Evaluating two implementation strategies for whiplash guidelines in physiotherapy: a cluster randomised 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 A theory-based cross-sectional survey demonstrated the important role of awareness in guideline implementation. 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. Adherence to physiotherapy clinical guideline acute ankle injury and determinants of adherence: a cohort study Evaluation of the theory-based Quality Improvement in Physical Therapy (QUIP) programme: a one-group, pre-test post-test pilot study Effectiveness of an interactive postgraduate educational intervention with patient participation on the adherence to a physiotherapy guideline for hip and knee osteoarthritis: a randomised controlled trial 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 Monitoring the change: current trends in outcome measure usage in physiotherapy. The Efficacy of a Short Education Program and a Short Physiotherapy Program for Treating Low Back Pain in Primary Care: A Cluster Randomized Trial Effectiveness of physiotherapy in Parkinson's disease: the feasibility of a randomised controlled trial. Implementation of a protocol facilitates evidence-based physiotherapy practice in intensive care units. Randomised trial of a brief physiotherapy intervention compared with usual physiotherapy for neck pain patients: outcomes and patients' preference The effectiveness of manual therapy, physiotherapy and continued treatment by the general practitioner for chronic nonspecific back and neck complaints: design of a randomized clinical trial. An Innovative Peer Assessment Approach to Enhance Guideline Adherence in Physical Therapy: Single-Masked, Cluster-Randomized Controlled Trial The Effectiveness of Manual Therapy, Physiotherapy, and Treatment by the General Practitioner for Nonspecific Back and Neck Complaints: A Randomized Clinical Trial Implementation of cancer pain guidelines by acute care nurse practitioners using an audit and feedback strategy
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 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 OBJECTIVE To assess physiotherapists ' adherence to the  Dutch guidelines  for nonspecific low back pain , the motivational determinants related to guideline adherence , and the role of physiotherapists ' awareness of their performance in this respect . STUDY DESIGN & SETTING This was a cross-sectional survey among a r and om sample of 1,500 private practice physiotherapists in the Netherl and s. The actual  guideline adherence  was measured by means of vali date d clinical vignettes and self-reported adherence by asking the physiotherapists to report their own level of adherence . The assessment of motivational determinants was based on a theoretical framework . RESULTS The  response rate was 31.5 % ( N=472 ) . The average guideline adherence rate was 50.4 % ( SD=16.8 ) . Only 38.5 % of the physiotherapists had realistic perceptions of their personal performance . Awareness levels seriously interfered with the relationship between motivational determinants and actual guideline adherence . Actual adherence was mainly related to the perceived relative advantages and awareness of adherence to the perceived social norm . CONCLUSION The moderating role of awareness in this study confirms the view that motivational determinants of a particular behavior can only be accurately assessed if people hold realistic perceptions of that behavior . Our approach illustrates the added value of a theory-based approach in guideline implementation studies 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 Clinical guidelines are considered important instruments to improve quality in health care . In physiotherapy , insight in adherence to guidelines is limited . Knowledge of adherence is important to identify barriers and to enhance implementation . Purpose of this study is to investigate the ability to adherence to recommendations of the guideline Acute ankle injury , and to identify patient characteristics that determine adherence to the guideline . Methods Twenty-two physiotherapists collected data of 174 patients in a prospect i ve cohort study , in which the course of treatment was systematic ally registered . Indicators were used to investigate adherence to recommendations . Patient characteristics were used to identify prognostic factors that may determine adherence to the guideline . Correlation between patient characteristics and adherence to outcome -indicators ( treatment sessions , functioning of patient , accomplished goals ) was calculated using univariate logistic regression . To calculate explained variance of combined patient characteristics , multivariate analysis was performed . Results Adherence to individual recommendations varied from 71 % to 100 % . In 99 patients ( 57 % ) the physiotherapists showed adherence to all indicators . Adherence to