Management of low back pain and lumbosacral radicular syndrome: the Guideline of the Royal Dutch Society for Physical Therapy (KNGF).

BACKGROUND: Significant progress and new insights have been gained since the Dutch Physical Therapy guideline on low back pain (LBP) in 2013 and the Cesar en Mensendieck guideline in 2009, necessitating an update of these guidelines. AIM: To update and develop an evidence-based guideline for the comprehensive management of LBP and lumbosacral radicular syndrome (LRS) without serious specific conditions (red flags) for Dutch physical therapists and Cesar and Mensendieck Therapists. DESIGN: Clinical practice guideline. SETTING: Inpatient and outpatient. POPULATION: Adults with LBP and/or LRS. METHODS: Clinically relevant questions were identified based on perceived barriers in current practice of physical therapy. All clinical questions were answered using published guidelines, systematic reviews, narrative reviews or systematic reviews performed by the project group. Recommendations were formulated based on evidence and additional considerations, as described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. Patients participated in every phase. RESULTS: The guideline describes a comprehensive assessment based on the International Classification of Functioning, Disability and Health (ICF) Core Set for LBP and LRS, including the identification of alarm symptoms and red flags. Patients are assigned to three treatment profiles (low, moderate and high risk of persistent symptoms) based on prognostic factors for persistent LBP. The guideline recommends offering simple and less intensive support to people who are likely to recover quickly (low-risk profile) and more complex and intensive support to people with a moderate or high risk of persistent complaints. Criteria for initiating and discontinuing physical therapy, and referral to a general practitioner are specified. Recommendations are formulated for information and advice, measurement instruments, active and passive interventions and behavior-oriented treatment. CONCLUSIONS: An evidence based physical therapy guideline for the management of patients with LBP and LRS without red flags for physical therapists and Cesar and Mensendieck therapists was developed. Cornerstones of physical therapy assessment and treatment are risk stratification, shared decision-making, information and advice, and exercises. CLINICAL REHABILITATION IMPACT: This guideline provides guidance for clinicians and patients to optimize treatment outcomes in patients with LBP and LRS and offers transparency for other healthcare providers and stakeholders.

Reliability, validity and discriminability of patient reported outcomes for non-specific low back pain in a nationwide physical therapy registry: A retrospective observational cohort study.

BACKGROUND: A national clinical registry was established in the Netherlands containing data directly sampled from electronic health record systems of physical therapists (PTs). This registry aims to evaluate the potential of patient reported outcome measures (PROMs) to develop quality indicators (QIs) in physical therapy care. PURPOSE: To test to what extent the collected PROM data are reliable, valid and discriminatory between practices in measuring outcomes of patients with non-specific low back pain (NSLBP). METHODS: In this retrospective cohort study 865 PT practices with 6,560 PTs voluntarily collected PROM data of patients with NSLBP, using the Quebec Back Pain Disability Scale (QBPDS), the Numeric Pain Rating Scale (NPRS) and the Patient Specific Functioning Scale (PSFS). Reliability was determined by analysing the completeness of the dataset, the comparability by using national reference data, and through checking selection bias in the included patients. Validity was tested using the known-groups contrast between patients with (sub)acute vs. chronic NSLBP. To determine discriminative ability of outcomes between PT practices, case-mix corrected hierarchical multilevel analyses were performed. RESULTS: Reliability was sufficient by confirming fifteen of the sixteen hypotheses: 59% of all patients opted in for data analysis, 42% of these included patients showed repeated measurement, comparing with reference data and potential selection bias showed < 5% between group differences, while differences between (sub)acute and chronic NSLB-groups were significantly larger than 5% (less treatment sessions, lager differences in outcomes in (sub)acute NSLB patients). In addition, all nine adjusted hierarchical multilevel models confirm that the collected dataset on outcomes in PT care is able to discriminate between practices using PROM results of patients with NSLBP (ICC-scores range 0.11-0.21). LIMITATIONS: Although we have shown the reliability, validity and discriminative ability of the dataset in the quest to develop QIs, we are aware that reducing missing values in patient records and the selective participation of PTs that belong to the innovators needs attention in the next stages of implementation to avoid bias in the results. CONCLUSION: PROMs of patients with NSLBP collected in the national clinical registry of KNGF are reliable, valid and able to discriminate between primary care PT practices.

