Abstract
Introduction A new set of clinical practice guidelines (CPGs) for the management of low back pain (LBP) and prevention of persistent disability entitled “Clinic on Low back pain in Interdisciplinary Practice” (CLIP) was developed in the province of Quebec, Canada. The literature shows that simply disseminating CPGs does not necessarily lead to their adoption by clinicians. To improve adherence to CPGs among healthcare professionals, the literature suggests that there is a need to identify and address the factors impeding or facilitating their use. The aim of this study was therefore to identify the barriers to and facilitators of CLIP CPG use, as perceived by physiotherapists (PTs). Methods A descriptive study using a qualitative method was conducted with a sample of 16 PTs from a variety of professional backgrounds. Each participant used the CPGs over a 6-week period with two patients suffering from LBP, and then participated in a semi-structured interview in which he or she was asked to identify the barriers and facilitators experienced. Results The participating PTs identified many barriers and facilitators pertaining to the guidelines themselves, the users and the environment. Four key nodes emerged from these barriers and facilitators during data analysis. It appears that the clinicians’ understanding of the CPGs, the level of compatibility between their practices and the CLIP CPG recommendations, the level of CPG relevance as perceived by the clinicians, and their level of agreement with the CPGs, all affected their use of the guidelines. Conclusions In order to increase CLIP CPG use, the implementation strategy to be developed should take into account the barriers and facilitators that were identified in this study.
Similar content being viewed by others
References
Rubin DI. Epidemiology and risk factors for spine pain. Neurol Clin. 2007;25(2):353–71. doi:10.1016/j.ncl.2007.01.004. Review.
Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine J. 2008;8(1):8–20. doi:10.1016/j.spinee.2007.10.005.
Sackett DL, Straus S, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine. How to practice and teach EBM. 2nd ed. New York: Churchill Livingstone; 2000.
Davis DA, Goldman J, Palda VA. Handbook on clinical practice guidelines. Ottawa: Canadian Medical Association; 2007.
Koes BW, van Tulder MW, Ostelo R, Burton AK, Waddell G. Clinical guidelines for the management of low back pain in primary care. An international comparison. Spine. 2001;26:2504–14. doi:10.1097/00007632-200111150-00022.
Burton AK, Waddell G. Clinical guidelines in the management of low back pain. Bailliere’s Clin Rheumatol. 1998;12(1):17–35. doi:10.1016/S0950-3579(98)80004-6.
van Tulder MW, Tuut M, Pennick V, Bombardier C, Assendelft WJ. Quality of primary care guidelines for acute low back pain. Spine. 2004;29(17):E357–62. doi:10.1097/01.brs.0000137056.64166.51.
Staal JB, Hlobil H, van Tulder MW, Waddell G, Burton AK, Koes BW, et al. Occupational health guidelines for the management of low back pain: an international comparison. Occup Environ Med. 2003;60(9):618–26.
Arnau JM, Vallano A, Lopez A, Pellise F, Delgado MJ, Prat N. A critical review of guidelines for low back pain treatment. Eur Spine J. 2006;15(5):543–53. doi:10.1007/s00586-005-1027-y.
Freemantle N. Implementation strategies. Fam Pract. 2000;17(Suppl 1):S7–10. doi:10.1093/fampra/17.suppl_1.S7.
van Tulder MW, Croft PR, van Splunteren P, Miedema HS, Underwood MR, Hendriks HJ, et al. Disseminating and implementing the results of back pain research in primary care. Spine. 2002;27(5):E121–7. doi:10.1097/00007632-200203010-00018.
Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001;39(8, Suppl 2):II2–45. doi:10.1097/00005650-200108002-00002.
Oxman AD, Flottorp S. An overview of strategies to promote implementation of evidence based health care. Evidence based practice in primary care. London: BMJ Books; 1998. p. 91–109.
Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. Can Med Assoc J. 1995;153(10):1423–31.
Lomas J. Words without action? The production, dissemination, and impact of consensus recommendations. Annu Rev Public Health. 1991;12:41–65. doi:10.1146/annurev.pu.12.050191.000353.
Gross PA. Implementing evidence-based recommendations for health care: a roundtable comparing European and American experiences. Jt Comm J Qual Improv. 2000;26(9):547–53.
Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8(6):iii–iv. Research Support, Non-U.S. Gov’t, Review.
