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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

GE Bekkering, PhD, is Researcher, Dutch Institute of Allied Health Care, Amersfoort, the Netherlands, and Researcher, Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, the Netherlands.
MW van Tulder, PhD, is Associate Professor, Health Technology Assessment, Institute for Research in Extramural Medicine, VU University Medical Center, and Associate Professor, Health Technology Assessment, Institute for Health Sciences, Faculty of Earth and Life Sciences, Free University, Amsterdam, the Netherlands
EJM Hendriks, PhD, is Physical Therapist, Health Scientist, and Epidemiologist, Dutch Institute of Allied Health Care, Amersfoort, the Netherlands; Senior Researcher, Department of Epidemiology, Maastricht University; and Co-director, Center of Evidence Based Physiotherapy (CEBP), Maastricht, the Netherlands
MA Koopmanschap, PhD, is Senior Health Economist, Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
DL Knol, PhD, is Statistician, Institute for Research in Extramural Medicine, VU University Medical Center, and Statistician, Department of Clinical Epidemiology and Biostatistics, VU University Medical Center
LM Bouter, PhD, is Professor of Epidemiology and Scientific Director, Institute for Research in Extramural Medicine, VU University Medical Center
RAB Oostendorp, PhD, is Physical Therapist, Manual Therapist, and Research Director, Dutch Institute of Allied Health Care; Professor of Allied Health Care, Department of Quality of Care, Research Centre for Allied Health Care, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands; and Professor of Manual Therapy, Free University of Brussels, Faculty of Medicine and Pharmacology, Postgraduate Education Manual Therapy, Brussels, Belgium
Dr van Tulder, Dr Hendriks, Dr Koopmanschap, Dr Bouter, and Dr Oostendorp provided concept/idea/research design. Dr Bekkering, Dr van Tulder, Dr Hendriks, Dr Koopmanschap, and Dr Bouter provided writing. Dr Bekkering provided data collection, and Dr Bekkering, Dr van Tulder, Dr Hendriks, and Dr Knol provided data analysis. Dr van Tulder, Dr Bouter, and Dr Hendriks provided fund procurement. Dr Bekkering provided subjects and clerical support. Dr Oostendorp provided facilities/equipment. Dr Hendriks provided institutional liaisons. Dr Bekkering, Dr Hendriks, Dr Koopmanschap, Dr Knol, Dr Oostendorp, and Dr Bouter provided consultation (including review of manuscript before submission). The authors acknowledge Arno J Engers' contribution to the development of the active strategy and provision of training sessions and Michel Wensing's advice on the content of the active strategy

Address all correspondence to Dr Bekkering at Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR United Kingdom (G.E.Bekkering{at}bristol.ac.uk)

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 randomly assigned to 1 of 2 groups. The control group received the guidelines by mail (standard 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 questionnaires 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.

Key Words: Cluster-randomized controlled trial • Implementation • Low back pain • Patient outcomes • Physical therapy • Practice guidelines

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