Both subacromial corticosteroid injection and a series of acupuncture treatments combined with home exercises significantly decreased pain and improved shoulder function in patients with SIS, but neither treatment was significantly superior to the other.

Background: Implementing clinical guidelines is challenging. To facilitate uptake, we developed a model of care (BetterBack Model of Care) and an implementation strategy to support management of low back pain in primary care. The aim of this study was to evaluate physiotherapists´confidence, attitudes and beliefs in managing patients with low back pain before and after a multifaceted implementation of the BetterBack Model of Care. A further aim was to evaluate determinants of implementation behaviours among physiotherapists. Methods: This clinical trial was an experimental before and after study within a hybrid type 2 effectivenessimplementation trial. The primary outcome was Practitioner Self-Confidence Scale (PCS), secondary outcomes were the Pain Attitude and Beliefs Scale for Physiotherapists (PABS-PT) and Determinants of Implementation Behaviour Questionnaire (DIBQ). Data was analysed using repeated measures ANOVA and pairwise comparisons. Results: One hundred sixteen physiotherapists answered a questionnaire before, directly after, as well as 3 and 12 months after implementation of the Model of Care. PCS improved over time with a large effect size post implementation (η p 2 = 0.197, p < 0.001). Changes in PABS-PT were only significant after 12 months with higher biopsychosocial orientation, (η p 2 = 0.071, p < 0.01) and lower biomedical orientation, (η p 2 = 0.136, p < 0.001). Directly after the workshop, after 3 and 12 months, physiotherapists had high ratings on all DIBQ domains, (scores > 50) implying that all were potential facilitators of the implementation. However, after 3 months, all domains had significantly decreased except for organisation, social influence and patient expectation domains. However, after 12 months, organisation and social influence domains had significantly decreased while domains such as knowledge, skills and beliefs about capabilities returned to initial levels.

IntroductionLow back pain (LBP) is a major health problem commonly requiring healthcare. In Sweden, there is a call from healthcare practitioners (HCPs) for the development, implementation and evaluation of a best practice primary healthcare model for LBP.Aims(1) To improve and understand the mechanisms underlying changes in HCP confidence, attitudes and beliefs for providing best practice coherent primary healthcare for patients with LBP; (2) to improve and understand the mechanisms underlying illness beliefs, self-care enablement, pain, disability and quality of life in patients with LBP; and (3) to evaluate a multifaceted and sustained implementation strategy and the cost-effectiveness of the BetterBack☺ model of care (MOC) for LBP from the perspective of the Swedish primary healthcare context.MethodsThis study is an effectiveness-implementation hybrid type 2 trial testing the hypothesised superiority of the BetterBack☺ MOC compared with current routine care. The trial involves simultaneous testing of MOC effects at the HCP, patient and implementation process levels. This involves a prospective cohort study investigating implementation at the HCP level and a patient-blinded, pragmatic, cluster, randomised controlled trial with longitudinal follow-up at 3, 6 and 12 months post baseline for effectiveness at the patient level. A parallel process and economic analysis from a healthcare sector perspective will also be performed. Patients will be allocated to routine care (control group) or the BetterBack☺ MOC (intervention group) according to a stepped cluster dogleg structure with two assessments in routine care. Experimental conditions will be compared and causal mediation analysis investigated. Qualitative HCP and patient experiences of the BetterBack☺ MOC will also be investigated.DisseminationThe findings will be published in peer-reviewed journals and presented at national and international conferences. Further national dissemination and implementation in Sweden and associated national quality register data collection are potential future developments of the project.Date and version identifier13 December 2017, protocol version 3.Trial registration numberNCT03147300; Pre-results.

Low back pain (LBP) occurs in all ages and first-line treatment by physiotherapists is common. The main aim of the current study was to evaluate the effectiveness of implementing a best practice model of care for LBP (intervention group—BetterBack☺ MoC) compared to routine physiotherapy care (control group) regarding longitudinal patient reported outcomes. The BetterBack☺ MoC contains clinical guideline recommendations and support tools to facilitate clinician adherence to guidelines. A secondary exploratory aim was to compare patient outcomes based on the fidelity of fulfilling a clinical practice quality index regarding physiotherapist care. A stepped cluster randomized design nested patients with LBP in the three clusters which were allocated to control (n = 203) or intervention (n = 264). Patient reported measures were collected at baseline, 3, 6 and 12 months and analyzed with mixed model regression. The primary outcome was between-group changes from baseline to 3 months for pain intensity and disability. Implementation of the BetterBack☺ MoC did not show any between-group differences in the primary outcomes compared with routine care. However, the intervention group showed significantly higher satisfaction at 3 months and clinically meaningful greater improvement in LBP illness perception at 3 months and quality of life at 3 and 6 months but not in patient enablement and global impression of change compared with the control group. Physiotherapists’ care that adhered to all clinical practice quality indices resulted in an improvement of most patient reported outcomes with a clinically meaningful greater improved LBP illness perception at 3 month and quality of life at 3 and 6 months, significantly greater improvement in LBP illness perception, pain and satisfaction at 3 and 6 months and significantly better enablement at all time points as well as better global improvement outcomes at 3 months compared with non-adherent care. This highlights the importance of clinical guideline based primary care for improving patient reported LBP outcomes.

Background and Aims Best‐practice low back pain (LBP) primary care programmes have been developed based on evidence‐based clinical guidelines and implemented in Sweden and Denmark. The theoretical domains framework (TDF) was utilized in the design of the implementation strategy. Based on the TDF domains, the Determinants of Implementation Behavior Questionnaire (DIBQ) has been developed to evaluate implementation determinants, but its feasibility and validity need to be tested and adapted to study specific contexts. This study aimed to tailor the DIBQ for evaluation of implementation for LBP primary care programmes. The objectives were to (a) translate the DIBQ into Swedish and Danish, (b) adapt the DIBQ into DIBQ‐tailored (DIBQ‐t) to study content validity, (c) test the DIBQ‐t for feasibility, and (d) perform validity testing of DIBQ‐t. Methods We used a mixed‐methods design. First, forward translation of the DIBQ, then adaptation into DIBQ‐t using qualitative face validity and quantitative content validity was done. Finally, to determine feasibility and construct validity using confirmatory factor analyses, we used data from DIBQ‐t collected after the programmes' 2‐day course. Results The final DIBQ‐t included 28 items describing 10 of the original 18 DIBQ domains and was considered feasible. A total of 598 clinicians out of 609 responded to the DIBQ‐t, with only 2‰ of the items missing. The confirmatory factor analyses showed a good fit after removing two items with the lowest domain loading. The DIBQ‐t maintained linkage to all domains within the Behavioral Change Wheel. The clinicians' expectations, according to the DIBQ‐t, indicate facilitating determinants outweighing barriers at the initiation of implementation processes. Conclusions The study resulted in a feasible and valid version of a questionnaire for evaluating clinicians' expectations regarding implementation determinants of best‐practice LBP primary care programmes.