IMPLEmenting a clinical practice guideline for acute low back pain evidence-based manageMENT in general practice (IMPLEMENT): Cluster randomised controlled trial study protocol Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain Implementation of the Dutch Low Back Pain Guideline for General Practitioners: A Cluster Randomized Controlled Trial Enhanced implementation of low back pain guidelines in general practice: study protocol of 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. Cost-effectiveness of a multifaceted implementation strategy for the Dutch multidisciplinary guideline for nonspecific low back pain: design of a stepped-wedge cluster randomised controlled trial 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 a Guideline for Low Back Pain Management in Primary Care: A Cost-Effectiveness Analysis The acceptability to primary care staff of a multidisciplinary training package on acute back pain guidelines. Implementation of cancer pain guidelines by acute care nurse practitioners using an audit and feedback strategy Knowledge transfer in family physicians managing patients with acute low back pain: a prospective randomized control trial. Routine primary care management of acute low back pain: adherence to clinical guidelines Improving the care for people with acute low-back pain by allied health professionals (the ALIGN trial): A cluster randomised trial protocol Evaluating two implementation strategies for whiplash guidelines in physiotherapy: a cluster randomised trial. Testing the feasibility of a knowledge translation intervention designed to improve chiropractic care for adults with neck pain disorders: study protocol for a pilot cluster-randomized controlled trial Implementing evidence-informed policy into practice for health care professionals managing people with low back pain in Australian rural settings: a preliminary prospective single-cohort study. Predictors of compliance with short-term treatment among patients with back pain.
Background Evidence generated from reliable research is not frequently implemented into clinical practice . Evidence -based clinical practice guidelines are a potential vehicle to achieve this . A recent systematic review of implementation strategies of guideline dissemination concluded that there was a lack of evidence regarding effective strategies to promote the uptake of guidelines . Recommendations from this review , and other studies , have suggested the use of interventions that are theoretically based because these may be more effective than those that are not . An evidence -based clinical practice guideline for the management of acute low back pain was recently developed in Australia . This provides an opportunity to develop and test a theory-based implementation intervention for a condition which is common , has a high burden , and for which there is an evidence - practice gap in the primary care setting . Aim This study aims to test the effectiveness of a theory-based intervention for implementing a clinical practice guideline for acute low back pain in general practice in Victoria , Australia . Specifically , our primary objectives are to establish if the intervention is effective in reducing the percentage of patients who are referred for a plain x-ray  , and improving mean level of disability for patients three months post-consultation . Methods / Design This study protocol describes the details of a cluster r and omised controlled trial . Ninety-two general practice s ( clusters ) , which include at least one consenting general practitioner , will be r and omised to an intervention or control arm using restricted r and omisation . Patients aged 18 years or older who visit a participating practitioner for acute non-specific low back pain of less than three months duration will be eligible for inclusion . An average of twenty-five patients per general practice will be recruited , providing a total of 2,300 patient participants . General practitioners in the control arm will receive access to the guideline using the existing dissemination strategy . Practitioners in the intervention arm will be invited to participate in facilitated face-to-face workshops that have been underpinned by behavioural theory . Investigators ( not involved in the delivery of the intervention ) , patients , outcome assessors and the study statistician will be blinded to group allocation . Trial registration Australian New Zeal and Clinical Trials Registry ACTRN012606000098538 ( date registered 14/03/2006 ) OBJECTIVE : The effect of clinical guidelines on re source utilization for complex conditions with substantial barriers to clinician behavior change has not been well studied . We report the impact of a multifaceted guideline implementation intervention on primary care clinician utilization of radiologic and specialty services for the care of acute low back pain . DESIGN : Physician groups were r and omized to receive guideline education and individual feedback , supporting patient education material s , both , or neither . The impact on guideline adherence and re source utilization was evaluated during the 12-month period before and after implementation . PARTICIPANTS : Fourteen physician groups with 120 primary care physician and associate practitioners from 2 group model HMO practice s. INTERVENTIONS : Guideline implementation utilized an education/audit/feedback model with local peer opinion leaders . The patient education component included written and videotaped material s on the care of low back pain . MAIN RESULTS : The clinician intervention was associated with an absolute increase in guideline -consistent behavior of 5.4 % in the intervention