Clinical Practice Guideline for Physical Therapist Management of People With Rheumatoid Arthritis.

OBJECTIVE: This guideline revises the 2008 Royal Dutch Society for Physical Therapy guideline for physical therapy for patients with rheumatoid arthritis (RA). METHOD: This revised guideline was developed according to the Appraisal of Guidelines for Research and Evaluation tool and the Guidelines International Network standards. A multidisciplinary guideline panel formulated clinical questions based on perceived barriers in current care. For every clinical question, a narrative or systematic literature review was undertaken, where appropriate. The guideline panel formulated recommendations based on the results of the literature reviews, the values and preferences of patients and clinicians, and the acceptability, feasibility, and costs, as described in the Grading of Recommendations Assessment, Development and Evaluation evidence-to-decision framework. RESULTS: The eventual guideline describes a comprehensive assessment based on the International Classification of Functioning, Disability and Health Core Set for RA. It also includes a description of yellow and red flags to support direct access. Based on the assessment, 3 treatment profiles are distinguished: (1) education and exercise instructions with limited supervision, (2) education and short-term supervised exercise therapy, and (3) education and intensified supervised exercise therapy. Education includes RA-related information, advice, and self-management support. Exercises are based on recommendations concerning the desired frequency, intensity, type, and time-related characteristics of the exercises (FITT factors). Their interpretation is compliant with the individual patient's situation and with public health recommendations for health-enhancing physical activity. Recommended measurement instruments for monitoring and evaluation include the Patient-Specific Complaint instrument, Numeric Rating Scales for pain and fatigue, the Health Assessment Questionnaire Disability Index, and the 6-minute walk test. CONCLUSION: An evidence-based physical therapy guideline was delivered, providing ready-to-use recommendations on the assessment and treatment of patients with RA. An active implementation strategy to enhance its use in daily practice is advised. IMPACT: This evidence-based practice guideline guides the physical therapist in the treatment of patients with RA. The cornerstones of physical therapist treatment for patients with RA are active exercise therapy in combination with education. Passive interventions such as massage, electrotherapy, thermotherapy, low-level laser therapy, ultrasound, and medical taping play a subordinate role.

Exploring the perspective of patients with musculoskeletal health problems in primary care on the use of patient-reported outcome measures to stimulate quality improvement in physiotherapist practice; a qualitative study.

Background: Patient-reported outcome measures (PROMs) in clinical practice might enhance patient- centeredness and effectiveness of physiotherapy practice. Although patients have a crucial role in using PROMs, little is known about their perspective on its usefulness.Purpose: Explore the perspective of patients with musculoskeletal health problems on using PROMs for quality improvement in primary care physiotherapy practice, and determine what barriers and facilitators patients perceive.Methods: Semi-structured interviews were performed in 21 patients recruited from primary care physiotherapy practice and analyzed using theoretical thematic analysis. Barriers and facilitators on PROMs implementation were categorized into four predefined domains conform.Results: Across all domains, three major themes were identified: 1) Practicality; 2) Interaction with the physiotherapist for decision-making; and 3) Sharing information outside the clinical context. Generally, PROMs were perceived practically applicable instruments with added value to the interaction with the physiotherapist for shared decision-making and for stimulating quality improvement. The perceived barriers were: difficulties in administering PROMs for patients with poor computer skills, suboptimal efficiency when PROMs were administered at the expense of the consultation, the insufficient added value of PROMs for patients with recurrent health problems, and reluctance about sharing aggregated data for accountability purposes.Limitations: The dependence on the participating physiotherapists in patient recruitment might have resulted in selection bias.Conclusion: Patients perceive that using PROMs has an added value in primary care physiotherapy practice. Optimizing implementation using tailored implementation strategies related to the identified barriers in all four domains might further improve the use of PROMs in clinical practice.

