''Knowing Is Not Enough; We Must Apply. Willing Is Not Enough; We Must Do'' Linda C. Li and Philip J. van der Wees PHYS THER. 2015; 95:486-491. doi: 10.2522/ptj.2015.95.4.486
The online version of this article, along with updated information and services, can be found online at: http://ptjournal.apta.org/content/95/4/486 Collections
This article, along with others on similar topics, appears in the following collection(s): All Editorials Clinical Decision Making Evidence-Based Practice Knowledge Translation and Implementation Special Series
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Editorial “Knowing Is Not Enough; We Must Apply. Willing Is Not Enough; We Must Do” Quote from Johann von Goethe
imely use of research knowledge to improve clinical practice and health policy decisions has attracted international interest. The need to “do something” is particularly urgent, as it takes on average 17 years for research evidence to reach clinical practice.1–5 The lengthy lag time to translate research into practice not only results in potential harm to patients, it also has important economic consequences.6 For example, a study of economic benefits of cardiovascular disease research in the United Kingdom between 1975 and 2005 found that a £1.00 investment in public research funding produced an earning of £0.39 per year indefinitely.6,7 About 9% of this earning was attributable to individuals’ health improvement based on a 17-year lag for research to reach practice. Interestingly, the rate of return rose to 13% when the lag time was 7 years shorter. The case for investing in research that addresses the “knowledge-to-action” (KTA) gap is compelling.
T
Over the past 2 decades, the field of knowledge translation (KT) has emerged to address this severe gap. Knowledge translation is essential to all fields of research and takes place within a complex system of interactions between researchers and knowledge users, from the start of a research project to the implementation of new knowledge.8 –11 Grimshaw and colleagues12 suggested that the basic unit of KT is up-to-date and high-quality systematic reviews. The synthesized literature can then be used to develop knowledge products—such as clinical practice guidelines (CPGs), best practice recommendations, quality indicators, or policy briefs—for different audiences. “If You Build It, They Will Come”. . . Think Again The conventional thinking was that “if you build it [the knowledge product], they [the clinicians] will come.” However, this belief has since been disputed in various disciplines, including physical therapy. In 1998, Li and Bombardier13 surveyed Canadian physical therapists on how they managed acute/subacute low back pain (LPB), using clinical vignettes. Despite the 1994 US practice guidelines on acute LPB management,14 the researchers found that more than one third of physical therapists would still use electrotherapeutic modalities of uncertain effectiveness, and only 46% agreed that CPGs were useful for managing LBP. In the United Kingdom, a 2002 survey reported that 41% of physical therapists used lumbar traction in patients with subacute LBP, despite guideline recommendations against it.15 A later study by Bishop et al16 found that 28% of health care professionals, including general practitioners and physical therapists, would advise a patient with acute LBP to remain off work, again despite guideline recommendations.
To comment, submit a Rapid Response to this editorial posted online at: ptjournal.apta.org.
486
f
Physical Therapy
Encouraging results were reported in a recent survey in New Zealand that more than 95% of manipulative and sports physical therapists would advise a patient with acute LBP to “return to normal work” or “return to part time or light duties” However, only 52% said that LBP guidelines were helpful in their clinical decision making. Knowledge products alone, such as CPGs, are insufficient for improving practice. Active, deliberate, and evidence-based implementation strategies are often required.9,17 The need for active implementation strategies in physical therapy is confirmed in a recent survey of Bernhardsson et al,18 showing the gap between positive attitudes toward guidelines and actual use of guidelines. They conducted a Web-based survey among 419
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April 2015
Editorial
Figure. Components of the Knowledge-to-Action11 process highlighted by the selected articles in the PTJ Knowledge Translation and Implementation Special Series. Adapted from Graham ID, Logan J, Harrison MB, et al. Lost in knowledge translation: time for a map? J Contin Educ Health Prof. 2006;26:13-24, with permission of John Wiley & Sons Inc.