group versus a decline of 2.7 % in the control group ( P=.04 ) . The patient education intervention produced no significant change in guideline -consistent behavior , but was poorly adopted . Patient characteristics including duration of pain , prior history of low back pain , and number of visits during the illness episode were strong predictors of service utilization and guideline -consistent behavior . CONCLUSIONS : Implementation of an education and feedback-supported acute low back pain care guideline for primary care clinicians was associated with an increase in guideline -consistent behavior . Patient education material s did not enhance guideline effectiveness . Implementation barriers could limit the utility of this approach in usual care setting Study Design . Cluster r and omized controlled trial for a multifaceted implementation strategy . Objectives . To assess the effectiveness of tailored  interventions ( multifaceted implementation strategy ) to implement the  Dutch low back pain guideline for general practitioners with regard to adherence to guideline recommendations . Summary of Background Data . Guidelines for the management of low back pain in primary care have been developed in various countries , but little is known about the optimal implementation strategy . A multifaceted implementation strategy was developed to overcome identified barriers to the implementation of the Dutch low back pain guideline for general practitioners . Methods . General practitioners were r and omized to an intervention or a control group . The general practitioners in the intervention group ( n = 21 ) received tailored interventions consisting of the Dutch low back pain guideline for general practitioners , a 2-hour educational and clinical practice workshop ; two scientific articles on low back pain management ; the guideline for occupational physicians ; a tool for patient education ; and a tool for reaching agreement on low back care with physical , exercise , and manual therapists . The control group ( n = 20 ) received no intervention . The participating general practitioners were asked to recruit consecutive patients with a new episode of low back pain as the main reason for consultation . General practitioners completed registration forms of each individual consultation with regard to the main outcome measures : advice and information , referral to other health-care providers , and prescription of medication . Results . Forty-one of the 67 r and omized general practitioners reported on a total of 616 consultations for 531 patients with nonspecific low back pain . The advice and explanation provided by the general practitioners , the prescription of paracetamol or nonsteroidal anti-inflammatory drugs , and prescription of pain medication on atime contingent or a pain contingent basis showed no statistically significant differences between the intervention and control groups . There were also no differences in overall referral rate . However , in follow-up consultations fewer patients were referred to a physical or exercise therapist by the general practitioners in the intervention group than in the control group . Conclusions . The multifaceted intervention strategy modestly improved implementation ( for parts of the recommendations in ) the Dutch low back pain guideline by general practitioners and produced small concomitant changes in patient management . The implementation strategy produced fewer referrals to therapists during follow-up consultations Background Evidence -based clinical practice guidelines may improve treatment quality , but the uptake of guideline recommendations is often incomplete and slow . Recently new low back pain guidelines are being launched in Denmark . The guidelines are considered to reduce personal and public costs . The aim of this study is to evaluate whether a complex , multifaceted implementation strategy of the low back pain guidelines will reduce secondary care referral and improve patient outcomes compared to the usual simple implementation strategy . Methods / design In a two-armed cluster r and omised trial , 100 general practice s ( clusters ) and 2,700 patients aged 18 to 65 years from the North Denmark region will be included . Practice s are r and omly allocated 1:1 to a simple or a complex implementation strategy . Intervention practice s will receive a complex implementation strategy , including guideline facilitator visits , stratification tools , and quality reports on low back pain treatment . Primary outcome is referral to secondary care . Secondary outcomes are pain , physical function , health-related quality of life , patient satisfaction with care and treatment outcome , employment status , and sick leave . Primary and secondary outcomes pertain to the patient level . Assessment s of outcomes are blinded and follow the intention-to-treat principle . Additionally , a process assessment will evaluate the degree to which the intervention elements will be delivered as planned , as well as measure changes in beliefs and behaviours among general practitioners and patients . Discussion This study provides knowledge concerning the process and effect of an intervention to implement low back pain guidelines in general practice , and will provide insight on essential elements to include in future implementation strategies in general practice .Trial registration Registered as NCT01699256 on Clinical Trials.gov 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 Low back pain ( LBP ) is one of the most prevalent and expensive health care problems in industrialised countries . LBP leads to high health care utility and productivity losses ; leaving