Congenital muscular torticollis (CMT) is one of the most common musculoskeletal deformities in infants, with an incidence reported as high as 16% in newborns.1 It is a result of excessive shortening of or injury to the sternocleidomastoid muscle, which leads to an imbalance of muscle function around the neck. It is characterized by a lateral flexion of the head toward the affected muscle and a rotation (or chin deviation) to the opposite side.2,3 Referrals to physical therapists (PTs) for CMT have continued to rise in recent years, perhaps due in part to the “Back to Sleep” campaign in the United States and Canada, as well as to improvement in physician identification of this condition.4
Partly as a response to the increasing incidence and number of referrals and the broader need for evidence-based information and materials to guide and support practice decisions, the APTA and its Academy of Pediatric Physical Therapy (APPT) supported the development of an evidence-based clinical practice guideline (CPG) for CMT (CMT-CPG).5 The purpose of the CMT-CPG is to describe current evidence, define and classify common CMT impairments of body structure and function, activity limitations, and participation restrictions, identify appropriate outcome measures, and identify interventions supported by current best evidence.5 This guideline, published in 2013, provides a standard of best practice for pediatric PTs and as such should influence clinicians to integrate the 16 action statements into routine clinical practice.
Clinical practice guidelines are one method of facilitating the translation of research into practice. They synthesize a relevant body of publicly available evidence using a systematic method of evaluating outcomes for bias to answer clinical questions and assist clinicians in identifying evidence-based treatment options and specific recommendations.6,7 Grimshaw et al8 suggested that CPGs may decrease the use of ineffective treatment options, promote evidence-based practice, and improve patient outcomes. Use of CPGs by PTs in the treatment of low back pain leads to better treatment outcomes with reduced costs.6,9 However historically, publication of CPGs does not ensure their uptake into practice.10,11 Physical therapist adherence to CPG recommendations for the use of active interventions to treat low back pain was only 40%.9 Fewer than half of the surveyed primary care PTs in Sweden reported using guidelines frequently, and only 9% reported having easy access to guidelines.12 Positive attitudes, awareness of guidelines, consideration of guidelines to facilitate practice, and knowing how to integrate patient preferences with guideline use were characteristics associated with frequent use of guidelines.12 In contrast, a variety of factors inhibit the uptake of CPGs, including difficulty changing practice habits, limited access to guidelines, resistance from colleagues, and lack of time.12–14
Beyond publishing and disseminating CPGs, the use of knowledge brokers (KBs) has been reported to enhance the uptake and application of new knowledge by practitioners. Knowledge brokers work collaboratively with stakeholders to facilitate the transfer and exchange of relevant information.14–16 They can assist clinicians with knowledge translation by packaging, translating, and disseminating research findings in manageable formats.17,18 They support the integration of information within local contexts by assessing barriers and facilitators, implementing strategies, and measuring outcomes related to sustained knowledge use. Knowledge brokers have been referred to as “opinion leaders” and “change agents,” as their credibility and expertise are instrumental in bringing about changes.14
The CMT-CPG required a considerable investment of resources by the APPT, and a companion document outlines the lengthy and rigorous process for the creation of APPT CPGs.7 Following publication in October 2013, the CMT-CPG was presented at the Section on Pediatrics Annual Conference in November 2013 (SoPAC 2013) and at the APTA Combined Sections Meeting in February 2014. Although education about guidelines is a form of knowledge translation, passive educational presentations are not strongly correlated with implementation.19 This study is an effort to describe the uptake of the CMT-CPG in clinical practice by PTs who work with infants with CMT and to identify trends in their knowledge brokering and implementation. The information may provide guidance for future CMT-CPG updates, implementation support, and inform the development of other CPGs and their related documents.