physical therapists in Sweden to investigate self-reported attitudes, knowledge, behavior, and barriers related to evidence-based practice (EBP) and guideline use. Most respondents had positive attitudes toward EBP and guidelines: 90% considered EBP necessary, and 96% considered guidelines important. However, only 13% knew where to find guidelines, and only 9% reported having easy access to guidelines. Fewer than half reported using guidelines frequently. Positive attitudes, awareness of guidelines, considering guidelines to facilitate practice, and knowing how to integrate patient preferences with guideline use were associated with frequent use of guidelines. KT in Action To guide KT, Graham and colleagues19 developed a framework to depict the KTA process. The original framework has been updated recently to emphasize the dynamic nature of KT (Figure).11 At the core is the “knowledge funnel” depicting different levels of knowledge creation activities and products that can be used in health care. As the knowledge moves through the funnel, it becomes more refined and potentially more useful to health care professionals and policy makers. The end of the knowledge funnel leads to the “action cycle,” which represents activities that might be needed for applying the knowledge and sustaining its use in real life. In addition to guiding KT activities, the KTA process also provides a compressive framework for researchers to identify gaps in care delivery, develop innovative solutions, assess their impact on clinician behaviors and patient outcomes, and plan initiatives to promote and sustain implementation beyond the research setting. It is, thereApril 2015
Volume 95 Number 4 Downloaded from http://ptjournal.apta.org/ by guest on April 20, 2015
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487
Editorial fore, not surprising that clinical and health services researchers are drawn to this framework to inform their work. This special series aims to highlight the state-of-the-art in KT and implementation research. We invited manuscript topics including: • Implementation of CPGs and “best practice” recommendations in physical therapy. • Development of novel tools or techniques to enhance shared decision making between patients and therapists. • Implementation and evaluation of strategies to improve treatment participation or inform health policies. • Barriers to implementing effective treatments or models of care in physical therapy.
More than 40 proposals were received. After careful consideration by a guest editorial panel and a rigorous peer review process, 13 manuscripts were selected. These articles cover a wide range, from pediatric care20 to gait and balance assessment in older adults,21 and from the implementation of physical activity recommendations22 to the management of upper extremity conditions.23 The study designs and viewpoints in most of the articles are informed by the KTA process. Two papers illustrate different approaches to identify problems in translating research knowledge in practice.21,24 In a case report, Sibley and Salbach21 applied the KTA process to identify discrepancies in the use of standardized balance and gait outcome measures in clinical practice and used the findings to guide a KT research program. Meanwhile, in an interview study, Manns et al24 focused on the use of evidence by physical therapists and uncovered that, although recent physical therapist graduates showed better knowledge of EBP skills compared with more experienced therapists, research evidence was infrequently used in clinical decision making by all cohorts. The KTA process suggests that research knowledge should be adapted to the users’ context, and barriers to its use should be properly assessed. Nanninga et al25 reported an administrative case that used a participatory action approach to engage local physical therapists to co-create contextualized knowledge in a stroke rehabilitation unit. Huijg and colleagues22 surveyed 268 physical therapists to assess the intricate relationships between individual attributes (knowledge, skills, beliefs, and other behavioral constructs) and how the therapists implement physical activity interventions. These lines of research are essential for developing targeted implementation interventions. The majority of papers address the selection and tailoring of implementation strategies. In a perspective, Hudon et al26 outline the benefits associated with the use of conceptual frameworks to develop interventions for promoting the use of evidence in physical therapist practice. Levac and associates27 offer recommendations to improve the development, implementation, and evaluation of online knowledge products. In a feasibility study, Hanson et al28 describe a locally developed in-person education intervention to improve the uptake of treatment frequency guidelines for episodic pediatric care. Engaging stakeholders is a crucial step in developing implementation interventions. This process is nicely illustrated by van Twillert et al29 in their development of a strategy to support evidence-based prosthetic rehabilitation. In their case report to be published in June 2015, Richardson et al30 report the implementation of an evidence-based program for improving self-management and task-oriented functions in people recovering from stroke in the home setting.