preset maximum of six treatment sessions for patients with severe ankle injury was 81 % ( 132 patients ) .The odds to receive more than six sessions were statistically significant for three patient characteristics : females ( OR:3.89 ; 95%CI : 1.41–10.72 ) , recurrent sprain ( OR : 6.90 ; 95%CI : 2.34 – 20.37 ) , co-morbidity ( OR : 25.92 ; 95 % CI : 6.79 – 98.93 ) . All factors together explained 40 % of the variance . Inclusion of physiotherapist characteristics in the regression model showed that work-experience reduced the odds to receive more than six sessions ( OR : 0.2 ; 95%CI : 0.06 – 0.77 ) , and increased explained variance to 45 % . Conclusion Adherence to the clinical guideline Acute ankle sprain showed that the guideline is applicable in daily practice . Adherence to the guideline , even in a group of physiotherapists familiar with the guideline , showed possibilities for improvement . The necessity to exceed the expected number of treatment sessions may be explained by co-morbidity and recurrent sprains . It is not clear why female patients were treated with more sessions . Experience of the physiotherapist reduced the number of treatment sessions . Quality indicators may be used for audit and feedback as part of the implementation strategy Background Guideline adherence in physical therapy is far from optimal , which has consequences for the effectiveness and efficiency of physical therapy care . Programmes to enhance guideline adherence have , so far , been relatively ineffective . We systematic ally developed a theory-based Quality Improvement in Physical Therapy ( QUIP ) programme aim ed at the individual performance level ( practicing physiotherapists ; PTs ) and the practice organization level ( practice quality manager ; PQM ) . The aim of the study was to pilot test the multilevel QUIP programme ’s effectiveness and the fidelity , acceptability and feasibility of its implementation . Methods A one-group , pre-test , post-test pilot study ( N = 8 practice s ; N = 32 PTs , 8 of whom were also PQMs ) done between September and December 2009 . Guideline adherence was measured using clinical vignettes that addressed 12 quality indicators reflecting the guidelines ’ main recommendations . Determinants of adherence were measured using quantitative methods ( question naires ) . Delivery of the programme and management changes were assessed using qualitative methods ( observations , group interviews , and document analyses ) . Changes in adherence and determinants were tested in the paired sample s T-tests and expressed in effect sizes ( Cohen ’s d ) . Results Overall adherence did not change ( 3.1 % ; p = .138 ) . Adherence to three quality indicators improved ( 8 % , 24 % , 43 % ; .000 ≤ p ≤ .023 ) . Adherence to one quality indicator decreased ( −15.7 % ; p = .004 ) . Scores on various determinants of individual performance improved and favourable changes at practice organizational level were observed . Improvements were associated with the programme ’s multilevel approach , collective goal setting , and the application of self-regulation ; unfavourable findings with programme deficits . The one-group pre-test post-test design limits the internal validity of the study , the self-selected sample its external validity . Conclusions The QUIP programme has the potential to change physical therapy practice but needs considerable revision to induce the ongoing quality improvement process that is required to optimize overall guideline adherence . To assess its value , the programme needs to be tested in a r and omized controlled trial Abstract Purpose : To determine the effectiveness of an interactive educational intervention on a physiotherapy guideline for hip and knee osteoarthritis . Method : Physiotherapists were r and omly allocated to a 3-h interactive educational course with the collaboration of three patient partners or no intervention . Assessment s comprised question naires on adherence ( score range 0–24 ) , knowledge ( score range 0–76 ) , and barriers to use the guideline ( score range 0–80 ) . Assessment s were conducted 1 week before the interactive course ( T0 ) immediately after ( T1 ) , and 3 months thereafter ( T2 ) . Change scores were compared between the groups by means of Mann – Whitney U tests and linear mixed models . Results : 284 of 4328 eligible PTs ( 7 % ) were included . The intervention ( n = 133 ) was significantly more effective than no intervention ( n = 151 ) concerning self-reported adherence and knowledge with mean differences in change scores ( 95 % CI ) at T1 and T2 being 1.4 ( 0.7–2.0 ) and 0.9 ( 0.2–1.7 ) for adherence and 6.8 ( 4.5–9.1 ) and 3.9 ( 1.7–6.2 ) for knowledge , ( all p values < 0.005 ) . In both groups the barrier score increased at T1 and decreased at T2 , with a significantly larger increase at T1 and decrease at T2 in the intervention group ( mean differences 3.1 ( 1.8–4.4 ) and 3.3 ( 0.5–6.1 ) , respectively . Conclusions : A short interactive educational course with patient participation on a PT guideline on hip and knee osteoarthritis showed a small to moderate positive effect on self-reported guideline adherence and knowledge , whereas for perceived barriers an advantage was only seen on the longer term . Implication s for Rehabilitation Continuing professional development is important and effective , it works very well when patients are engaged in the process , and hence it is supportive overall of enhancing clinical practice . Interactive education can reduce barriers in guideline usage in daily practice Background 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 . Methods 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 practice s including 277 physical therapists ( PTs ) ( intervention group ) . In two adjacent areas , 171 PTs at 32 practice s received no intervention ( control group ) . The core component of the intervention was an implementation seminar with group discussion s. Among other components were a website and email reminders . Data were collected at baseline and follow-up with a web-based question naire . 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 . Results 168 PTs ( 60.6 % ) in the intervention group and 88 PTs ( 51.5 % ) in the control group responded to the follow-up question naire . 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 . Conclusions 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 Physiotherapists have traditionally relied on impairment measures such as range of motion and muscle strength to monitor patient progress . The impact of treatment on patients ' daily activities can be assessed with valid and reliable question naires , but the use of st and ardized question naires by physiotherapists appeared to be limited . A range of strategies were implemented that aim ed to increase physiotherapists ' use of st and ardized measures of functional activities . A simple r and om sample of 300 was drawn from a data base of physiotherapy providers to a transport accident scheme , and was surveyed in March and September 2003 , with response rates of 51 % and 55 % , respectively . There was a statistically significant ( P<.05 ) increase in reported use of seven question naires and a significant reduction in the perception of barriers that were targeted by the interventions The most frequently utilized tests were a pain rating scale and question naires for lumbar and cervical problems . Physiotherapists ' attitudes to outcome measurement were generally positive although there was a small but statistically significant ( P=.02 ) reduction in mean attitude score over the re-test period . Physiotherapists in the population sample d significantly increased their reported use of a range of st and ardized outcome measures over the re-test period . The trend towards greater objectivity in measuring the progress of rehabilitation can enable physiotherapists to develop improved treatment plans with the patients ' needs at the centre of the equation Study Design . Cluster r and omized clinical trial . Objective . To assess the efficacy of a short education program and short physiotherapy program for treating low back pain ( LBP ) in primary care . Summary of Background Data . There is sparse evidence on the effectiveness of education and physiotherapy programs that are short enough to be feasible in primary care . Methods . Sixty-nine primary care physicians were r and omly assigned to 3 groups and recruited 348 patients consulting for LBP ; 265 ( 79.8 % ) were chronic . All patients received usual care , were given a booklet and received a consistent 15 minutes group talk on health education , which focused on healthy nutrition habits in the control group , and on active management for LBP in the “ education ” and “ education + physiotherapy ” groups . Additionally , in the “ education + physiotherapy ” group , patients were given a second booklet and a 15-minute group talk on postural hygiene , and 4 one-hour physiotherapy sessions of exercise and stretching which they were encouraged to keep practicing at home . The main outcome measure was improvement of LBP-related disability at 6 months . Patients ' assessment and data analyses were blinded . Results . During the 6-month follow-up period , improvement in the “ control ” group was negligible . Additional improvement in the “ education ” and “ education + physiotherapy ” groups was found for disability ( 2.0 and 2.2 Rol and Morris Question naire points , respectively ) , LBP ( 1.8 and 2.10 Visual Analogue Scale points ) , referred pain ( 1.3 and 1.6 Visual Analogue Scale points ) , catastrophizing ( 1.6 and 1.8 Coping Strategies Question naire points ) , physical quality of life ( 2.9 and 2.9 SF-12 points ) , and mental quality of life ( 3.7 and 5.1 SF-12 points ) . Conclusion . The addition of a short