A clinical practice guideline for physical therapy in patients with hip or knee osteoarthritis.

OBJECTIVE: The purpose of this paper is to revise the 2010 Dutch guideline for physical therapy (PT) in patients with hip or knee osteoarthritis (OA), issued by the Royal Dutch Society for Physical Therapy (KNGF). METHOD: This revised guideline was developed according to the Appraisal of Guidelines for Research and Evaluation (AGREE) and Guidelines International Network (G-I-N) standards. A multidisciplinary guideline panel formulated clinical questions based on perceived barriers to current care. A narrative or systematic literature review was undertaken in response to each clinical question. The panel formulated recommendations based on evidence and additional considerations, as described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Evidence-to-Decision framework. RESULTS: A comprehensive assessment should be based on the International Classification of Functioning Disability and Health (ICF) core set for OA, including the identification of OA-related red flags. Based on the assessment, four treatment profiles were distinguished: (1) education and instructions for unsupervised exercises, (2) education and short-term supervised exercise therapy, (3) education and longer term supervised exercise therapy, and (4) education and exercise therapy before and/or after total hip or knee surgery. Education included individualized information, advice, instructions, and self-management support. Exercise programs were tailored to individual OA-related issues, were adequately dosed, and were in line with public health recommendations for physical activity. Recommended measurement instruments included the Patient-Specific Complaints Instrument, the Numeric Pain Rating Scale, the Hip Disability and Osteoarthritis Outcome Score/the Knee Injury Osteoarthritis Outcome Score, and the Six Minute Walk Test. CONCLUSION: An evidence-based PT guideline for the management of patients with hip or knee OA was developed. To improve quality of care for these patients, an extensive implementation strategy is necessary.

Profiling of Patients with COPD for Adequate Referral to Exercise-Based Care: The Dutch Model.

A loss of physical functioning (i.e., a low physical capacity and/or a low physical activity) is a common feature in patients with chronic obstructive pulmonary disease (COPD). To date, the primary care physiotherapy and specialized pulmonary rehabilitation are clearly underused, and limited to patients with a moderate to very severe degree of airflow limitation (GOLD stage 2 or higher). However, improved referral rates are a necessity to lower the burden for patients with COPD and for society. Therefore, a multidisciplinary group of healthcare professionals and scientists proposes a new model for referral of patients with COPD to the right type of exercise-based care, irrespective of the degree of airflow limitation. Indeed, disease instability (recent hospitalization, yes/no), the burden of disease (no/low, mild/moderate or high), physical capacity (low or preserved) and physical activity (low or preserved) need to be used to allocate patients to one of the six distinct patient profiles. Patients with profile 1 or 2 will not be referred for physiotherapy; patients with profiles 3-5 will be referred for primary care physiotherapy; and patients with profile 6 will be referred for screening for specialized pulmonary rehabilitation. The proposed Dutch model has the intention to get the right patient with COPD allocated to the right type of exercise-based care and at the right moment.

Which Factors Influence the Use of Patient-Reported Outcome Measures in Dutch Physiotherapy Practice? A Cross-Sectional Study.

Purpose: Patient-reported outcome measures (PROMs) have the potential to enhance the quality of health care but, as a result of suboptimal implementation, it is unclear whether they fulfil this role in physiotherapy practice. This cross-sectional study aimed to identify the factors influencing PROM use in Dutch private physiotherapy practices. Method: A total of 444 physiotherapists completed a self-assessment questionnaire and uploaded the data from their electronic health record (EHR) systems to the national registry of outcome data. Univariate and multivariate ordinal logistic and linear regression analysis were used to identify the factors associated with self-reported PROM use and PROM use registered in the EHR systems, which were derived from the self-assessment questionnaire and from the data in the national registry, respectively. Five categories with nine independent variables were selected as potential factors for regression analysis. The similarity between self-reported and registered PROM use was verified. Results: On the basis of self-report and EHR report, we found that 21.6% and 29.8% of participants, respectively, used PROMs with more than 80% of their patients, and we identified the factors associated with PROM use. Conclusions: The factors associated with PROM use are EHR systems that support PROM use and more knowledge about PROM use. These findings can guide future strategies to enhance the use of PROMs in physiotherapy practice.

