group consisted of physiotherapists that received the same information as the control group, along with additional training and information about active strategy implementation in LBP treatment.13 Adherence rates within the intervention group and the control group were 42% and 30%, respectively. Hysong SJ, Best RG, Pugh JA. Careers in Physical Therapy; Career Advancement; Courses and Events; Find PT and PTA Jobs; Your Practice. Clin J Pain. Pilot Feasibility Stud. HCU rates did not appear to be significantly impacted by factors such as guideline delivery (active versus standard) [25], the addition of intensive group training [24] or symptom chronicity (acute versus chronic) [21]. Audit and provide feedback was utilized in almost every included study. Because we utilized the classification system proposed by Powell et al. BMC Musculoskelet Disord. Criteria for final selection included a reporting of adherence rates to clinical practice guidelines, plus a reporting of at least one of the following outcome variables: pain, disability, patient perception, patient satisfaction, and number of treatments performed in total treatment timespan. Article Using this compilation by Powell et al. A second primary author verified and confirmed the data (WJH). Google Scholar. This is an update to the 2012 Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therap However, one [30] did not utilize a control or comparator. BMC Musculoskelet Disord. Five studies [18, 19, 22, 24, 34] reported on utilization of imaging, as seen in Table 4. Powell et al. From best evidence to best practice: effective implementation of change in patients care. Pernold G, Mortimer M, Wiktorin C, Tornqvist EW, Vingrd E; Musculoskeletal Intervention Center-Norrtlje Study Group. already built in. However, there were inconsistent findings for the benefit of guideline implementation for improvements in pain and function in patients. The method of data analysis was based on a previous systematic literature review published by Hanney et al15 that used a modified Downs and Black checklist to score article quality. The primary outcome measure was the numeric pain rating scale (NPRS) or numeric rating scale (NRS), utilized in all but one study [35]. Health Policy. While there are no specific cut points to define favoring guideline treatment, we utilized information gleaned from a previously published systematic review.15 While it appears this criterion can be subjective, further criteria should be considered in order to be more specific. Cote AM, Durand MJ, Tousignant M, Poitras S. Physiotherapists and use of low back pain guidelines: a qualitative study of the barriers and facilitators. The studies analyzed in this review showed a general trend of reduced disability and improved patient outcomes when adhering to an active approach practice guideline. Low back Pain. Guidelines regularly recommend the use of physical exercise for non-specific LBP [ 7 ]. Hanney WJ, Masaracchio M, Liu X, Kolber MJ. This systematic review is the first to our knowledge that assesses the impact of physical therapist implementation of CPGs on patient-level outcomes in back and neck pain. The study further explored whether this relationship differs for the individual steps of the process of care and for distinct subgroups of patients. cute and Chronic Lo ac Pain Clinical Practice Guidelines EDUCATION FOR ACUTE LOW BACK PAIN B Physical therapists may use active education strategies rather than passive strategies (ie, providing access to ed-ucational materials only). 2021;34(4):60511. 2018;98(12):10009. Some authors [29] have suggested this lack of improvement may be due to high-quality care already provided by physical therapists. This course will help PTs prioritize the most appropriate treatment to use for acute and chronic LBP in Primary Care. The purpose of this systematic review was to determine the influence of guideline implementation on clinical outcomes of pain, physical function/disability, and HCU metrics in patients seeking physical therapy for neck and/or low back pain. The remaining included studies failed to incorporate assessment of barriers and subsequent tailored strategies. A recent review indicated that most patient-reported outcome measures assessing physical functioning in low back pain were insufficient to garner a full understanding of the patients physical functioning [58]. There exists significant overlap between SCOPUS and Web of Science, and therefore, we chose to only search SCOPUS [13]. This review aimed to determine the impact of CPG implementation on patient-level outcomes for spinal pain. Al Zoubi FM, Menon A, Mayo NE, Bussires AE. Similar to our findings, a systematic review by Hanney et al. The following keywords were used in combination: clinical practice guidelines, patient outcomes, low back pain, treatment, and physical therapy. 2021;21(8):94354. Musculoskeletal disorders. Kersten R, Fikkers J, Wolterbeek N, Oner FC, van Gaalen SM. Implementation strategies for CPGs were also examined to determine the variance in the focus of implementation strategies on success of the implementation. Improved Clinical Effectiveness through Behavioural Research G. Designing theoretically-informed implementation interventions. Duration of physical therapy treatment for LBP is variable and dependent on various factors that can affect patient outcomes.18 Bekkering et al13 reported that physical therapists were more likely to limit the number of therapy sessions with the active intervention group (n = 247) in 27% of the patients in that group. Zadro J, O'Keeffe M, Maher C. Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? There is still a lack of implementation of these communities, even with the research and evidence of its benefits.10. Low back pain (LBP) is a common condition that affects a significant proportion of the population, with an estimated prevalence of 70%-85% .Current Clinical Practice Guidelines (CPGs) recommend various LBP treatments, such as pharmacotherapy, physical therapy, manual therapy, educational therapy, psychological therapy, and invasive therapy , . Implementation of a shared care guideline for back pain: effect on unnecessary referrals. Full-text articles were then reevaluated to determine specific inclusion criteria by a second reviewer (WJH). Childs JD, Cleland JA, Elliott JM, Teyhen DS, Wainner RS, Whitman JM, et al. Treatment was separated into 2 phases: phase I was treatment received in the first 2 weeks while phase II was treatment received from day 14 until care ended.8 Guideline adherence for both phases was determined by categorizing procedural codes (CPT) codes used for billing into active, passive, or allowed treatment.8 During each phase of treatment, the percentage of active treatment codes used must have been at least 75% in comparison to passive treatment codes, and at least one active treatment code must have been used per visit.8, Fritz et al16 considered guideline adherence in accordance to the Agency for Health Care Policy and Researchs recommendation for patients with LBP to remain active within pain limits.16 Specific interventions for LBP were not recommended until after 4 weeks of watchful waiting while remaining active within limits.16 This study does not identify effective treatment methods within the clinical practice guidelines but rather suggests that treatment should be based more on a classification system that groups patients into different treatment categories based on clinical assessment and self-reported signs and symptoms.16 The classification system would allow for adjustments of treatment based on the changes in signs and symptoms, while the clinical practice guidelines remain consistent throughout treatment.16 The treatment-based classification system separated subjects into 4 different treatment classifications: mobilization, specific exercise, immobilization, and traction.16 The patients were examined at the beginning of each treatment by testing lumbar range of motion and special tests, and if signs and symptoms changed, the patients would be placed in a new classification.16 The main difference between this approach and just consistently following the active approach as outline in the clinical practice guidelines is the ability to reassess and adjust treatment as necessary.16 Both methods do suggest a more active approach when it comes to LBP treatment, but one does allow for more assessments and readjustments as tailored for the patients needs. Financing includes discrete strategies modifying incentives and facilitating financial support. The Influence of an Active Treatment Approach in Patients With Low Back Pain: A Systematic Review, Departments of Health Professions (EGL, WJH, CER), University of Central Florida, Orlando, Florida, Health Management and Informatics (XL), University of Central Florida, Orlando, Florida, Department of Physical Therapy, Nova Southeastern University, Fort Lauderdale, Florida (MJK), Department of Physical Therapy, Long Island University, Brooklyn, New York (MM). Were study subjects randomized to intervention groups? The reliability and validity of measurements designed to quantify posterior shoulder tightness. Int J Surg. Meet the Speaker: Brandon I. Peterson, DPT, MDT. Seven studies [16, 17, 19, 20, 22, 24, 35] used strategies within only one key implementation process, all of which used strategies within Managing Quality. A point was awarded when the study provided a specific time line for patient recruitment (prospective studies) or when data were collected between reported dates of patient care (retrospective studies). Clinical practice guidelines (CPGs) also called 'clinical guidelines' can improve healthcare by promoting best practice, reducing the use of lowvalue interventions and unwarranted. The lack of improvement in patient-reported function and pain following guideline implementation is consistent with findings in other reviews [37, 49, 57]. Karlen E, McCathie B. 2019;9(12):e032483. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. Grey literature was not searched and may be a limitation to this review. Identify the current clinical practice guidelines (CPG) for patients with low back pain (LBP) as developed by the orthopedic section of the American Physical Therapy Association. Manage cookies/Do not sell my data we use in the preference centre. Conclusion. The definition of active may vary significantly among therapists and patients; therefore, it is unclear which interventions may have the greatest influences on patient outcomes. A systematic review highlights the need to investigate the content validity of patient-reported outcome measures for physical functioning in patients with low back pain. CPG implementation appears to have a beneficial effect on healthcare utilization outcomes, but may not impact pain and physical functioning outcomes. Implement Sci. Neck pain: clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopedic Section of the American Physical Therapy Association. Schroder et al. The results of this review suggest guideline implementation and adherence may decrease HCU, but the results are inconclusive when comparing pain and physical function outcomes. Five studies were conducted in private practice clinics [16, 18, 21, 29, 35], two studies were conducted in military treatment centers [16, 33], and one study was conducted based on a review of workers compensation [20]. We utilized Powell et al. CPG: clinical practice guideline ICD: International Classification of Diseases ICF: International Classification of Functioning, Disability and Health JOSPT: Journal of Orthopaedic & Sports Physical Therapy LBP: low back pain MDT: Mechanical Diagnosis and Therapy MSI: movement system impairment NPRS: numeric pain-rating scale ODI: Oswestry . One challenge in implementation literature is that implementation strategies are not always clearly defined and there is often inconsistent language utilized. The most effective implementation strategy is unknown, but use of blended or published implementation frameworks may help guide effective strategies. See Additional file 1. One study [27] reported that the addition of an individualized restoration program to guideline-based advice resulted in significantly improved function at 10 weeks and 52 weeks compared to guideline-based advice alone. We included all data pertaining to PT or other