“Knowing Is Not Enough; We Must Apply. Willing Is Not Enough; We Must Do”

“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.

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 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.

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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.

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, therefore, 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.

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.