Jennifer Klaber Moffett

Barriers to implementing the evidence base in four NHS therapies

Summary Background and purpose This study aimed to examine the attitudes to research and the barriers to implementing evidence-based practice in four professions allied to medicine: dietitians, occupational therapists, physiotherapists, and speech and language therapists. Method Postal questionnaire survey of a 20% sample (n = 715) of four professions allied to medicine in the Northern and Yorkshire region of the NHS. Results The survey achieved a response rate of 80% (N = 572). The majority of therapists (97%) agreed that research findings are important for the development of professional practice. Only 5% had no interest in reading research findings. The majority reported problems with the literature including understanding statistics (78%), the literature not being compiled in one place (78%) and implications for practice not being made clear (66%). Problems with the evidence included conflicting results (75%), methodological problems (66%), a lack of replication (54%) and poor generalisability (53%). The main institutional barriers included insufficient time (66%), inadequate facilities (57%), being isolated from colleagues (37%) and doctors not co-operating with change (36%). Two subscales — perceived importance of research, and perceived barriers — revealed significant differences between professions. Conclusions Therapists value research findings, but the majority have problems accessing and understanding the literature, which is perceived as flawed and incomplete. This suggests a need to improve training at both undergraduate and postgraduate level, improve the quality of publications in professional journals, and commission therapy-relevant trials, systematic reviews and meta-analyses. A substantial number of respondents reported institutional barriers, including poor resources and resistance to change by medical staff.

Back to Fitness Programme

Summary This paper provides physiotherapists with a manual to set up and run the Back to Fitness programme that was recently evaluated in a trial published in the British Medical Journal (Klaber Moffett et al, 1999). The promising findings have attracted interest nationally and internationally. Reactivation of back pain patients is widely accepted as important for those who are not recovering at about four to six weeks and this is endorsed by clinical guidelines. Different approaches may be effective. However, some evidence is now available which demonstrates that a simple Back to Fitness programme delivered by physiotherapists with some additional understanding of cognitive-behavioural principles can be both clinically effective and cost-effective. The programme consists of eight one-hour sessions carried out usually in the early evening over a four-week period, and includes a simple message of educational advice consistent with The Back Book . This is referred to as ‘Tip for the Day. One of the main aims is to help participants overcome their fear of movement and pain, thus helping them to return to normal activities. This manual, which has not been published elsewhere, should enable physiotherapists to set up the programme. We would urge interested physiotherapists to familiarise themselves with the relevant literature provided in the reference list before setting up the classes. We also recommend that close liaison or ‘coaching from a clinical psychologist working in the field of pain would be helpful, particularly if patients with chronic disabilities and inappropriate pain behaviour are to be included. The programme has been tested mainly on mild to moderately disabled patients and may not be appropriate for more intractable conditions where a more intensive multidisciplinary pain programme might be appropriate.

Measurement of Cervical Spine Movements Using a Simple Inclinometer

Summary This is a study to test the reliability of a simple method of measuring neck movements. Twelve healthy volunteers had their neck movements measured three times within one hour by the same observer to test for intra-observer reliability. Another 14 subjects had their neck movements measured by two observers on the same occasion to test interobserver reliability. Statistical analysis of the data by analysis of variance and paired t-tests respectively showed no significant differences in either intra-observer or between-observer measurements. Taking into account coexisting variables such as motivation and discomfort at the limit of the range, which are likely to fluctuate, the simple inclinometer as described provides a relatively objective and accurate method of measuring neck movements. However, it is recommended from the findings of this study that a change of less than ten degrees in range of movement should not be used as evidence of a patients progress or regression.

Physiotherapy Management of Chronic Low Back Pain

Summary Disability reported as a result of low back pain (LBP) has increased dramatically over the last 20 years. This paper reviews some of the scientific evidence currently available for the treatment of patients with LBP. The advantages of a more active approach to the management of this complex problem are discussed and compared with passive forms of treatment. A rehabilitation programme, developed in Oxford over the last four years for chronic LBP (CLBP) sufferers is described. The need for further research to evaluate the current treatment of CLBP is emphasised.

Book reviews : Donatelli R, Wooden MJ editors 1989: Orthopaedic physical therapy. Churchill Livingstone. 599pp. £52.50

ter surprisingly emphasises ’cardiopulmonary and peripheral responses’ rather than, for example, the effect of exercise on muscle physiology. The second section on the neck and upper limb begins with a chapter on the temperomandibular joint, swallowing and occlusion, in somewhat excessive detail. The two chapters that follow on the cervical and thoracic spine include discussion on dysfunction, evaluation and treatment, the second chapter concentrating on passive mobilization. They are written by different authors and suffer from a slight tendency to repetition. There is some emphasis on cervical traction, but the use of ’combined movements’, for example,

Book reviews : Grant R editor 1988: Physical therapy of the cervical and thoracic spine. Edinburgh: Churchill Livingstone. 338pp. £26.00:

language pathology students, neurology students and practising clinicians, and my overall impression is that it achieves its purpose and more. The layout of the book is in two sections with section one providing an overview of neurogenic communicative disorders. The eight pages of this section concentrate mainly on fairly detailed definitions. The classification used is that of the Mayo clinic: aphasia; generalized intellectual impairment or dementia; confused language; apraxia of speech; the dysarthrias. Section two consists of 63 case studies, with a good range of ages, based on patients’ medical records. The authors do point out that the chosen cases lent themselves to definitive diagnosis and that in everyday practice certain conditions may involve more complex assessing and reviewing, thus making diagnosis more difficult. Each case study follows the same format of five pages. The first page presents with an outline of the clinical history and the examination. Page two is a work sheet where three areas can be