488
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Volume 95 Number 4 Downloaded from http://ptjournal.apta.org/ by guest on April 20, 2015
April 2015
Editorial Interestingly, in their systematic review, Jones et al31 conclude that education-based interventions continue to be the focus of implementation research in rehabilitation. In contrast, strategies that have been found to be effective in other disciplines—such as the use of reminders or audit and feedback— have been understudied. The findings of Jones et al highlight the need for the physical therapy profession to study the use of other promising interventions to improve practice. A challenge to health care organizations is the development of a structure to monitor and sustain the use of evidence to inform practice. Stevans and colleagues32 describe the launch of a multifaceted implementation strategy for an LBP management initiative with distinct improvement cycles to monitor knowledge use, identify barriers on a continuous basis, and develop solutions to sustain the improved clinical practice. An important aspect of the KTA process is to evaluate outcomes of implementation strategies. Schreiber et al20 report a pretreatment/posttreatment study of a KT initiative involving a knowledge broker to improve outpatient pediatric care. This study is unique, as the evaluation was conducted from the program administrator’s perspective. Finally, as advocated by Grol and others,9,33 high-quality evidence is needed to inform the selection of implementation strategies by physical therapists and health care administrators. To this end, Maas and colleagues’23 cluster-randomized controlled trial provides insight on the effectiveness of peer assessment as an implementation strategy to improve physical therapists’ adherence to CPGs for managing upper extremity conditions. The physical therapy field has made tremendous progress in supporting KT activities and advancing KT science. Through this special series, we intend to generate further interest in KT research relevant to physical therapist practice and invite discussions about ideas to support local KT activities. Acknowledgments We are grateful for the enthusiastic support of Editor-in-Chief Rebecca Craik and the expert guidance of the editorial staff in preparing this special series. Our sincere thanks also go to Dr Maura Iversen for her participation on the guest editorial panel and to all manuscript reviewers for their expertise, insights, and valuable time; they are recognized on page 491.
Linda C. Li, Philip J. van der Wees L.C. Li, PT, PhD, is a guest co-editor of this special series. She is Associate Professor, Harold Robinson/ Arthritis Society Chair in Arthritic Diseases, Canada Research Chair in Patient-oriented Knowledge Translation, Department of Physical Therapy, University of British Columbia, Vancouver, BC; and Senior Scientist, Arthritis Research Canada, Richmond, BC, Canada. P.J. van der Wees, PT, PhD, is a guest co-editor of this special series and a PTJ editorial board member. He is Senior Researcher, Scientific Institute for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
References 1 Balas E, Boren S. Managing clinical knowledge for health care improvement. In: van Bemmel JH, McCray AT, eds. Yearbook of Medical Informatics. Stuttgart, Germany: Schattauer Verlagsgesellschaft mbH; 2015:65–70. 2 Grant J, Green L, Mason B. Basic research and health: a reassessment of the scientific basis for the support of biomedical science. Res Eval. 2003;12:217–224. 3 Green LW. Making research relevant: if it is an evidence-based practice, where’s the practice-based evidence? Fam Pract. 2008;25(suppl 1):i20 –i24.
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Editorial 4 Green LW, Ottoson JM, Garcı´a C, Hiatt RA. Diffusion theory and knowledge dissemination, utilization, and integration in public health. Annu Rev Public Health. 2009;30:151–174. 5 Westfall J, Mold J, Fagnan L. Practice-based research: “Blue Highways” on the NIH roadmap. JAMA. 2007;297:403– 406. 6 Health Economics Research Group, Office of Health Economics, RAND Europe. Medical Research: What’s It Worth? Estimating the Economic Benefits From Medical Research in the UK. London, United Kingdom: UK Evaluation Forum; 2008. 7 Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med. 2011;104:510 –520. 8 Lavis JN, Robertson D, Woodside JM, et al; Knowledge Transfer Study Group. How can research organizations more effectively transfer research knowledge to decision makers? Milbank Q. 2003;81:221–248. 