the individual , the employer , and society with substantial costs . To improve the care for LBP patients and reduce the high societal and financial burden of LBP , in 2010 the ‘ Multidisciplinary care guideline for nonspecific low back pain ’ was developed in the Netherl and s. The current paper describes the design of a study aim ing to evaluate the ( cost- ) effectiveness of a multifaceted strategy to implement this guideline . Methods In a cluster-r and omised controlled trial , the ( cost- ) effectiveness of a multifaceted implementation strategy will be compared to passive guideline dissemination . Using a stepped-wedge approach , participating general practitioners , physiotherapists , and occupational physicians are allocated into clusters and will attend a multidisciplinary continuing medical education training session . The timing these clusters receive the training is the unit of r and omisation . LBP patients visiting the participating health care providers are invited to participate in the trial and will receive access to a multimedia intervention aim ed at improving beliefs , cognitions , and self-management . The primary outcome measure of this study is patient back beliefs . Secondary outcome measures on patient level include pain , functional status , quality of life , health care utility , and productivity losses . Outcome measures on professional level include knowledge and attitude towards the guideline , and guideline adherence . A process evaluation for the implementation strategy will be performed among the health care providers and the patients . Furthermore , a qualitative subgroup analysis among patients with various ethnic background s will be performed . Discussion This study will give insight into the ( cost- ) effectiveness of a multifaceted implementation strategy for the Dutch multidisciplinary guideline for non-specific back pain to improve outcomes on patient and professional level . The valuable information gained with this study may prove useful for policy-makers , health care providers , and research ers who are in the process of reducing the burden of back pain on individuals and society . Trial Registration Netherl and s Trial Register ( NTR ) : NTR4329 . Registered December 20th , 2013 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 Study Design . Cost-effectiveness analysis alongside a cluster r and omized controlled trial . Objective . To study the cost-effectiveness of 2 low back pain guideline implementation ( GI ) strategies . Summary of Background Data . Several evidence -based guidelines on management of low back pain have been published . However , there is still no consensus on the effective implementation strategy . Especially studies on the economic impact of different implementation strategies are lacking . Methods . This analysis was performed alongside a cluster r and omized controlled trial on the effectiveness of 2 GI strategies ( physician education alone [ GI ] or physician education in combination with motivational counseling [ MC ] by practice nurses)-–both compared with the postal dissemination of the guideline ( control group , C ) . Sociodemographic data , pain characteristics , and cost data were collected by interview at baseline and after 6 and 12 months . low back pain – related health care costs were valued for 2004 from the societal perspective . Results . For the cost analysis , 1322 patients from 126 general practice s were included . Both interventions showed lower direct and indirect costs as well as better patient outcomes during follow-up compared with controls . In addition , both intervention arms showed superiority of cost-effectiveness to C. The effects attenuated when adjusting for differences of health care utilization prior to patient recruitment and for clustering of data . Conclusion . Trends in cost-effectiveness are visible but need to be confirmed in future studies . Research ers performing cost-evaluation studies should test for baseline imbalances of health care utilization data instead of judging on the r and omization success by review ing non-cost parameters like clinical data alone BACKGROUND Implementing clinical guidelines is more likely to be successful when the whole practice team is committed to the process . Practice s from the MRC General Practice Research Framework in two distinct geographical centres in the UK ( West Yorkshire and Greater Manchester ) participated in the feasibility study for the UK Back pain Exercise And Manipulation ( UK BEAM ) trial . Practice teams were r and omized to continue with their usual care for back pain patients , or to be trained in managing back pain in line with national guidelines . Those r and omized to the intervention arm of the trial were invited to attend training , delivered by either a generic trainer or a back pain expert . OBJECTIVES Our aims were to assess the general acceptability of the training package to staff , to assess the acceptability of the multidisciplinary approach and to determine if a generic primary care educator could deliver the training as effectively as a clinical back pain expert . METHODS All staff ( clinical and non- clinical ) from intervention practice s were invited to attend multidisciplinary training sessions on the active management of back pain .  