Adherence to Clinical Practice Guidelines for Low Back Pain in Physical Therapy: Do Patients Benefit?

Rutten, Geert M.; Degen, Saskia; Hendriks, Erik J.; Braspenning, Jozé C.; Harting, Janneke; Oostendorp, Rob A.

doi:10.2522/ptj.20090173

Adherence to Clinical Practice Guidelines for Low Back Pain in Physical Therapy: Do Patients Benefit?

G.M. Rutten, MPH, PT, MPT, is Researcher, Physical Therapist, and Manipulative Physical Therapist, Scientific Institute for Quality in Healthcare, Radboud University Nijmegen Medical Centre, PO Box 9101, 114 IQhealthcare, 6500 HB Nijmegen, the Netherlands, and Department of Health Promotion and Health Education/GVO, Maastricht University, PO Box 616, 6200 MD Maastricht, the Netherlands.
S. Degen, PT, MSc, is Physical Therapist, Practice for Physical Therapy FysioPlus Rozendaal, Nijmegen, the Netherlands.
E.J. Hendriks, PT, PhD, is Senior Researcher, Epidemiologist, and Health Scientist, Centre for Evidence Based Physiotherapy, Department of Epidemiology, Maastricht University Medical Centre, Maastricht, the Netherlands.
J.C. Braspenning, PhD, is Associate Professor, Scientific Institute for Quality in Healthcare, Radboud University Nijmegen Medical Centre.
J. Harting, PhD, BA in Physiotherapy, is Postdoctoral Researcher, Department of Social Medicine, Amsterdam Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.
R.A. Oostendorp, PhD, PT, MPT, is Emeritus Professor in Allied Health Sciences, Scientific Institute for Quality in Healthcare, Radboud University Nijmegen Medical Centre.

Address all correspondence to Dr Rutten at: g.rutten{at}gvo.unimaas.nl.

Abstract

Background Various guidelines for the management of low back pain have been developed to enhance the effectiveness and efficiency of care. Evidence that guideline-adherent care results in better health outcomes, however, is not conclusive.

Objective The main objective of this study was to assess whether a higher percentage of adherence to the Dutch physical and manual therapy guidelines for low back pain is related to improved outcomes. The study further explored whether this relationship differs for the individual steps of the process of care and for distinct subgroups of patients.

Design This was an observational prospective cohort study (2005–2006) in the Netherlands that included a sample of 61 private practice therapists and 145 patients.

Methods Therapists recorded the process of care and the number of treatment sessions in Web-based patient files. Guideline adherence was assessed using quality indicators. Physical functioning was measured by the Dutch version of the Quebec Back Pain and Disability Scale, and average pain was measured with a visual analog scale. Relationships between the percentage of guideline adherence and outcomes of care were evaluated with regression analyses.

Results Higher percentages of adherence were associated with fewer functional limitations (β=−0.21, P=.023) and fewer treatment sessions (β=−0.27, P=.005).

Limitations The relatively small self-selected sample might limit external validity, but it is not expected that the small sample greatly influenced the internal validity of the study. Larger samples are required to enable adequate subgroup analyses.

Conclusions The results indicate that higher percentages of guideline adherence are related to better improvement of physical functioning and to a lower utilization of care. A proper assessment of the relationship between the process of physical therapy care and outcomes may require a comprehensive set of process indicators to measure guideline adherence.

Footnotes

Mr Rutten, Ms Degen, Dr Hendriks, Dr Braspenning, and Dr Oostendorp provided concept/idea/research design. Mr Rutten, Dr Hendriks, Dr Braspenning, Dr Harting, and Dr Oostendorp provided writing. Mr Rutten and Ms Degen provided data collection. Mr Rutten provided data analysis. Dr Hendriks provided institutional liaisons. Dr Oostendorp provided project management, fund procurement, and facilities/equipment. Ms Degen, Dr Hendriks, Dr Braspenning, Dr Harting, and Dr Oostendorp provided consultation (including review of manuscript before submission).
The Medical Ethics Committee of Radboud University Nijmegen Medical Centre in the Netherlands authorized the study.
The results of this study, in part, were presented orally at the 15th International Congress of the World Confederation for Physical Therapy, June 2–6, 2007, Vancouver, British Columbia, Canada, and at the Dutch National Physiotherapy Conference, November 9–10, 2007.
The study was funded by CZ, a health insurance company in the Netherlands.