9 Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003;362:1225–1230. 10 Graham ID, Tetroe J. How to translate health research knowledge into effective healthcare action. Healthc Q. 2007;10:20 –22. 11 Straus SE, Tetroe J, Graham ID. Introduction. Knowledge translation: what it is and what it isn’t. In: Straus SE, Tetroe J, Graham ID, eds. Knowledge Translation in Health Care: Moving from Evidence to Practice. 2nd ed. Hoboken, NJ: John Wiley & Sons; 2013:3–13. 12 Grimshaw J, Eccles M, Lavis J, et al. Knowledge translation of research findings. Implement Sci. 2012;7:50. 13 Li LC, Bombardier C. Physical therapy management of low back pain: an exploratory survey of therapist approaches. Phys Ther. 2001;81:1018 –1028. 14 Bigos SJ, Bowyer OR, Braen GR, et al. Clinical Practice Guideline Number 14: Acute Low Back Problems in Adults. 95-0642. Rockville, MD: US Department of Health and Human Services, Agency for Health Care Policy and Research; 1994. 15 Harte AA, Gracey JH, Baxter GD. Current use of lumbar traction in the management of low back pain: results of a survey of physiotherapists in the United Kingdom. Arch Phys Med Rehabil. 2005;86:1164 –1169. 16 Bishop A, Foster NE, Thomas E, Hay EM. How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health care practitioners? A survey of UK general practitioners and physiotherapists. Pain. 2008;135:187–195. 17 Grol R, Grimshaw JM. Evidence-based implementation of evidence-based medicine. Jt Comm J Qual Improv. 1999;25:503–513. 18 Bernhardsson S, Johansson K, Nilsen P, et al. Determinants of guideline use in primary care physical therapy: a cross-sectional survey of attitudes, knowledge, and behavior. Phys Ther. 2014;94:343–354. 19 Graham ID, Logan J, Harrison M, et al. Lost in knowledge translation: time for a map? J Contin Educ Health Prof. 2006;26:13–24. 20 Schreiber J, Marchetti GF, Racicot B, Kaminski E. The use of a knowledge translation program to increase use of standardized outcome measures in an outpatient pediatric physical therapy clinic: administrative case report. Phys Ther. 2015;95:613– 629. 21 Sibley KM, Salbach NM. Applying knowledge translation theory to physical therapy research and practice in balance and gait assessment: case report. Phys Ther. 2015;95:579 –587. 22 Huijg JM, Dusseldorp E, Gebhardt WA, et al. Factors associated with physical therapists’ implementation of physical activity interventions in the Netherlands. Phys Ther. 2015;95:539 –557. 23 Maas MJM, van der Wees PJ, Braam C, et al. An innovative peer assessment approach to enhance guideline adherence in physical therapy: single-masked, cluster-randomized controlled trial. Phys Ther. 2015;95:600 – 612. 24 Manns PJ, Norton AV, Darrah J. Cross-sectional study to examine evidence-based practice skills and behaviors of physical therapy graduates: is there a knowledge-to-practice gap? Phys Ther. 2015;95:568 –578. 25 Nanninga CS, Postema K, Scho ˜ nherr MC, et al. Combined clinical and home rehabilitation: case report of an integrated knowledge-to-action study in a Dutch rehabilitation stroke unit. Phys Ther. 2015;95:558 –567. 26 Hudon A, Gervais M-J, Hunt M. The contribution of conceptual frameworks to knowledge translation interventions in physical therapy. Phys Ther. 2015;95:630 – 639. 27 Levac D, Glegg SMN, Camden C, et al. Best practice recommendations for the development, implementation, and evaluation of online knowledge translation resources in rehabilitation. Phys Ther. 2015;95:648 – 662. 28 Hanson H, Harrington AT, Nixon-Cave K. Implementing treatment frequency and duration guidelines in a hospital-based pediatric outpatient setting: administrative case report. Phys Ther. 2015;95:678 – 684. 29 van Twillert S, Postema K, Geertzen JHB, Lettinga AT. Incorporating self-management in prosthetic rehabilitation: case report of an integrated knowledge-to-action process. Phys Ther. 2015;95:640 – 647. 30 Richardson J, DePaul V, Officer A, et al. Development and evaluation of Self-Management and Task-Oriented Approach to Rehabilitation Training (START) in the home: case report. Phys Ther. doi: 10.2522/ptj. 20130617. 31 Jones CA, Roop SC, Pohar SL, et al. Translating knowledge in rehabilitation: systematic review. Phys Ther. 2015;95:663– 677. 32 Stevans JM, Bise CG, McGee JC, et al. Evidence-based practice implementation: case report of the evolution of a quality improvement program in a multicenter physical therapy organization. Phys Ther. 2015;95:588 –599. 33 Grol R. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care. 2001;39(8 suppl 2):II46 –II54.