Objectif : les mesures des résultats déclarées par les patients (MRDP) peuvent améliorer la qualité des soins, mais en raison de leur mise en œuvre sous-optimale, on ne sait pas si elles remplissent cette fonction en physiothérapie. La présente étude transversale visait à nommer les facteurs qui influent sur l'utilisation des MRDP dans des cabinets de physiothérapie privés hollandais. Méthodologie : au total, 444 physiothérapeutes ont rempli un questionnaire d'autoévaluation et ont téléchargé les données de leurs systèmes de dossiers de santé électroniques (DSÉ) dans le registre national de données de résultats. Les chercheurs ont procédé à l'analyse de régression logistique et linéaire ordinale univariée et multivariée pour déterminer les facteurs associés à l'utilisation autodéclarée des MRDP et à celle figurant dans leurs systèmes de DSÉ, en fonction des questionnaires d'autodéclaration et des données du registre national, respectivement. Ils ont retenu cinq catégories comportant neuf variables indépendantes comme facteurs potentiels d'analyse de régression. Ils ont vérifié la similarité entre les MRDP autodéclarées et celles qui étaient enregistrées. Résultats : les chercheurs ont découvert que, d'après leur autodéclaration et leur rapport de DSÉ, respectivement, 21,6 % et 29,8 % des participants ont utilisé les MRDP auprès de plus de 80 % de leurs patients, et ont établi les facteurs associés à l'utilisation des MRDP. Conclusion : ces facteurs étaient les systèmes de DSÉ qui favorisent l'utilisation des MRDP et une meilleure compréhension de l'utilisation des MRDP. Ces observations pourront orienter de futures stratégies pour accroître l'utilisation des MRDP dans les cabinets de physiothérapie.

Impact of Self- and Peer Assessment on the Clinical Performance of Physiotherapists in Primary Care: A Cohort Study.

Purpose: This study evaluated the impact of a quality improvement programme based on self- and peer assessment to justify nationwide implementation. Method: Four professional networks of physiotherapists in The Netherlands (n = 379) participated in the programme, which consisted of two cycles of online self-assessment and peer assessment using video recordings of client communication and clinical records. Assessment was based on performance indicators that could be scored on a 5-point Likert scale, and online assessment was followed by face-to-face feedback discussions. After cycle 1, participants developed personal learning goals. These goals were analyzed thematically, and goal attainment was measured using a questionnaire. Improvement in performance was tested with multilevel regression analyses, comparing the self-assessment and peer-assessment scores in cycles 1 and 2. Results: In total, 364 (96%) of the participants were active in online self-assessment and peer assessment. However, online activities varied between cycle 1 and cycle 2 and between client communication and recordkeeping. Personal goals addressed client-centred communication (54%), recordkeeping (24%), performance and outcome measurement (15%), and other (7%). Goals were completely attained (29%), partly attained (64%), or not attained at all (7%). Self-assessment and peer-assessment scores improved significantly for both client communication (self-assessment = 11%; peer assessment = 8%) and recordkeeping (self-assessment = 7%; peer assessment = 4%). Conclusions: Self-assessment and peer assessment are effective in enhancing commitment to change and improving clinical performance. Nationwide implementation of the programme is justified. Future studies should address the impact on client outcomes.

