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Peer assessment as an effective strategy for implementing a physical therapy low back pain guideline
WCPT Congress 2015 / Physiotherapy 2015; Volume 101, Supplement 1 eS1238–eS1642
direction. Yet, the centre of mass (COM) in the horizontal plane makes a diagonal displacement during walking. Purpose: The aim of this study was to investigate voluntary diagonal and lateral displacements of the COM towards the unaffected and affected side, and to relate displacements with clinical outcome measures of balance, gait and risk of falling. Methods: We recruited people in the sub-acute phase after stroke from two inpatient stroke rehabilitation wards who were able to walk under supervision or alone (Functional Ambulation Category ≥3). COM displacements were investigated with the Biorescue system (RM Ingénierie, France), a commercially available force plate. A standardized protocol was derived with instructions for COM displacement shown on a screen in front of the participants. Instructions were given in order to displace the COM randomly towards the unaffected and affected side in the (1) diagonal forward direction, (2) lateral direction, and (3) diagonal backward direction. After two pilot trials, a mean of three subsequent trials was used for data analysis. Clinical outcome measures collected were the Berg Balance Scale, Community Balance and Mobility Scale, Dynamic Gait Index, 10-meter walk test, and Falls Efficacy Scale, International version. Results: Our study included 36 participants with a mean (SD) age of 62 (14) years, 9 females, 16 people with leftsided hemiparesis and 20 right-sided, 28 ischemic infarcts and 8 hemorrhagic strokes, mean (SD) 85 (51) days post stroke on assessment. Wilcoxon signed rank analysis showed a significant greater COM displacement in the diagonal forward direction towards the unaffected side when compared with the affected side (p = 0.037). There was no significant difference in the lateral or diagonal backward direction. COM displacements towards the affected side showed the highest correlations with measures of balance, and interestingly, spearman correlation coefficients were stronger for displacements in all directions and the Community Balance and Mobility Scale (r = 0.62–0.65) in comparison with coefficients for the Berg Balance Scale which were moderate (r = 0.46–0.52). COM displacements in the diagonal forward and lateral direction correlated also significantly with measures of gait (r = 0.41–0.43) and risk of falling (r = −0.44 to −0.51). Conclusion(s): In our sample of supervised and independent ambulatory people attending inpatient stroke rehabilitation, COM displacements were significantly greater in the diagonal forward direction towards the unaffected side when compared to the affected side. Significant relations were found between displacements towards the affected side and our clinical measures, most strongly with the Community Balance and Mobility Scale, which measures advanced balance and mobility such as tandem walking, hopping on one leg, running and descending stairs.
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Implications: Diagonal displacements of the COM could be assessed among ambulatory people attending inpatient stroke rehabilitation, as displacements seem to be strongly linked to advanced balance and mobility. The Community Balance and Mobility Scale could be a more suitable outcome measure in this population. Keywords: Stroke; Limits of stability; Balance Funding acknowledgements: Not applicable. Ethics approval: This study obtained ethical approval from the University Hospitals Leuven Ethics Committee (Belgium). http://dx.doi.org/10.1016/j.physio.2015.03.1575 Research Report Platform Presentation Number: RR-PL-3686 Sunday 3 May 2015 16:44 Rooms 300–301 PEER ASSESSMENT AS AN EFFECTIVE STRATEGY FOR IMPLEMENTING A PHYSICAL THERAPY LOW BACK PAIN GUIDELINE S.A. van Dulmen 1,2 , M. Maas 1,3 , J.B. Staal 1 , G. Rutten 4 , H. Kiers 5 , M.W.G. Nijhuis-Van der Sanden 1 , P.J. van der Wees 1 1 Radboud
University Medical Center, Radboud Institute for Health Sciences, Department of Scientific Institute for Quality of Healthcare, Nijmegen, Netherlands; 2 Royal Dutch Society for Physical Therapy, Amersfoort, Netherlands; 3 HAN University of Applied Sciences, Department of Allied Health Studies, Nijmegen, Netherlands; 4 Maastricht University, Capri School for Public Health and Primary Care, Maastricht, Netherlands; 5 University of Applied Sciences, Utrecht, Netherlands Background: Clinical practice guidelines are considered important instruments to improve quality of care. In physical therapy, a discrepancy between current practice and the recommendations of the guidelines is related to the knowledge and skills of the physiotherapists. Educational meetings, such as discussions and information tailored to the individual physiotherapist’ perception might improve guideline adherence. A particular type of education of professionals is peer-assessment; a strategy in which professionals assess performance of colleagues in a simulated setting and providing structured feedback. Purpose: The aim of this cluster randomized controlled trial is to determine the effectiveness of peer-assessment among physiotherapists to improve the adherence to the Dutch physical therapy guideline for a-specific low back pain in comparison to regular case discussions.