Pediatric PTs were recruited to participate in this Survey Monkey survey (Supplemental Digital Content 1, available at: http://links.lww.com/PPT/A180) in a variety of ways. Attendees at a SoPAC 2013 continuing education session (N = 48) volunteered to share their e-mail contacts with the authors. Invitations to participate, and to share the survey with colleagues, were posted at the SoPAC 2013 registration desk, on the APPT listserv and Web page, and in E-blast communications throughout the fall of 2014 and early spring of 2015. In addition, individuals were invited to participate through announcements at APPT continuing education courses and through contacts with the investigators. All PTs who self-identified that they treat children with CMT or had an interest in CMT were eligible to participate. Once participants entered the survey, no names or e-mail addresses were collected so that responses were anonymous. Chatham University's Institutional Review Board approved the study.
The survey was designed to determine the frequency with which respondents reported implementing any of the 16 action statements from the CPG prior to its 2013 publication, and their changes in clinical practice following publication. A 4-part Likert scale of never, rarely, frequently, and always was used for prior to and after publication responses. Additional questions addressed the ability to act as knowledge brokers within practice settings and in the wider community, descriptions of successes and challenges with implementing the CPG action statements, demographic information, and suggestions for products or services that would facilitate implementation.
The survey had 54 content questions, of which the first 5 established survey eligibility and respondent exposure to the CMT-CPG. There were 29 questions about practice of the 16 action statements and 20 questions about knowledge brokering (KB) within and outside of the respondents' practice settings. Before closing, participants were provided a link to a different survey site to register for an optional qualitative follow-up interview and/or for an Apple iPad minidrawing as a token of appreciation for participating in the survey.
Data were analyzed for frequencies of recommendation implementation before and after the CMT-CPG was published and trends in effectiveness in implementing changes in practice. The Friedman test (α = .05) was used to compare differences in ranked choices between pre- and post-CPG publication practices. By author consensus, a meaningful change between pre and postpublication ratings was defined as a 15-point or more change in the percentage of PTs who reported implementing an action statement after publication and a significant Friedman result. Data were analyzed using SPSS v.24.
There were 282 respondents with 81.5% APTA members, 78% APPT members, and an average of 18.79 years of experience (Table 1). Two-thirds treat CMT frequently, with 44% treating in hospital-based outpatient PT clinics and 24% in private outpatient clinics. Almost two-thirds of the respondents had read the CMT-CPG in its entirety, 28% had attended a continuing education course about the CPG, and 13% had attended a SoPAC 2013 workshop focused on setting personal goals for implementing the CPG action statements (Table 1).
Practice Prior to Publication of the CPG
Prior to the publication of the CMT-CPG, 90% or more of respondents reported that they frequently or always examined 9 of 12 recommended items and provided the 5 first-choice interventions in their treatments. This suggests that the practices of the vast majority of respondents were aligned with the evidence on examination and intervention. In contrast, 70% of respondents reported that they never, or rarely, referred infants at birth; 61% rarely or never requested images or imaging reports; 90% never or rarely classified the type of CMT; and 60% never or rarely provided follow-up care (Table 2).
Practice After Publication of the CPG
After publication of the CMT-CPG, increases occurred across all action statements with 90% or more of respondents implementing 14 of the possible 29 specific items and all items were reportedly implemented by at least 50% of respondents. Identification of newborns at risk for CMT was only frequently or always implemented by 36% of the respondents. Of note, 96% or more of respondents reported either frequently or always examining 12 of the 12 recommended items, 92% or more were treating neck passive range of motion with stretching, and 99% or more were providing the remaining 4 first-choice interventions. Following publication, most respondents (63%) continued to never or rarely refer infants at birth. However, only 40% to 45% report never or rarely requesting images or imaging reports, classifying the type of CMT, or providing follow-up. Each of these represents a meaningful and statistical improvement.
Significant Changes in Uptake
After combining frequently and always-ranked responses, the Friedman test resulted in 27 of 29 items with significant increases in implementation (Table 2). The 2 items that did not change significantly were intervention recommendations for the use of passive stretching and parent education, which were both more than 90% prepublication. On the basis of the criteria of 15% or more change, meaningful changes in implementation occurred for item 4—screening infants, item 6—requesting images and reports, item 8—classifying severity, item 10—alternating feeding sides, item 11—determining a prognosis, item 14—referring for consultation when change is minimal, and item 16—providing follow-up after the infant is walking or at 1-year postdischarge (Table 2).