Objectif : évaluer les répercussions d'un programme d'amélioration de la qualité reposant sur l'autoévaluation et l'évaluation par les pairs pour en justifier la mise en œuvre nationale. Méthodologie : quatre réseaux professionnels de physiothérapeutes des Pays-Bas (n=379) ont participé au programme, composé de deux cycles d'autoévaluation en ligne et d'évaluation par les pairs à l'aide d'enregistrements vidéo des communications des clients et des dossiers cliniques. L'évaluation était fondée sur des indicateurs de la performance qui pouvaient être cotés sur une échelle de Likert de cinq points, et l'évaluation en ligne était suivie de rencontres de rétroaction. Après le cycle 1, les participants se sont donné des objectifs d'apprentissage personnel. Les chercheurs ont évalué ces objectifs par thème et en ont mesuré l'atteinte au moyen d'un questionnaire. Ils ont vérifié l'amélioration de la performance à l'aide d'analyses de régression multiniveaux et ont comparé les cotes d'autoévaluation et d'évaluation par les pairs des cycles 1 et 2. Résultats : au total, 364 des participants (96 %) étaient actifs dans l'autoévaluation en ligne et l'évaluation par les pairs. Cependant, les activités en ligne variaient entre le cycle 1 et le cycle 2 et entre les communications avec le client et la tenue de dossier. Les objectifs personnels portaient sur les communications axées sur le client (54 %), la tenue de dossiers (24 %), les mesures de la performance et des résultats cliniques (15 %) et d'autres points (7 %). Les objectifs étaient complètement atteints (29 %), partiellement atteints (64 %) ou pas du tout atteints (7 %). Les cotes d'autoévaluation et d'évaluation par les pairs s'amélioraient sensiblement dans les secteurs des communications avec le client (autoévaluation = 11 %; évaluation par les pairs = 8 %) et de la tenue de dossiers (autoévaluation = 7 %; évaluation par les pairs = 4 %). Conclusions : l'autoévaluation et l'évaluation par les pairs sont efficaces pour accroître la volonté de changer et améliorer la performance clinique. La mise en œuvre nationale du programme est justifiée. De futures études devraient aborder les répercussions de ce programme sur les résultats cliniques des clients.

Clinical Practice Guideline for Physical Therapy Assessment and Treatment in Patients With Nonspecific Neck Pain.

The Royal Dutch Society for Physical Therapy (KNGF) issued a clinical practice guideline for physical therapists that addresses the assessment and treatment of patients with nonspecific neck pain, including cervical radiculopathy, in Dutch primary care. Recommendations were based on a review of published systematic reviews.During the intake, the patient is screened for serious pathologies and corresponding patterns. Patients with cervical radiculopathy can be included or excluded through corresponding signs and symptoms and possibly diagnostic tests (Spurling test, traction/distraction test, and Upper Limb Tension Test). History taking is done to gather information about patients' limitations, course of pain, and prognostic factors (eg, coping style) and answers to health-related questions.In case of a normal recovery (treatment profile A), management should be hands-off, and patients should receive advice from the physical therapist and possibly some simple exercises to supplement "acting as usual."In case of a delayed/deviant recovery (treatment profile B), the physical therapist is advised to use, in addition to the recommendations for treatment profile A, forms of mobilization and/or manipulation in combination with exercise therapy. Other interventions may also be considered. The physical therapist is advised not to use dry needling, low-level laser, electrotherapy, ultrasound, traction, and/or a cervical collar.In case of a delayed/deviant recovery with clear and/or dominant psychosocial prognostic factors (treatment profile C), these factors should first be addressed by the physical therapist, when possible, or the patient should be referred to a specialist, when necessary.In case of neck pain grade III (treatment profile D), the therapy resembles that for profile B, but the use of a cervical collar for pain reduction may be considered. The advice is to use it sparingly: only for a short period per day and only for a few weeks.

Development and Evaluation of an Implementation Strategy for Collecting Data in a National Registry and the Use of Patient-Reported Outcome Measures in Physical Therapist Practices: Quality Improvement Study.

