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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.
Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Health Sciences. Region Västra Götaland.
Region Västra Götaland, Göteborgs universitet.
Region Västra Götaland, Göteborgs universitet.
Göteborgs universitet.
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2014 (English)In: BMC Health Services Research, ISSN 1472-6963, Vol. 14, no 1, 105- p.Article in journal (Refereed) Published
Abstract [en]


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.


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.


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.


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. Vol. 14, no 1, 105- p.
Keyword [en]
Implementation; Physical therapy; Evidence-based practice; Practice guidelines
National Category
URN: urn:nbn:se:liu:diva-105610DOI: 10.1186/1472-6963-14-105ISI: 000333535400002PubMedID: 24589291OAI: diva2:708766
Available from: 2014-03-28 Created: 2014-03-28 Last updated: 2015-11-09
In thesis
1. Advancing evidence-based practice in primary care physiotherapy: Guideline implementation, clinical practice, and patient preferences
Open this publication in new window or tab >>Advancing evidence-based practice in primary care physiotherapy: Guideline implementation, clinical practice, and patient preferences
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.
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1486
National Category
Physiotherapy Public Health, Global Health, Social Medicine and Epidemiology
urn:nbn:se:liu:diva-122558 (URN)10.3384/diss.diva-122558 (DOI)978-91-7685-935-3 (print) (ISBN)
Public defence
2015-12-09, Berzeliussalen, Campus US, Linköping, 13:00 (English)
Available from: 2015-11-09 Created: 2015-11-09 Last updated: 2015-11-30Bibliographically approved

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