eS1574
WCPT Congress 2015 / Physiotherapy 2015; Volume 101, Supplement 1 eS1238–eS1642
Methods: Ten Communities of Practice (CoP), which included 90 primary care physical therapists and manual therapists, were randomly allocated to peer-assessment (n = 49) as intervention group or regular case discussions (n = 41) relevant to the guideline. After a joint meeting to discuss characteristics of the Dutch physical therapy guideline for a-specific low back pain, both groups participated in four meetings during a six months period in 2010. Peerassessment CoPs consisted of the performance of tasks of individual physiotherapists based on patient cases that were derived from the guideline. The performance was assessed by peers in the CoPs under supervision of an expert assessor. The regular case discussion CoPs discussed similar patient cases without peer-assessment and supervision. Outcomes were assessed at baseline and at 6 months. The primary outcome measure was knowledge and guidelineconsistent reasoning, measured with 12 performance indicators using 4 vignettes with specific guideline-related patient profiles. For each participant, the total score was calculated by adding up the percentage scores (0–100) per vignette, divided by 4. The secondary outcome measure was reflective practice, as measured by the Self-Reflection and Insight Scale (20–100). Results: Vignettes were completed by 78 participants (87%). The mean baseline score of the peer-assessment group was 63.7% and follow up score 72.0%. The baseline score of the case discussion group was 66.8 and the follow up score was 66.7%. The estimated group difference was 8.7%, 95% confidence interval = 3.9 to 13.4; p = 0.001). We found no significant differences between the groups in self-reflection. Conclusion(s): Peer-assessment is associated with an increase in knowledge of the guideline and guidelineconsistent behavior. Reflective practice did not increase through peer-assessment. Implications: Peer-assessment leads to an increase in knowledge and guideline-consistent clinical reasoning and may be useful for implementing physical therapy guidelines. Keywords: Guidelines; Peer assessment; Low back pain Funding acknowledgements: Royal Dutch Society for Physical Therapy (KNGF) with cofunding of Radboud university medical center and HAN University of Applied Sciences. Ethics approval: The study was approved by the Medical Ethical Committee of Radboud University Nijmegen Medical Centre (ref no 2012/211). http://dx.doi.org/10.1016/j.physio.2015.03.1576
Research Report Poster Presentation Number: RR-PO-16-12-Sat Saturday 2 May 2015 13:00 Exhibit halls 401–403 THE USE OF PATIENT REPORTED OUTCOME MEASURES FOR GOALS SETTING AND COMPARING OUTCOMES OF CARE: A COHORT STUDY S.A. van Dulmen 1,2 , P.J. van der Wees 1 , J.B. Staal 1 , M.W.G. Nijhuis-Van der Sanden 1 1 Radboud
University Medical Center, Radboud Institute for Health Sciences, Department of Scientific Institute for Quality of Healthcare, Nijmegen, Netherlands; 2 Royal Dutch Society for Physical Therapy, Amersfoort, Netherlands Background: Routine use of Patient Reported Outcome Measures (PROMs) by health care providers in their daily practice may provide an effective way of both monitoring the processes and outcomes of care. In clinical practice, clinicians can use PROMs to focus on a patient’s individual health goals and guide diagnostic and treatment decisions. When aggregated, PROMs can be used for practice improvement and performance measurement. Little is known about the actual use of PROMs in primary care physical therapy and their fit with goal setting. Purpose: In this study we explore 1) current use of PROMs in patients with neck and low back problems, 2) to what extent the goals for treatment are related to the PROMs selected; 3) to explore if PROMS can be used to provide information on the outcomes of care at aggregate level. Methods: We conducted a prospective cohort study in Dutch primary care practices. The International Classification of Functioning (ICF) was used to map the intervention goals at the level of physical function, and activity/participation. PROMs included were for pain the Visual Analogue Scale (VAS), and at activity and participation level the Patient Specific Function Scale (PSFS), the Quebec Back Pain Disability Scale (QBPDS), and the Neck Disability Index (NDI). Descriptive statistics were calculated for the use of PROMs and correlations between outcomes at function vs. activity/participation level with Pearson’s r. Outcome of care was assessed by calculating the percentage of patients that improved based on the minimal clinical important difference (MCID). MCID was defined by 1) absolute cut off point, and 2) with 30% improvement from baseline. Results: Some 299 patients were included by 39 physical therapists. The selected PROMs were 661 times used in