BACKGROUND: In 2013, the Royal Dutch Society for Physical Therapy launched the program "Quality in Motion." This program aims to collect data from electronic health record systems in a registry that is fed back to physical therapists, facilitating quality improvement. PURPOSE: The purpose of this study was to describe the development of an implementation strategy for the program and to evaluate the feasibility of building a registry and implementing patient-reported outcome measures (PROMs) in physical therapist practices. METHODS: A stepwise approach using mixed methods was established in 3 consecutive pilots with 355 physical therapists from 66 practices. Interim results were evaluated using quantitative data from a self-assessment questionnaire and the registry and qualitative data from 21 semistructured interviews with physical therapists. Descriptive statistics and McNemar's symmetry chi-squared test were used to summarize the feasibility of implementing PROMs. RESULTS: PROMs were selected for the 5 most prevalent musculoskeletal conditions in Dutch physical therapist practices. A core component of the implementation strategy was the introduction of knowledge brokers to support physical therapists in establishing the routine use of PROMs in clinical practice and to assist in executing peer assessment workshops. In February 2013, 30.3% of the physical therapist practices delivered 4.4 completed treatment episodes per physical therapist to the registry; this increased to 92.4% in November 2014, delivering 54.1 completed patient episodes per physical therapist. Pre- and posttreatment PROM use increased from 12.2% to 39.5%. LIMITATIONS: It is unclear if the participating physical therapists reflect a representative sample of Dutch therapists. CONCLUSION: Building a registry and implementing PROMs in physical therapist practices are feasible. The routine use of PROMs needs to increase to ensure valid feedback of outcomes. Using knowledge brokers is promising for implementing the program via peer assessment workshops.

Using Outcome Measures in Daily Practice: Development and Evaluation of an Implementation Strategy for Physiotherapists in the Netherlands.

PURPOSE: To describe the development of an educational programme for physiotherapists in the Netherlands, two toolkits of measurement instruments, and the evaluation of an implementation strategy. METHOD: The study used a controlled pre- and post-measurement design. A tailored educational programme for the use of outcome measures was developed that consisted of four training sessions and two toolkits of measurement instruments. Of 366 invited physiotherapists, 265 followed the educational programme (response rate 72.4%), and 235 randomly chosen control physiotherapists did not (28% response rate). The outcomes measured were participants' general attitude toward measurement instruments, their ability to choose measurement instruments, their use of measurement instruments, the applicability of the educational programme, and the changes in physiotherapy practice achieved as a result of the programme. RESULTS: Consistent (not occasional) use of measurement instruments increased from 26% to 41% in the intervention group; in the control group, use remained almost the same (45% vs 48%). Difficulty in choosing an appropriate measurement instrument decreased from 3.5 to 2.7 on a 5-point Likert-type scale. Finally, 91% of respondents found the educational programme useful, and 82% reported that it changed their physiotherapy practice. CONCLUSIONS: The educational programme and toolkits were useful and had a positive effect on physiotherapists' ability to choose among many possible outcome measures.

Objectif : Décrire l'élaboration d'un programme de formation pour des physiothérapeutes aux Pays-Bas, deux trousses d'instruments de mesure et l'évaluation d'une stratégie de mise en œuvre. Méthode : L'étude a utilisé un concept de mesure contrôlé de type avant-après. Un programme de formation personnalisé pour l'utilisation des mesures de résultats a été élaboré; il consistait en quatre séances de formation et deux trousses d'instruments de mesure. Des 366 physiothérapeutes invités, 265 ont suivi le programme de formation (taux de réponse de 72,4 %), en plus de 235 physiothérapeutes témoins sélectionnés de façon aléatoire qui ne l'ont pas fait (taux de réponse de 28 %). Les résultats mesurés étaient l'attitude générale des participants envers les instruments de mesure, leur capacité de choisir des instruments de mesure, leur utilisation des instruments, l'applicabilité du programme de formation et les changements entraînés dans la pratique de la physiothérapie grâce au programme. Résultats : L'utilisation constante (non occasionnelle) des instruments de mesure a augmenté de 26 % à 41 % dans le groupe d'intervention; dans le groupe témoin, l'utilisation est restée presque la même (45 % par rapport à 48 %). La difficulté de choisir un instrument de mesure approprié a diminué de 3,5 à 2,7 sur échelle Likert à 5 points. Finalement, 91 % des répondants ont trouvé le programme de formation utile et 82 % ont indiqué que ce programme a changé leur pratique de la physiothérapie. Conclusions : Le programme de formation et les trousses se sont avérés utiles et ont eu un effet positif sur la capacité des physiothérapeutes à faire un choix parmi les nombreuses possibilités de mesure de résultats.