Practice staff in West Yorkshire were trained by a generic primary care educator and practice staff in Greater Manchester were trained by a clinical back pain expert . The content of sessions was st and ardized for both trainers and included didactic and interactive components and small group , case study discussion s. Detailed notes were taken of observations made of participants during sessions , and evaluation forms were completed by all those who attended . RESULTS The majority of participants found the training useful and said that the session had lived up to their expectations . Most found that the session was well planned and that they had sufficient opportunity to participate in learning . The training package was well received by clinical staff , but was less acceptable to non- clinical staff . GPs dominated the small group work discussion s. No differences were found between the preferences of participants for the two different trainers . CONCLUSION The training package was appropriate for clinical staff , but did not always meet the needs of non- clinical staff and may require modification for this group . A generic educator can successfully lead multidisciplinary educational sessions addressing clinical issues Purpose : Despite the availability of clinical practice guidelines ( CPGs ) for cancer pain , consistent integration of these principles into practice has not been achieved . The optimal method for implementing CPGs and the impact of guidelines on healthcare outcomes remain uncertain . This study evaluated the effect of an audit and feedback ( A/F ) intervention on  nurse  practitioner ( NP ) implementation of cancer pain CPGs and on hospitalized patients ' self‐report of pain and satisfaction with pain relief . Data sources : Eight NPs and two groups of 96 patients were the sources of data . Eligible patients in both groups completed the Brief Pain Inventory‐Short Form ( BPI‐SF ) within 24 h of admission and every 48 h until discharge . During A/F , NPs received weekly feedback on pain scores and guideline adherence . Conclusions : Nurse practitioner adherence to CPGs increased during A/F. Pain intensity did not significantly differ between groups . Intervention group patients reported significantly less overall pain interference ( p < .0001 ) , interference with general activity ( p = .0003 ) , and sleep ( p = .006 ) . Satisfaction with pain relief increased from 68.4 % to 95.1 % during A/F ( p < .0001 ) . Implication s for practice : A/F is an effective strategy to promote CPG use . Improved functional status in the absence of decreased pain severity underscores the need to consider symptom clusters when study ing pain BACKGROUND CONTEXT The process through which new scientific developments are incorporated into clinical practice is referred to as " knowledge transfer " and is currently the subject of great interest in many areas of clinical medicine . Family physicians managing patients with acute low back pain have been shown to have a poor overall rate of concordance with clinical practice guideline -recommended treatments . New methods need to be developed to help physicians bridge the guideline implementation gap . PURPOSE To determine the efficacy of a knowledge transfer method that communicates clinical practice guidelines to family physicians and their patients using patient-specific , physician-to-physician communications . STUDY DESIGN A prospect i ve r and omized controlled study . PATIENT SAMPLE 428 patients with acute mechanical low back pain and accepted Workers ' Compensation Board cl aims were studied . OUTCOME MEASURES Concordance with specific clinical practice guideline -derived history taking items , physical examination procedures and treatment recommendations was determined . METHODS Patients with acute mechanical back pain of less than 4 weeks duration and accepted Workers ' Compensation Board cl aims were r and omly assigned to one of three groups . In Group 1 ( control group ) neither the patients nor their family physicians received any information concerning the guidelines . In Group 2 , family physicians alone or as well as their patients ( Group 3 ) received a summary of clinical practice guidelines at approximately 2 weeks postinjury . In addition , both Groups 2 and 3 received reminders summarizing the recommended guidelines for patients at three specific stages of their clinical course . All guideline correspondence was addressed to a specific family physician or patient , signed by the study physician-investigators , and specified the patient by name . RESULTS Family physicians in the control and intervention groups demonstrated a high degree of concordance with the guideline -recommended history taking and physical examination procedures , but were generally highly discordant with guideline -recommended treatments . Significant improvement in guideline -concordant treatments was seen only with diminished recommendations of prolonged bed rest and passive therapies and an increase in recommended aerobic exercise . Concordance with guideline recommendations relating to the use of spinal manipulative therapy was poor in all study groups . CONCLUSIONS A knowledge transfer method that involved patient-specific , physician-to-physician communication to family physicians or their patients at three stages of the patient 's clinical course was largely unsuccessful in improving concordance with guideline treatment recommendations One of the major challenges for general practitioners is to manage individuals with acute low back pain appropriately to reduce the risk of chronicity . A prospect i ve study was design ed to assess the actual management of acute low back pain in one primary care setting and to determine whether existing practice patterns conform to published guidelines . Twenty-four family physicians from public primary care centers of the Basque Health Service in Bizkaia , Basque Country ( Spain ) , participated in the study . A total of 105 patients aged 18–65 years presenting with acute low back pain over a 