education program on active management to usual care in primary care leads to small but consistent improvements in disability , pain , and quality of life . The addition of a short physiotherapy program composed of education on postural hygiene and exercise intended to be continued at home , increases those improvements , although the magnitude of that increase is clinical ly irrelevant To study the feasibility of a large r and omised controlled trial ( RCT ) evaluating the effectiveness of physiotherapy in Parkinson 's disease ( PD ) , 173 patients were asked to participate in a study with r and om allocation to best practice physiotherapy , or to no physiotherapy . The primary outcome measures were the Parkinson 's disease question naire-39 , the Parkinson activity scale , and a patient preference outcome scale ( PPOS ) . Only 14 % of the patients could be included in the study . The PPOS showed the largest effect size ( 0.74 ) with a significant group effect ( p<0.05 ) . Specific alterations to the study design to ensure successful RCTs in this field are recommended OBJECTIVES To compare the physiotherapy service provided when therapists ' decisions are guided by an evidence -based protocol with usual care ( i.e. patient management based on therapists ' clinical decisions ) . DESIGN Exploratory , controlled , pragmatic sequential time block clinical trial . SETTING Level 3 surgical unit in a tertiary hospital in South Africa . PARTICIPANTS All patients admitted consecutively to the surgical unit over a 3-month period were allocated to usual or protocol care based on date of admission . INTERVENTIONS Usual care was provided by clinicians from the hospital department , and non-specialised physiotherapists were appointed as locum tenens to provide evidence -based protocol care . MAIN OUTCOME MEASURES Patient waiting time , frequency of treatment sessions , tasks performed and adverse events . RESULTS During protocol -care periods , treatment sessions were provided more frequently ( P<0.001 ) and with a shorter waiting period ( P<0.001 ) . It was more likely for a rehabilitation management option to be included in a treatment session during protocol -care periods ( odds ratio 2.34 , 95 % confidence interval 1.66 to 3.43 ; P<0.001 ) . No difference in the risk of an adverse event was found between protocol -care and usual-care periods ( P=0.34 ) . CONCLUSIONS Physiotherapy services provided in intensive care units ( ICUs ) when the decisions of non-specialised therapists are guided by an evidence -based protocol are safe , differ from usual care , and reflect international consensus on current best evidence for physiotherapy in ICUs . Non-specialised therapists can use this protocol to provide evidence -based physiotherapy services to their patients . Future trials are needed to establish whether or not this will improve patient outcome Abstract Objectives Firstly , to compare the effectiveness of a brief physiotherapy intervention with “ usual ” physiotherapy for patients with neck pain . Secondly , to evaluate the effect of patients ' preferences on outcome . Design Non-inferiority r and omised controlled trial eliciting preferences independently of r and omisation . Setting Physiotherapy departments in a community setting in Yorkshire and north Lincolnshire . Participants 268 patients ( mean age 48 years ) with subacute and chronic neck pain , who were referred by their general practitioner and r and omly assigned to a brief physiotherapy intervention ( one to three sessions ) using cognitive behaviour principles to encourage self management and return to normal function or usual physiotherapy , at the discretion of the physiotherapist concerned . Main outcome measures The Northwick Park neck pain question naire ( NPQ ) , a specific measure of functional disability result ing from neck pain . Also , the short form 36 ( SF-36 ) question naire , a generic , health related , quality of life measure ; and the Tampa scale for kinesophobia , a measure of fear and avoidance of movement . Results At 12 months , patients allocated to usual physiotherapy had a small but significant improvement in NPQ scores compared with patients in the brief intervention group ( mean difference 1.99 , 95 % confidence interval 0.45 to 3.52 ; P = 0.01 ) . Although the result shows a significant inferiority of the intervention , the confidence interval shows that the effect could be in the non-inferiority range for the brief intervention ( below 1.2 points of NPQ score ) . Patients who preferred the brief intervention and received this treatment had similar outcomes to patients receiving usual physiotherapy . Conclusions Usual physiotherapy may be only marginally better than a brief physiotherapy intervention for neck pain . Patients with a preference for the brief intervention may do at least as well with this approach . Additional training for the physiotherapists