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Manuscript Reviewers for PTJ’s Knowledge Translation and Implementation Special Series Editor in Chief Dr Rebecca Craik and Special Series Guest Co-Editors Dr Linda Li and Dr Philip van der Wees gratefully acknowledge the manuscript reviewers who contributed their time, expertise, and constructive comments to this special series: Madeleine Abrandt Dahlgren, PhD Paul Adam, MSW Woei nan Bair, PhD Doreen Bartlett, PT, PhD Danielle Moeske Bellows, PT, MHS Annette Bishop, PT, PhD Gerard Brennan, PT, PhD Lucie Brosseau, PhD, MSc, BSc Johanna Darrah, PhD Elizabeth Dean, PT, PhD Sara Demain, PhD, MSc Carol DeMatteo, MSc Elizabeth Domholdt, PT, EdD Marie Earl, PT, PhD Ian Edwards, PhD Dawn Ehde, PhD Michael D. Ellis, MPT, DPT Patti Ephraim, MPH Lynne Feehan, PT, PhD Rebecca Fisher, PhD Simon French, PhD, MPH Pamela Gallagher, PhD Rose Galvin, PhD Mary E. Gannotti, PT, PhD Nancy Getchell, PhD Steven E. Hanna, PhD Bea Hemmen, MD, PhD Bev Holmes, PhD Lynn Jeffries, PT, MS, PCS Diane U. Jette, PT, DSc Peter Kent, PhD Michelle E. Kho, PT, PhD Thomas Kliche, DiplPol, DiplPsych Nicol Korner-Bitensky, PhD Suzanne Kuys, PhD Gert Kwakkel, PhD
Mary Law, PhD Joy C. MacDermid, PT, PhD Lara Maxwell, MSc Patricia Quinn McGinnis, PT, PhD Lori A. Michener, PT, PhD, ATC, SCS William C. Miller, PhD, OT Michael J. Mueller, PT, PhD, FAPTA Susan W. Muir-Hunter, BScPT Gina Maria Musolino, PT, EdD Jennifer Nitz, PhD Jacqueline Nuysink, PT, MSc, PCS Matthew Plow, PhD Kathryn E. Roach, PT, PhD Michael D. Ross, PT, DHS, OCS Nancy M. Salbach, PhD Katherine L. Salter, PhD(candidate) Nancy Santesso, RD, MLIS Barbara Sassen, PhD Margaret Schenkman, PT, PhD Joseph Michael Schreiber, PhD Maureen J. Simmonds, PhD Rob Smeets, PhD Jennifer S. Stith, PT, PhD, LCSW Sharon E. Straus, MD Aliki Thomas, PhD Anne Frances Townsend, PhD Catherine Trombly Latham, ScD Ann M. Vendrely, PT, EdD, DPT Susan Flannery Wainwright, PT, PhD Marion F. Walker, PhD, MPhil, FCOT Vicky Ward, PhD Stephen Wegener, PhD Marie D. Westby, BScPT Maureen Whitford, PT, PhD, MS, MHS, NCS Virginia Wright, PT, PhD
[DOI: 10.2522/ptj.2015.95.4.486]
April 2015
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''Knowing Is Not Enough; We Must Apply. Willing Is Not Enough; We Must Do'' Linda C. Li and Philip J. van der Wees PHYS THER. 2015; 95:486-491. doi: 10.2522/ptj.2015.95.4.486
References
This article cites 28 articles, 16 of which you can access for free at: http://ptjournal.apta.org/content/95/4/486#BIBL
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The online version of this article, along with updated information and services, can be found online at: http://ptjournal.apta.org/content/95/4/486 Collections
This article, along with others on similar topics, appears in the following collection(s): All Editorials Clinical Decision Making Evidence-Based Practice Knowledge Translation and Implementation Special Series
e-Letters
To submit an e-Letter on this article, click here or click on "Submit a response" in the right-hand menu under "Responses" in the online version of this article.
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Editorial “Knowing Is Not Enough; We Must Apply. Willing Is Not Enough; We Must Do” Quote from Johann von Goethe
imely use of research knowledge to improve clinical practice and health policy decisions has attracted international interest. The need to “do something” is particularly urgent, as it takes on average 17 years for research evidence to reach clinical practice.1–5 The lengthy lag time to translate research into practice not only results in potential harm to patients, it also has important economic consequences.6 For example, a study of economic benefits of cardiovascular disease research in the United Kingdom between 1975 and 2005 found that a £1.00 investment in public research funding produced an earning of £0.39 per year indefinitely.6,7 About 9% of this earning was attributable to individuals’ health improvement based on a 17-year lag for research to reach practice. Interestingly, the rate of return rose to 13% when the lag time was 7 years shorter. The case for investing in research that addresses the “knowledge-to-action” (KTA) gap is compelling.