6-month period were included . Immediately after consultation , a research assistant performed a structured clinical interview . The patients ’ care provided by the general practitioner was compared with the Agency for Health Care Policy and Research ( AHCPR ) guidelines and guidelines issued by the Royal College of General Practitioners . The diagnostic process showed a low rate of appropriate use of history ( 27 % ) , physical examination ( 32 % ) , lumbar radiographs ( 31 % ) , and referral to specialized care ( 33 % ) . Although the therapeutic process showed a relatively high rate of appropriateness in earlier mobilization ( 77 % ) and educational advice ( 65 % ) , only 23 % of patients were taught about the benign course of back pain . The study revealed that management of acute low back pain in the primary care setting is far from being in conformance with published clinical guidelines Background Variability between clinical practice guideline recommendations and actual clinical practice exists in many areas of health care . A 2004 systematic review examining the effectiveness of guideline implementation interventions concluded there was a lack of evidence to support decisions about effective interventions to promote the uptake of guidelines . Further , the review recommended the use of theory in the development of implementation interventions . A clinical practice guideline for the management of acute low-back pain has been developed in Australia ( 2003 ) . Acute low-back pain is a common condition , has a high burden , and there is some indication of an evidence - practice gap in the allied health setting . This provides an opportunity to develop and test a theory-based implementation intervention which , if effective , may provide benefits for patients with this condition . Aims This study aims to estimate the effectiveness of a theory-based intervention  to increase allied health practitioners ' ( physiotherapists and chiropractors in Victoria , Australia ) compliance with a clinical practice guideline for acute non-specific low back pain ( LBP ) , compared with providing practitioners with a printed copy of the guideline . Specifically , our primary objectives are to establish if the intervention is effective in reducing the percentage of acute non-specific LBP patients who are either referred for or receive an x-ray  , and improving mean level of disability for patients three months post-onset of acute LBP . Methods The design of the study is a cluster r and omised trial . Restricted r and omisation was used to r and omise 210 practice s ( clusters ) to an intervention or control group . Practitioners in the control group received a printed copy of the guideline . Practitioners in the intervention group received a theory-based intervention developed to address prospect ively identified barriers to practitioner compliance with the guideline . The intervention primarily consisted of an educational symposium .  Patients aged 18 years or older who visit a participating practitioner for acute non-specific LBP of less than three months duration over a two-week data collection period , three months post the intervention symposia , are eligible for inclusion . Sample size calculations are based on recruiting between 15 to 40 patients per practice . Outcome assessors will be blinded to group allocation . Trial registration Australian New Zeal and Clinical Trials Registry ACTRN12609001022257 ( date registered 25th November 2009 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 Neck pain in adults is common and a leading cause of physical disability . Recently , a guideline was developed for the management of non-specific neck pain ( NSNP ) with an aim to improve the quality of the delivery of chiropractic care . One key guideline recommendation is to undertake multimodal care for patients with NSNP . The aim of this pilot study is to determine the feasibility of implementing a multifaceted knowledge translation intervention by promoting the use of multimodal care by chiropractors managing patients with NSNP . Methods / design The design is a cluster-r and omized controlled pilot and feasibility trial . Chiropractors in private practice in Canada will be approached to participate in the study . Thirty consenting chiropractors will be r and omized to receive either a theory-based educational intervention in the experimental group or simply a printed copy of the guideline in the control group .  Each chiropractor will recruit five neck pain patients ( a total of 150 patients ) into the study . Development of the multifaceted intervention was informed by the results of a related qualitative study based on the Theoretical Domains Framework and consists of a series of three webinars , two online case scenarios , a self-management video on Brief Action Planning , and a printed copy of the practice guideline . Primary feasibility outcomes for both chiropractors and patients include rates of ( 1 ) recruitment , ( 2 ) retention , and ( 3 ) adherence to the intervention . A checklist of proxy measures embedded within patient encounter forms will be used to assess chiropractors ’ compliance with guideline recommendations ( e.g. exercise and self-care prescriptions ) at study onset and at 3 months . Secondary outcomes include scores of behavioural constructs ( level of knowledge and self-efficacy ) for recommended multimodal care . Clinical outcomes include pain intensity and neck pain-specific disability . Analyses from this study will focus on generating point estimates and corresponding 95 % confidence intervals for parameters of a priori interest ( recruitment , retention , adherence , pain intensity , Neck Disability Index ) . Discussion Results of this study will inform the design of a larger cluster-r and omized controlled trial aim ed at evaluating the effectiveness of the theory-based tailored intervention and increasing the use of multimodal care by chiropractors managing patients with NSNP.Trial registration https:// clinical trials.gov/ , OBJECTIVE To provide access to professional development opportunities for health care professionals , especially in rural Australian regions , consistent with recommendations in the Australian National Pain Strategy and state government policy . DESIGN AND SETTING A preliminary prospect i ve , single-cohort study design , which aligned health policy with evidence -informed clinical practice , evaluated the implementation and effectiveness of an interprofessional , health care provider pain education program ( hPEP ) for management of nonspecific low back pain ( nsLBP ) in rural Western Australia . INTERVENTION The 6.5-hour hPEP intervention was delivered to 60 care providers ( caseload nsLBP 19.8 % ± 22.5 ) at four rural WA regions . OUTCOME MEASURES Outcomes were recorded at baseline and 2 months post-intervention regarding attitudes , beliefs ( modified Health Care Providers Pain and Impairment Relationship Scale [ HC-PAIRS ] ) , Back Pain Beliefs Question naire [ BBQ ] ) , and self-reported evidence -based clinical practice ( knowledge and skills regarding nsLBP , rated on a 5-point Likert scale with 1 = nil and 5 = excellent ) . RESULTS hPEP was feasible to implement . At 2 months post-hPEP , responders ' ( response rate 53 % ) improved evidence -based beliefs were indicated by HC-PAIRS scores : baseline mean ( SD ) [ 43.2 ( 9.3 ) ] ; mean difference ( 95 % CI ) [ -5.9 ( -8.6 to -3.1 ) ] ; and BBQ baseline [ 34.3 ( 6.8 ) ] ; mean difference [ 2.1 ( 0.5 to 3.6 ) ] . Positive shifts were observed for all measures of clinical knowledge and skills ( P < 0.001 ) and increased assistance with planning lifestyle changes ( P < 0.001 ) , advice on self-management ( P = 0.010 ) , and for decreased referrals for spinal imaging ( P = 0.03 ) . CONCLUSIONS This policy-into- practice educational program is feasible to implement in rural Western Australia ( WA ) . While preliminary data are encouraging , a further r and omized controlled trial is recommended OBJECTIVE Great efforts have been made to find effective treatments for back pain . Nevertheless , the effectiveness of a particular treatment can depend on patient compliance . The objective of this study was to prospect ively investigate whether patients ' demographic factors , clinical factors , external barriers in following the treatment , and perceptions of disability , quality of life , depression , and control over health were predictive of compliance with a physical therapy program carried out with patients with low back pain . METHODS This was an exploratory prospect i ve cohort study that was carried out in New York City during 1999 . All study participants answered a question naire at the initial clinical evaluation by a physical therapist and were followed during the treatment . The study assessed compliance with the three treatment regimens that were prescribed for every patient : attending scheduled physical therapy sessions , following a program of home exercises , and watching back-education videotapes . Depending on the individual patient , the planned treatment program could last from 2 to 6 weeks . The study employed a battery of instruments to measure patient characteristics that included perceived functional limitations , perceived quality of life , depression , and their beliefs about their health . Student 's t tests and chi-square tests were used to determine if non- and low-compliant patients differed significantly from high-compliant patients . Logistic regression was used to estimate adjusted odds ratios expressing the association of selected variables with compliance . RESULTS We found that 51 % of the patients were either noncompliant or low-compliant overall with the low back pain treatment program . There were differences in compliance behavior among the three treatment regimens , with compliance being highest for watching the back-education videotapes and lowest for doing the home exercises . Poor compliance overall was positively associated with the expectation of barriers in following the proposed treatment , with comorbidity , and with longer duration of treatment in this program . CONCLUSIONS The findings of our study indicate that patient compliance with back pain treatment is a serious and complex problem . Nevertheless , while this study was only an exploratory one , we believe that the results of this study can be used by care providers to identify patients likely to become noncompliant and also by research ers to plan specific studies on the effectiveness of treatment programs for patients with low back pain
Meta-analyses did not reveal any differences in effect between multifaceted strategies and controls .
Conclusion This review showed that multifaceted strategies for the implementation of neck and /or back pain guidelines in health care do not significantly improve professional behaviour outcomes .
No effects on patient outcomes or cost of care could be found .
Background For the optimal use of clinical guidelines in daily practice , mere distribution of guidelines and material s is not enough , and active implementation is needed .
This review investigated the effectiveness of multifaceted implementation strategies compared to minimal , single , or no implementation strategy for the implementation of non-specific low back and /or neck pain guidelines in health care .