Gross PA, Greenfield S, Cretin S, Ferguson J, Grimshaw J, Grol R, et al. Optimal methods for guideline implementation: conclusions from Leeds Castle meeting. Med Care. 2001;39(8, Suppl 2):II85–92.
Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. J Am Med Assoc. 1995;274(9):700–5. doi:10.1001/jama.274.9.700.
Thomson O’Brien M, Oxman A, Davis D, Haynes R, Freemantle N, Harvey E. Audit and feedback versus alternative strategies: effects on professional practice and health care outcomes. Cochrane Database Syst Rev (Online: Update Software). 2000; (2):CD000260. Review.
Grol R. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care. 2001;39(8, Suppl 2):II46–54. doi:10.1097/00005650-200108002-00003.
Grol R. Beliefs and evidence in changing clinical practice. BMJ (Clin Res Ed). 1997;315:418–21.
Grol R. Personal paper. Beliefs and evidence in changing clinical practice. BMJ (Clin Res Ed). 1997;315(7105):418–21.
Mittman BS, Tonesk X, Jacobson PD. Implementing clinical practice guidelines: social influence strategies and practitioner behavior change. Qual Rev Bull. 1992;18(12):413–22.
Moulding NT, Silagy CA, Weller DP. A framework for effective management of change in clinical practice: dissemination and implementation of clinical practice guidelines. Qual Health Care. 1999;8(3):177–83.
Solberg LI, Brekke ML, Fowles J, Jacobsen DN, Kottke TE, Mosser G, et al. Lessons from experienced guideline implementers: attend to many factors and use multiple strategies. Jt Comm J Qual Improv. 2000;26(4):171–88.
Shaw B, Cheater F, Baker R, Gillies C, Hearnshaw H, Flottorp S, et al. Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2005;20(3):CD005470. Meta-Analysis, Review.
Grilli R, Lomas J. Evaluating the message: the relationship between the compliance rate and the subject of a practice guideline. Med Care. 1994;32:202–13. doi:10.1097/00005650-199403000-00002.
Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, et al. Lost in knowledge translation: time for a map? J Contin Educ Health Prof. 2006;26(1):13–24. doi:10.1002/chp.47.
Lomas J. Diffusion, dissemination, and implementation: who should do what? Ann NY Acad Sci. 1993;703:226–35. doi:10.1111/j.1749-6632.1993.tb26351.x. Review.
Chenot J, Becker A, Leonhardt C, Keller S, Donner-Banzhoff N, Baum E, et al. The impact of specialist care for low back pain on health service utilization in primary care patients: a prospective cohort study. Eur J Pain (London, England). 2008;12(3):275–83. doi:10.1016/j.ejpain.2007.06.004. Epub 2007 Jul 27.
Stevenson K, Lewis M, Hay E. Do physiotherapists’ attitudes towards evidence-based practice change as a result of an evidence-based educational programme? J Eval Clin Prac. 2004;10(2):207–17. doi:10.1111/j.1365-2753.2003.00479.x.
Jette DU, Bacon K, Batty C, Carlson M, Ferland A, Hemingway RD, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786–805.
Iles R, Davidson M. Evidence based practice: a survey of physiotherapists’ current practice. Physiother Res Int. 2006;11(2):93–103. doi:10.1002/pri.328.
Swinkels IC, van den Ende CH, van den Bosch W, Dekker J, Wimmers RH. Physiotherapy management of low back pain: does practice match the Dutch guidelines? Aust J Physiother. 2005;51(1):35–41.
Poitras S, Rossignol M, Dionne C, Tousignant M, Truchon M, Arsenault B, et al. An interdisciplinary clinical practice model for the management of low-back pain in primary care: the CLIP project. BMC Musculoskelet Disord. 2008;9:54.
Rossignol M, Poitras S, Dionne C, Tousignant M, Truchon M, Arsenault B, et al. An interdisciplinary guideline development process: the Clinic on Low-back pain in Interdisciplinary Practice (CLIP) low-back pain guidelines. Implement Sci. 2007;2:36. doi:10.1186/1748-5908-2-36.
Fortin M-F. Le processus de la recherche de la conception à la réalisation. Montréal: Décarie Éditeur; 1996.
Crabtree BF, Miller WL. Doing qualitative research. Thousand Oak: Sage Publications; 1999.
Deslauriers J-P, Kérisit M. Le devis de recherche qualitative. In: Poupart J, Deslauriers J-P, Groulx L-H, Laperrière A, Mayer R, Pires A, editors. La recherche qualitative Enjeux épistémologiques et méthodologiques. Boucherville: Gaetan Morin Éditeur; 1997. p. 85–111.