healthcare visits or associated costs and medication or procedure usage or costs associated with low back or neck pain under healthcare utilization. Note. Lancet. Furthermore, each of the studies had varied treatment durations, which may affect the overall interpretation of patient outcomes. No studies used strategies within the Attending to Policy Context key implementation process. Acta Anaesthesiol Scand. To continue viewing this pocket guide, please purchase it. By using this website, you agree to our Hence, variability in which clinicians follow clinical practice guidelines creates difficulty for researchers in identifying what is considered to be an adherent intervention. The remaining studies did not compare implementation strategies or have a control group. clinical practice guidelines low back pain physical therapy download link clinical practice guidelines low back pain physical therapy read online Search Sign Up A point was not awarded if at least one of the primary outcome measures in the study was not valid or reliable or if this information was not reported or could not be determined (ie, a questionnaire without reported validity or reliability). Childs JD, Fritz JM, Wu SS, Flynn TW, Wainner RS, Robertson EK, et al. A compilation of strategies for implementing clinical innovations in health and mental health. A third reviewer (DC) settled any discrepancies between the primary reviewers. Sharma S, Jensen MP, Moseley GL, Abbott JH. Additionally, utilizing a uniform outcome measure to assess function may further highlight the effect of implementation, or lack thereof. Slade SC, Kent P, Patel S, Bucknall T, Buchbinder R. Barriers to primary care clinician adherence to clinical guidelines for the management of low back pain: a systematic review and metasynthesis of qualitative studies. However, it has been established that there is significant variability in the care provided to patients with low back and neck pain by physical therapists despite the existence of clinical practice guidelines (CPGs) to treat these conditions [3]. Managing quality includes putting strategies and systems in place to evaluate and improve quality. Provided by the Springer Nature SharedIt content-sharing initiative. Physical therapy for acute low back pain: associations with subsequent healthcare costs, Managing low back pain in the primary care setting: the know-do gap. Since the majority of studies utilizing this strategy did not provide individualized feedback, rather using the information as an aggregate measure, improvement in providers adherence and thus patient outcomes is less likely. Six reviewers (BR, JM, KP, MC, RF, DC) performed data extraction on the final studies included in the review. BMJ Open. Of the studies that assessed guideline implementation and LBP, two specifically included only back-related leg pain [27, 31] and three included only acute LBP [17, 18, 20]. 2021;22(1):507. The benefits of clinical practice guidelines include [2]: Improve clinical outcomes [3] Reduce variability in clinical practice [4] Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. There was significant heterogeneity across studies related to the type of implementation, the interventions used, and measured outcomes, limiting the ability to effectively synthesize the results. Fritz JM, Cleland JA, Speckman M, Brennan GP, Hunter SJ. 2016;32(9):80016. Guideline implementation appears to reduce health care utilization for patients with neck and low back pain. Bekkering GE, Hendriks HJ, van Tulder MW, et al. Only two articles [25, 29] in our review, reporting on one study, assessed the impact of active versus passive guideline implementation and found no difference in patient outcomes between groups. Clinical practice guidelines are developed with the best available evidence; however, they generally fail to identify specific interventions that physical therapists may have utilized in clinical practice. Previous systematic reviews have identified active, multifactorial implementation strategies as more effective [37, 38]; however, a more recent review [39] found no benefit to an active over passive implementation. BMC Health Serv Res. 2012;69(2):12357. The variance of treatments for LBP may lead to selection of inappropriate interventions and overuse of ineffective therapies.8 The various treatment options used by the clinician may further affect the course of treatment for LBP. The authors declare that they have no competing interests. One of the studies [34] found no differences in the number of PT visits; however, the duration of care was decreased for those that received guideline-based care. Another study by Fritz et al8 looked at adherence rates in 1190 patients with LBP, concluding that 481 (40%) received adherent care and 709 (60%) received nonadherent care. Of the included studies assessing pain, only two found significant improvements favoring guideline implementation. Results. Salamh PA, Corrao M, Hanney WJ, Kolber MJ. 2020;1:42. Gartner FR, Portielje JE, Langendam M, Hairwassers D, Agoritsas T, Gijsen B, et al. 12/31/2023, For Advertisers, Exhibitors, and Sponsors, Review JOSPT recommendations for treatment. QBPDS measures pain and disability using a 20-item self-report questionnaire ranging from scores of 0 to 100higher the scores reflective of greater the limitations in physical functioning.17 Subjects reported scores of 40.5 for baseline and 21.3 for posttreatment, indicative of a decrease in pain and improvement in function following adherent care.17 This study also used the Visual Analog Scale, which measures the level of pain in millimeters, 0 mm being no pain and 100 mm meaning unbearable pain.17 For baseline measurements, patients reported a VAS average score of 56.9 and for posttreatment an average score of 22.9, also indicative of a decrease in pain and improvement of function following adherent care.17 A limitation of the Rutten study is a small sample size that can affect the external validity of the results, and may not be representative of patient outcomes in longer terms.17, Reporting of the total number of treatments completed by patients in the studies was another important outcome variable of interest.