T
Over the past 2 decades, the field of knowledge translation (KT) has emerged to address this severe gap. Knowledge translation is essential to all fields of research and takes place within a complex system of interactions between researchers and knowledge users, from the start of a research project to the implementation of new knowledge.8 –11 Grimshaw and colleagues12 suggested that the basic unit of KT is up-to-date and high-quality systematic reviews. The synthesized literature can then be used to develop knowledge products—such as clinical practice guidelines (CPGs), best practice recommendations, quality indicators, or policy briefs—for different audiences. “If You Build It, They Will Come”. . . Think Again The conventional thinking was that “if you build it [the knowledge product], they [the clinicians] will come.” However, this belief has since been disputed in various disciplines, including physical therapy. In 1998, Li and Bombardier13 surveyed Canadian physical therapists on how they managed acute/subacute low back pain (LPB), using clinical vignettes. Despite the 1994 US practice guidelines on acute LPB management,14 the researchers found that more than one third of physical therapists would still use electrotherapeutic modalities of uncertain effectiveness, and only 46% agreed that CPGs were useful for managing LBP. In the United Kingdom, a 2002 survey reported that 41% of physical therapists used lumbar traction in patients with subacute LBP, despite guideline recommendations against it.15 A later study by Bishop et al16 found that 28% of health care professionals, including general practitioners and physical therapists, would advise a patient with acute LBP to remain off work, again despite guideline recommendations.
To comment, submit a Rapid Response to this editorial posted online at: ptjournal.apta.org.
486
f
Physical Therapy
Encouraging results were reported in a recent survey in New Zealand that more than 95% of manipulative and sports physical therapists would advise a patient with acute LBP to “return to normal work” or “return to part time or light duties” However, only 52% said that LBP guidelines were helpful in their clinical decision making. Knowledge products alone, such as CPGs, are insufficient for improving practice. Active, deliberate, and evidence-based implementation strategies are often required.9,17 The need for active implementation strategies in physical therapy is confirmed in a recent survey of Bernhardsson et al,18 showing the gap between positive attitudes toward guidelines and actual use of guidelines. They conducted a Web-based survey among 419
Volume 95 Number 4 Downloaded from http://ptjournal.apta.org/ by guest on April 20, 2015
April 2015
Editorial
Figure. Components of the Knowledge-to-Action11 process highlighted by the selected articles in the PTJ Knowledge Translation and Implementation Special Series. Adapted from Graham ID, Logan J, Harrison MB, et al. Lost in knowledge translation: time for a map? J Contin Educ Health Prof. 2006;26:13-24, with permission of John Wiley & Sons Inc.
physical therapists in Sweden to investigate self-reported attitudes, knowledge, behavior, and barriers related to evidence-based practice (EBP) and guideline use. Most respondents had positive attitudes toward EBP and guidelines: 90% considered EBP necessary, and 96% considered guidelines important. However, only 13% knew where to find guidelines, and only 9% reported having easy access to guidelines. Fewer than half reported using guidelines frequently. Positive attitudes, awareness of guidelines, considering guidelines to facilitate practice, and knowing how to integrate patient preferences with guideline use were associated with frequent use of guidelines. KT in Action To guide KT, Graham and colleagues19 developed a framework to depict the KTA process. The original framework has been updated recently to emphasize the dynamic nature of KT (Figure).11 At the core is the “knowledge funnel” depicting different levels of knowledge creation activities and products that can be used in health care. As the knowledge moves through the funnel, it becomes more refined and potentially more useful to health care professionals and policy makers. The end of the knowledge funnel leads to the “action cycle,” which represents activities that might be needed for applying the knowledge and sustaining its use in real life. In addition to guiding KT activities, the KTA process also provides a compressive framework for researchers to identify gaps in care delivery, develop innovative solutions, assess their impact on clinician behaviors and patient outcomes, and plan initiatives to promote and sustain implementation beyond the research setting. It is, thereApril 2015
Volume 95 Number 4 Downloaded from http://ptjournal.apta.org/ by guest on April 20, 2015
Physical Therapy f
487
Editorial fore, not surprising that clinical and health services researchers are drawn to this framework to inform their work. This special series aims to highlight the state-of-the-art in KT and implementation research. We invited manuscript topics including: • Implementation of CPGs and “best practice” recommendations in physical therapy. • Development of novel tools or techniques to enhance shared decision making between patients and therapists. • Implementation and evaluation of strategies to improve treatment participation or inform health policies. • Barriers to implementing effective treatments or models of care in physical therapy.