Miles MB, Huberman AM. Qualitative data analysis: an expanded sourcebook. 2nd ed. Thousand Oak: Sage Publications; 1994.
Harrison S, Dowswell G, Wright J, Russell I. General practitioners’ uptake of clinical practice guidelines: a qualitative study. J Health Serv Res Policy. 2003;8(3):149–53. doi:10.1258/135581903322029494.
Schers H, Wensing M, Huijsmans Z, van Tulder M, Grol R. Implementation barriers for general practice guidelines on low back pain a qualitative study. Spine. 2001;26(15):E348–53. doi:10.1097/00007632-200108010-00013.
Shiffman R, Dixon J, Brandt C, Essaihi A, Hsiao A, Michel G, et al. The GuideLine Implementability Appraisal (GLIA): development of an instrument to identify obstacles to guideline implementation. BMC Med Inform Decis Mak. 2005;5(1):23. doi:10.1186/1472-6947-5-23.
Pathman DE, Konrad TR, Freed GL, Freeman VA, Koch GG. The awareness-to-adherence model of the steps to clinical guideline compliance. The case of pediatric vaccine recommendations. Med Care. 1996;34(9):873–89. doi:10.1097/00005650-199609000-00002.
Maue SK, Segal R, Kimberlin CL, Lipowski EE. Predicting physician guideline compliance: an assessment of motivators and perceived barriers. Am J Manag Care. 2004;10(6):383–91.
Ajzen I. Attitudes, personality, and behavior. Chicago: Dorsey Press; 1988.
Saillour-Glenisson F, Michel P. Individual and collective facilitators of and barriers to the use of clinical practice guidelines by physicians: a literature review. Revue d’Epidemiologie et de Sante Publique. 2003;51(1 Pt 1):65–80.
Turner P, Whitfield TW. Physiotherapists’ use of evidence based practice: a cross-national study. Physiother Res Int. 1997;2(1):17–29. doi:10.1002/pri.76.
Stewart RE, Vroegop S, Kamps GB, van der Werf GT, Meyboom-de Jong B. Factors influencing adherence to guidelines in general practice. Int J Technol Assess Health Care. 2003;19(3):546–54. doi:10.1017/S0266462303000497.
Poitras S. Pratiques cliniques des physiothérapeutes dans le traitement des travailleurs souffrant de maux de dos aigus ou subaigus. Montréal: Université de Montréal; 2005.
Gauthier B. Recherche Sociale de la problématique à la collecte des données. 4th ed. Sainte-Foy: Presses de l’Université du Québec; 2004.
Van der Maren J-M. Méthodes de recherche pour l’éducation. Montréal: De Boeck; 1996.
Krippendorff K. Content analysis: an introduction to its methodology. Thousand Oak: Sage Publications; 1980.
Carey JW, Morgan M, Oxtoby MJ. Intercoder agreement in analysis of responses to open-ended interview questions: example from tuberculosis research. Cult Anthropol Methods. 1996;8(3):1–5.
Landry R. L’analyse de contenu. In: Gauthier B, editor. Recherche sociale de la problématique à la collecte des données. Québec: Presses de l’université du Québec; 1997. p. 329–56.
Loisel P, Buchbinder R, Hazard R, Keller R, Scheel I, Tulder M, et al. Prevention of work disability due to musculoskeletal disorders: the challenge of implementing evidence. J Occup Rehabil. 2005;15(4):507. doi:10.1007/s10926-005-8031-2.
Guzman J, Jones D, Cassidy JD, Furlan AD, Loisel P, Frank JW. Key factors in back disability prevention: what influences the choice of priorities? Spine. 2007;32(9):E281–9. Research Support, Non-U.S. Gov’t.
Atlas SJ, Chang Y, Kammann E, Keller RB, Deyo RA, Singer DE. Long-term disability and return to work among patients who have a herniated lumbar disc: the effect of disability compensation. J Bone Jt Surg. 2000;82(1):4–15. Comparative Study, Research Support, U.S. Gov’t, P.H.S.
Atlas SJ, Chang Y, Keller RB, Singer DE, Wu YA, Deyo RA. The impact of disability compensation on long-term treatment outcomes of patients with sciatica due to a lumbar disc herniation. Spine. 2006;31:3061–9. doi:10.1097/01.brs.0000250325.87083.8d.