direction. Yet, the centre of mass (COM) in the horizontal plane makes a diagonal displacement during walking. Purpose: The aim of this study was to investigate voluntary diagonal and lateral displacements of the COM towards the unaffected and affected side, and to relate displacements with clinical outcome measures of balance, gait and risk of falling. Methods: We recruited people in the sub-acute phase after stroke from two inpatient stroke rehabilitation wards who were able to walk under supervision or alone (Functional Ambulation Category ≥3). COM displacements were investigated with the Biorescue system (RM Ingénierie, France), a commercially available force plate. A standardized protocol was derived with instructions for COM displacement shown on a screen in front of the participants. Instructions were given in order to displace the COM randomly towards the unaffected and affected side in the (1) diagonal forward direction, (2) lateral direction, and (3) diagonal backward direction. After two pilot trials, a mean of three subsequent trials was used for data analysis. Clinical outcome measures collected were the Berg Balance Scale, Community Balance and Mobility Scale, Dynamic Gait Index, 10-meter walk test, and Falls Efficacy Scale, International version. Results: Our study included 36 participants with a mean (SD) age of 62 (14) years, 9 females, 16 people with leftsided hemiparesis and 20 right-sided, 28 ischemic infarcts and 8 hemorrhagic strokes, mean (SD) 85 (51) days post stroke on assessment. Wilcoxon signed rank analysis showed a significant greater COM displacement in the diagonal forward direction towards the unaffected side when compared with the affected side (p = 0.037). There was no significant difference in the lateral or diagonal backward direction. COM displacements towards the affected side showed the highest correlations with measures of balance, and interestingly, spearman correlation coefficients were stronger for displacements in all directions and the Community Balance and Mobility Scale (r = 0.62–0.65) in comparison with coefficients for the Berg Balance Scale which were moderate (r = 0.46–0.52). COM displacements in the diagonal forward and lateral direction correlated also significantly with measures of gait (r = 0.41–0.43) and risk of falling (r = −0.44 to −0.51). Conclusion(s): In our sample of supervised and independent ambulatory people attending inpatient stroke rehabilitation, COM displacements were significantly greater in the diagonal forward direction towards the unaffected side when compared to the affected side. Significant relations were found between displacements towards the affected side and our clinical measures, most strongly with the Community Balance and Mobility Scale, which measures advanced balance and mobility such as tandem walking, hopping on one leg, running and descending stairs.
eS1573
Implications: Diagonal displacements of the COM could be assessed among ambulatory people attending inpatient stroke rehabilitation, as displacements seem to be strongly linked to advanced balance and mobility. The Community Balance and Mobility Scale could be a more suitable outcome measure in this population. Keywords: Stroke; Limits of stability; Balance Funding acknowledgements: Not applicable. Ethics approval: This study obtained ethical approval from the University Hospitals Leuven Ethics Committee (Belgium). http://dx.doi.org/10.1016/j.physio.2015.03.1575 Research Report Platform Presentation Number: RR-PL-3686 Sunday 3 May 2015 16:44 Rooms 300–301 PEER ASSESSMENT AS AN EFFECTIVE STRATEGY FOR IMPLEMENTING A PHYSICAL THERAPY LOW BACK PAIN GUIDELINE S.A. van Dulmen 1,2 , M. Maas 1,3 , J.B. Staal 1 , G. Rutten 4 , H. Kiers 5 , M.W.G. Nijhuis-Van der Sanden 1 , P.J. van der Wees 1 1 Radboud
University Medical Center, Radboud Institute for Health Sciences, Department of Scientific Institute for Quality of Healthcare, Nijmegen, Netherlands; 2 Royal Dutch Society for Physical Therapy, Amersfoort, Netherlands; 3 HAN University of Applied Sciences, Department of Allied Health Studies, Nijmegen, Netherlands; 4 Maastricht University, Capri School for Public Health and Primary Care, Maastricht, Netherlands; 5 University of Applied Sciences, Utrecht, Netherlands Background: Clinical practice guidelines are considered important instruments to improve quality of care. In physical therapy, a discrepancy between current practice and the recommendations of the guidelines is related to the knowledge and skills of the physiotherapists. Educational meetings, such as discussions and information tailored to the individual physiotherapist’ perception might improve guideline adherence. A particular type of education of professionals is peer-assessment; a strategy in which professionals assess performance of colleagues in a simulated setting and providing structured feedback. Purpose: The aim of this cluster randomized controlled trial is to determine the effectiveness of peer-assessment among physiotherapists to improve the adherence to the Dutch physical therapy guideline for a-specific low back pain in comparison to regular case discussions.