in cognitive behaviour techniques might improve this approach further There are strong arguments for publishing research protocol s before the results are available . First , it permits a critical judgment of the design unbiased by knowledge of the results , and second it may prevent publication bias . We present the design of a r and omized trial on the effectiveness of manual therapy , physiotherapy , ( continued ) treatment by the general practitioner and a placebo treatment for patients ( n = 300 ) with chronic ( more than 6 wk ) nonspecific back and neck complaints . In design ing this trial in close cooperation with manual therapists and physiotherapists , special attention has been given to inclusion and exclusion criteria , ( blinded ) outcome measurements and control ( placebo ) treatment(s ) . Outcome measures include severity of complaints rated by a blinded research assistant , global perceived effect assessed by the patient , pain severity , functional status , range of motion ( ROM ) of the spine and recurrence . Measurements are carried out at baseline and after 3 wk , 6 wk , 3 months , 6 months and 1 yr Background Clinical practice guidelines ( CPGs ) are not readily implemented in clinical practice . One of the impeding factors is that physical therapists do not hold realistic perceptions of their adherence to CPGs . Peer assessment ( PA ) is an implementation strategy that aims at improving guideline adherence by enhancing reflective practice , awareness of professional performance , and attainment of personal goals . Objective The purpose of this study was to compare the effectiveness of PA with the usual case discussion ( CD ) strategy on adherence to CPGs for physical therapist management of upper extremity complaints . Design A single-masked , cluster-r and omized controlled trial with pretest-posttest design was conducted . Intervention Twenty communities of practice ( n=149 physical therapists ) were r and omly assigned to groups receiving PA or CD , with both interventions consisting of 4 sessions over 6 months . Both PA and CD groups worked on identical clinical cases relevant to the guidelines . Peer assessment focused on individual performance observed and evaluated by peers ; CD focused on discussion . Outcomes Guideline adherence was measured with clinical vignettes , reflective practice was measured with the Self-Reflection and Insight Scale ( SRIS ) , awareness of performance was measured via the correlation between perceived and assessed improvement , and attainment of personal goals was measured with written commitments to change . Results The PA groups improved more on guideline adherence compared with the CD groups ( effect=22.52 ; 95 % confidence interval [ 95 % CI]=2.38 , 42.66 ; P=.03 ) . The SRIS scores did not differ between PA and CD groups . Awareness of performance was greater for the PA groups ( r=.36 ) than for the CD groups ( r=.08 ) ( effect=14.73 ; 95 % CI=2.78 , 26.68 ; P=.01 ) . The PA strategy was more effective than the CD strategy in attaining personal goals ( effect=0.50 ; 95 % CI=0.04 , 0.96 ; P=.03 ) . Limitations Limited validity of clinical vignettes as a proxy measure of clinical practice was a limitation of the study . Conclusions  Peer assessment  was more effective than CD in improving adherence to CPGs . Personal feedback may have contributed to its effectiveness . Future research should address the role of the group coach In a r and omized trial , the effectiveness of manual therapy , physiotherapy , continued treatment by the general practitioner , and placebo therapy ( detuned ultrasound and detuned short-wave diathermy ) were compared for patients ( n = 256 ) with nonspecific back and neck complaints lasting for at least 6 weeks . The principle outcome measures were severity of the main complaint , global perceived effect , pain , and functional status . These are presented for 3 , 6 , and 12 weeks follow-up . Both physiotherapy and manual therapy decreased the severity of complaints more and had a higher global perceived effect compared to continued treatment by the general practitioner . Differences in effectiveness between physiotherapy and manual therapy could not be shown . A substantial part of the effect of manual therapy and physiotherapy appeared to be due to nonspecific ( placebo ) effects 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
There was no evidence that patient health was improved or that the cost of care was reduced .
This review shows that multifaceted interventions based on educational meetings to increase implementation of clinical guidelines may improve some outcomes of professional practice but do not improve patient health or reduce cost of care .
These findings are comparable with results among other health professions
QUESTION What is the effectiveness of strategies to increase the implementation of physiotherapy clinical guidelines ?