More than 40 proposals were received. After careful consideration by a guest editorial panel and a rigorous peer review process, 13 manuscripts were selected. These articles cover a wide range, from pediatric care20 to gait and balance assessment in older adults,21 and from the implementation of physical activity recommendations22 to the management of upper extremity conditions.23 The study designs and viewpoints in most of the articles are informed by the KTA process. Two papers illustrate different approaches to identify problems in translating research knowledge in practice.21,24 In a case report, Sibley and Salbach21 applied the KTA process to identify discrepancies in the use of standardized balance and gait outcome measures in clinical practice and used the findings to guide a KT research program. Meanwhile, in an interview study, Manns et al24 focused on the use of evidence by physical therapists and uncovered that, although recent physical therapist graduates showed better knowledge of EBP skills compared with more experienced therapists, research evidence was infrequently used in clinical decision making by all cohorts. The KTA process suggests that research knowledge should be adapted to the users’ context, and barriers to its use should be properly assessed. Nanninga et al25 reported an administrative case that used a participatory action approach to engage local physical therapists to co-create contextualized knowledge in a stroke rehabilitation unit. Huijg and colleagues22 surveyed 268 physical therapists to assess the intricate relationships between individual attributes (knowledge, skills, beliefs, and other behavioral constructs) and how the therapists implement physical activity interventions. These lines of research are essential for developing targeted implementation interventions. The majority of papers address the selection and tailoring of implementation strategies. In a perspective, Hudon et al26 outline the benefits associated with the use of conceptual frameworks to develop interventions for promoting the use of evidence in physical therapist practice. Levac and associates27 offer recommendations to improve the development, implementation, and evaluation of online knowledge products. In a feasibility study, Hanson et al28 describe a locally developed in-person education intervention to improve the uptake of treatment frequency guidelines for episodic pediatric care. Engaging stakeholders is a crucial step in developing implementation interventions. This process is nicely illustrated by van Twillert et al29 in their development of a strategy to support evidence-based prosthetic rehabilitation. In their case report to be published in June 2015, Richardson et al30 report the implementation of an evidence-based program for improving self-management and task-oriented functions in people recovering from stroke in the home setting.
488
f
Physical Therapy
Volume 95 Number 4 Downloaded from http://ptjournal.apta.org/ by guest on April 20, 2015
April 2015
Editorial Interestingly, in their systematic review, Jones et al31 conclude that education-based interventions continue to be the focus of implementation research in rehabilitation. In contrast, strategies that have been found to be effective in other disciplines—such as the use of reminders or audit and feedback— have been understudied. The findings of Jones et al highlight the need for the physical therapy profession to study the use of other promising interventions to improve practice. A challenge to health care organizations is the development of a structure to monitor and sustain the use of evidence to inform practice. Stevans and colleagues32 describe the launch of a multifaceted implementation strategy for an LBP management initiative with distinct improvement cycles to monitor knowledge use, identify barriers on a continuous basis, and develop solutions to sustain the improved clinical practice. An important aspect of the KTA process is to evaluate outcomes of implementation strategies. Schreiber et al20 report a pretreatment/posttreatment study of a KT initiative involving a knowledge broker to improve outpatient pediatric care. This study is unique, as the evaluation was conducted from the program administrator’s perspective. Finally, as advocated by Grol and others,9,33 high-quality evidence is needed to inform the selection of implementation strategies by physical therapists and health care administrators. To this end, Maas and colleagues’23 cluster-randomized controlled trial provides insight on the effectiveness of peer assessment as an implementation strategy to improve physical therapists’ adherence to CPGs for managing upper extremity conditions. The physical therapy field has made tremendous progress in supporting KT activities and advancing KT science. Through this special series, we intend to generate further interest in KT research relevant to physical therapist practice and invite discussions about ideas to support local KT activities. Acknowledgments We are grateful for the enthusiastic support of Editor-in-Chief Rebecca Craik and the expert guidance of the editorial staff in preparing this special series. Our sincere thanks also go to Dr Maura Iversen for her participation on the guest editorial panel and to all manuscript reviewers for their expertise, insights, and valuable time; they are recognized on page 491.