eS1574
WCPT Congress 2015 / Physiotherapy 2015; Volume 101, Supplement 1 eS1238–eS1642
Methods: Ten Communities of Practice (CoP), which included 90 primary care physical therapists and manual therapists, were randomly allocated to peer-assessment (n = 49) as intervention group or regular case discussions (n = 41) relevant to the guideline. After a joint meeting to discuss characteristics of the Dutch physical therapy guideline for a-specific low back pain, both groups participated in four meetings during a six months period in 2010. Peerassessment CoPs consisted of the performance of tasks of individual physiotherapists based on patient cases that were derived from the guideline. The performance was assessed by peers in the CoPs under supervision of an expert assessor. The regular case discussion CoPs discussed similar patient cases without peer-assessment and supervision. Outcomes were assessed at baseline and at 6 months. The primary outcome measure was knowledge and guidelineconsistent reasoning, measured with 12 performance indicators using 4 vignettes with specific guideline-related patient profiles. For each participant, the total score was calculated by adding up the percentage scores (0–100) per vignette, divided by 4. The secondary outcome measure was reflective practice, as measured by the Self-Reflection and Insight Scale (20–100). Results: Vignettes were completed by 78 participants (87%). The mean baseline score of the peer-assessment group was 63.7% and follow up score 72.0%. The baseline score of the case discussion group was 66.8 and the follow up score was 66.7%. The estimated group difference was 8.7%, 95% confidence interval = 3.9 to 13.4; p = 0.001). We found no significant differences between the groups in self-reflection. Conclusion(s): Peer-assessment is associated with an increase in knowledge of the guideline and guidelineconsistent behavior. Reflective practice did not increase through peer-assessment. Implications: Peer-assessment leads to an increase in knowledge and guideline-consistent clinical reasoning and may be useful for implementing physical therapy guidelines. Keywords: Guidelines; Peer assessment; Low back pain Funding acknowledgements: Royal Dutch Society for Physical Therapy (KNGF) with cofunding of Radboud university medical center and HAN University of Applied Sciences. Ethics approval: The study was approved by the Medical Ethical Committee of Radboud University Nijmegen Medical Centre (ref no 2012/211). http://dx.doi.org/10.1016/j.physio.2015.03.1576
Research Report Poster Presentation Number: RR-PO-16-12-Sat Saturday 2 May 2015 13:00 Exhibit halls 401–403 THE USE OF PATIENT REPORTED OUTCOME MEASURES FOR GOALS SETTING AND COMPARING OUTCOMES OF CARE: A COHORT STUDY S.A. van Dulmen 1,2 , P.J. van der Wees 1 , J.B. Staal 1 , M.W.G. Nijhuis-Van der Sanden 1 1 Radboud
University Medical Center, Radboud Institute for Health Sciences, Department of Scientific Institute for Quality of Healthcare, Nijmegen, Netherlands; 2 Royal Dutch Society for Physical Therapy, Amersfoort, Netherlands Background: Routine use of Patient Reported Outcome Measures (PROMs) by health care providers in their daily practice may provide an effective way of both monitoring the processes and outcomes of care. In clinical practice, clinicians can use PROMs to focus on a patient’s individual health goals and guide diagnostic and treatment decisions. When aggregated, PROMs can be used for practice improvement and performance measurement. Little is known about the actual use of PROMs in primary care physical therapy and their fit with goal setting. Purpose: In this study we explore 1) current use of PROMs in patients with neck and low back problems, 2) to what extent the goals for treatment are related to the PROMs selected; 3) to explore if PROMS can be used to provide information on the outcomes of care at aggregate level. Methods: We conducted a prospective cohort study in Dutch primary care practices. The International Classification of Functioning (ICF) was used to map the intervention goals at the level of physical function, and activity/participation. PROMs included were for pain the Visual Analogue Scale (VAS), and at activity and participation level the Patient Specific Function Scale (PSFS), the Quebec Back Pain Disability Scale (QBPDS), and the Neck Disability Index (NDI). Descriptive statistics were calculated for the use of PROMs and correlations between outcomes at function vs. activity/participation level with Pearson’s r. Outcome of care was assessed by calculating the percentage of patients that improved based on the minimal clinical important difference (MCID). MCID was defined by 1) absolute cut off point, and 2) with 30% improvement from baseline. Results: Some 299 patients were included by 39 physical therapists. The selected PROMs were 661 times used in