Dahan R, Borkan J, Brown J-B, Reis S, Hermoni D, Harris S. The challenge of using the low back pain guidelines: a qualitative research. J Eval Clin Prac. 2007;13(4):616–20. doi:10.1111/j.1365-2753.2007.00855.x.
Espeland A, Baerheim A. Factors affecting general practitioners’ decisions about plain radiography for back pain: implications for classification of guideline barriers—a qualitative study. BMC Health Serv Res. 2003;3(1):8. doi:10.1186/1472-6963-3-8.
Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. J Am Med Assoc. 1999;282(15):1458–65. doi:10.1001/jama.282.15.1458.
Christiaens T, De Backer D, Burgers J, Baerheim A. Guidelines, evidence, and cultural factors. Scand J Prim Health Care. 2004;22(3):141–5. doi:10.1080/02813430410006521.
Fishbein M. The role of theory in HIV prevention. AIDS Care. 2000;12(3):273–8. doi:10.1080/09540120050042918.
Rhodes F, Stein JA, Fishbein M, Goldstein RB, Rotheram-Borus MJ. Using theory to understand how interventions work: Project RESPECT, condom use, and the Integrative Model. AIDS Behav. 2007;11(3):393–407. doi:10.1007/s10461-007-9208-9. Epub 2007 Feb 24.
Armstrong MP, McDonough S, Baxter GD. Clinical guidelines versus clinical practice in the management of low back pain. Int J Clin Pract. 2003;57(1):9–13.
Foster NE, Thompson KA, Baxter GD, Allen JM. Management of nonspecific low back pain by physiotherapists in Britain and Ireland. A descriptive questionnaire of current clinical practice. Spine. 1999;24(13):1332–42. doi:10.1097/00007632-199907010-00011.
Poitras S, Blais R, Swaine B, Rossignol M. Management of work-related low back pain: a population-based survey of physical therapists. Phys Ther. 2005;85(11):1168–81.
Jette AM, Smith K, Haley SM, Davis KD. Physical therapy episodes of care for patients with low back pain. Phys Ther. 1994;74(2):101–10. discussion 10-5.
Turner PA, Harby-Owren H, Shackleford F, So A, Fosse T, Whitfield TW. Audits of physiotherapy practice. Physiother Theory Prac. 1999;15:261–74. doi:10.1080/095939899307667.
Bekkering GE, Engers AJ, Wensing M, Hendriks HJ, van Tulder MW, Oostendorp RA, et al. Development of an implementation strategy for physiotherapy guidelines on low back pain. Aust J Physiother. 2003;49(3):208–14.
Waddell G, Burton AK, Main CJ. Screening to identify people at risk of long term incapacity for work: a conceptual and scientific review. London: Royal Society of Medicine Press; 2003. ISBN 9781853155642.
Truchon M. Determinants of chronic disability related to low back pain: towards an integrative biopsychosocial model. Disabil Rehabil. 2001;23(17):758–67. doi:10.1080/09638280110061744.
Truchon M, Fillion L, Truchon G, Dionne C, Arsenault B, Viau C. Les déterminants de l’incapacité liés à la lombalgie. Études et recherches/Rapport R-487. Montréal: IRSST; 2007. p. 108.
Frank J, Brooker A, DeMaio S, Kerr M, Maetzel A, Shannon H, et al. Disability resulting from occupational low back pain. Part II: What do we know about secondary prevention? A review of the scientific evidence on prevention after disability begins. Spine. 1996;21(24):2918–29. doi:10.1097/00007632-199612150-00025. Review.
Schers H, Braspenning J, Drijver R, Wensing M, Grol R. Low back pain in general practice: reported management and reasons for not adhering to the guidelines in the Netherlands. Brit J Gen Prac. 2000;50:640–4.
Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003;362(9391):1225–30. doi:10.1016/S0140-6736(03)14546-1.
Harrington JT, Dopf CA, Chalgren CS. Implementing guidelines for interdisciplinary care of low back pain: a critical role for pre-appointment management of specialty referrals. Jt Comm J Qual Improv. 2001;27(12):651–63.
Acknowledgments
This study was supported by a grant from the Quebec Rehabilitation Research Network.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Côté, AM., Durand, MJ., Tousignant, M. et al. Physiotherapists and Use of Low Back Pain Guidelines: A Qualitative Study of the Barriers and Facilitators. J Occup Rehabil 19, 94–105 (2009). https://doi.org/10.1007/s10926-009-9167-2
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10926-009-9167-2