Linda C. Li, Philip J. van der Wees L.C. Li, PT, PhD, is a guest co-editor of this special series. She is Associate Professor, Harold Robinson/ Arthritis Society Chair in Arthritic Diseases, Canada Research Chair in Patient-oriented Knowledge Translation, Department of Physical Therapy, University of British Columbia, Vancouver, BC; and Senior Scientist, Arthritis Research Canada, Richmond, BC, Canada. P.J. van der Wees, PT, PhD, is a guest co-editor of this special series and a PTJ editorial board member. He is Senior Researcher, Scientific Institute for Quality of Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
References 1 Balas E, Boren S. Managing clinical knowledge for health care improvement. In: van Bemmel JH, McCray AT, eds. Yearbook of Medical Informatics. Stuttgart, Germany: Schattauer Verlagsgesellschaft mbH; 2015:65–70. 2 Grant J, Green L, Mason B. Basic research and health: a reassessment of the scientific basis for the support of biomedical science. Res Eval. 2003;12:217–224. 3 Green LW. Making research relevant: if it is an evidence-based practice, where’s the practice-based evidence? Fam Pract. 2008;25(suppl 1):i20 –i24.
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Manuscript Reviewers for PTJ’s Knowledge Translation and Implementation Special Series Editor in Chief Dr Rebecca Craik and Special Series Guest Co-Editors Dr Linda Li and Dr Philip van der Wees gratefully acknowledge the manuscript reviewers who contributed their time, expertise, and constructive comments to this special series: Madeleine Abrandt Dahlgren, PhD Paul Adam, MSW Woei nan Bair, PhD Doreen Bartlett, PT, PhD Danielle Moeske Bellows, PT, MHS Annette Bishop, PT, PhD Gerard Brennan, PT, PhD Lucie Brosseau, PhD, MSc, BSc Johanna Darrah, PhD Elizabeth Dean, PT, PhD Sara Demain, PhD, MSc Carol DeMatteo, MSc Elizabeth Domholdt, PT, EdD Marie Earl, PT, PhD Ian Edwards, PhD Dawn Ehde, PhD Michael D. Ellis, MPT, DPT Patti Ephraim, MPH Lynne Feehan, PT, PhD Rebecca Fisher, PhD Simon French, PhD, MPH Pamela Gallagher, PhD Rose Galvin, PhD Mary E. Gannotti, PT, PhD Nancy Getchell, PhD Steven E. Hanna, PhD Bea Hemmen, MD, PhD Bev Holmes, PhD Lynn Jeffries, PT, MS, PCS Diane U. Jette, PT, DSc Peter Kent, PhD Michelle E. Kho, PT, PhD Thomas Kliche, DiplPol, DiplPsych Nicol Korner-Bitensky, PhD Suzanne Kuys, PhD Gert Kwakkel, PhD
Mary Law, PhD Joy C. MacDermid, PT, PhD Lara Maxwell, MSc Patricia Quinn McGinnis, PT, PhD Lori A. Michener, PT, PhD, ATC, SCS William C. Miller, PhD, OT Michael J. Mueller, PT, PhD, FAPTA Susan W. Muir-Hunter, BScPT Gina Maria Musolino, PT, EdD Jennifer Nitz, PhD Jacqueline Nuysink, PT, MSc, PCS Matthew Plow, PhD Kathryn E. Roach, PT, PhD Michael D. Ross, PT, DHS, OCS Nancy M. Salbach, PhD Katherine L. Salter, PhD(candidate) Nancy Santesso, RD, MLIS Barbara Sassen, PhD Margaret Schenkman, PT, PhD Joseph Michael Schreiber, PhD Maureen J. Simmonds, PhD Rob Smeets, PhD Jennifer S. Stith, PT, PhD, LCSW Sharon E. Straus, MD Aliki Thomas, PhD Anne Frances Townsend, PhD Catherine Trombly Latham, ScD Ann M. Vendrely, PT, EdD, DPT Susan Flannery Wainwright, PT, PhD Marion F. Walker, PhD, MPhil, FCOT Vicky Ward, PhD Stephen Wegener, PhD Marie D. Westby, BScPT Maureen Whitford, PT, PhD, MS, MHS, NCS Virginia Wright, PT, PhD
[DOI: 10.2522/ptj.2015.95.4.486]
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''Knowing Is Not Enough; We Must Apply. Willing Is Not Enough; We Must Do'' Linda C. Li and Philip J. van der Wees PHYS THER. 2015; 95:486-491. doi: 10.2522/ptj.2015.95.4.486
References
This article cites 28 articles, 16 of which you can access for free at: http://ptjournal.apta.org/content/95/4/486#BIBL
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