Participants (n = 167-193) provided information regarding KB activities to implement effective changes both within and outside of their own practice or work setting. Responses included I haven't tried to implement this recommendation, not effective at all, minimally effective, very effective, and was already meeting the statement criteria. For questions related to effectiveness beyond one's own setting, an additional question was asked about dissemination to referring physicians, midwives, and other providers who have contact with newborns. Table 3 includes the participants' self-assessment of KB. Participants provided additional comments with their self-rating.
Factors Influencing Implementation of the CMT-CPG. Participants provided information on successes (n = 106), barriers (n = 115), and products or services that supported implementation of the recommendations (n = 198). Successes included earlier referrals, standardization in examination, documentation and intervention, greater use of objective measures including the severity scale, enhanced use of “red flags,” usefulness in explaining processes to families and health care practitioners, and lending additional justification and credence for current practices for third-party payers and one's own confidence. These changes are consistent with the use of CPGs to enhance best practice and reduce unwarranted variation.
Reported barriers to implementation of the CMT-CPG, in addition to those previously noted, included lack of awareness of the CMT-CPG among health care practitioners, including other physical therapists, resistance to change, lack of acceptance of something new, difficulty using measurement tools (eg, arthrodial protractor), and the length and complexity of the document. Nine participants expressed disagreement with specific elements of the CMT-CPG such as the individual criteria for discharge, the number of elements in an initial examination, and lack of support for alternative interventions or philosophies, even if there are no published studies to support them.
Of a list of potential strategies that could be implemented, respondents checked all that they believed would be helpful. The top 3 most frequently chosen strategies were a parent-friendly brochure that explained the recommended actions (85.42%), a standardized documentation form (62.5%), and continuing education courses on how to perform specific tests and measures identified by the CPG (47.92%). Participants provided additional suggestions via an open-ended text box (Table 4).
The publication and dissemination of the CMT-CPG are consistent with the commitment to the development of CPGs as an integral component of the APPT strategic plan. The goal of translating research into practice, reducing unwarranted variation in practice, and supporting best practice for infants with CMT appears to be met through the successful uptake of the practice recommendations by these respondents. These positive results demonstrate that the allocation of financial and human resources by the APPT was worthwhile and justified.
Evidence suggests that there are a number of challenges related to the translation of evidence into practice20 including uptake of CPGs by PTs.12,21 Despite these challenges, respondents reported an increase in practice behaviors to align more with the recommended action statements, with 15 of the 16 action statements exceeding a 50% threshold of implementation and 22 of the 29 specific actions implemented by 90% or more. Specifically, the items related to examination and first-choice interventions were all implemented prior to the CPG publication. The respondents were highly experienced (mean of 19 years in practice) and professionally committed (78% are APTA APPT members); thus, it was not surprising that standard measures like range of motion and interventions such as stretching the tight muscle and educating parents were consistently high before the CMT-CPG.
In contrast, the only action statement that did not exceed 50% by combining frequently and always responses following publication is the identification of newborns at risk for CMT. This may reflect the fact that few respondents identified the neonatal intensive care unit or inpatient acute care hospital as their primary work setting. Although practitioners in these settings are likely to be involved with newborn screenings, most PTs do not routinely participate in these screens.
Requesting images and reports (action statement 6) increased from 38% to 60% implementation after the CPG publication. Although this is a significant improvement, at least 40% of respondents are still not requesting images or reports from families when they are available. Of the respondents, approximately 44% were hospital based; although access to images may be easier in this setting, x-rays, computerized tomography scans, and magnetic resonance images are not typically performed on infants with CMT.22 Ultrasound is gaining in usefulness for imaging the sternocleidomastoid muscle23; however, it is the least often taught content in physical therapy programs.24 Clinicians in the outpatient and early intervention settings may not be in the habit of requesting images or imaging reports; thus, this lower rate of implementation may be a misinterpretation of the survey question or an assumption that, because images are not typically ordered for CMT, clinicians need not ask about them.
Action statement 8 recommends that clinicians should classify the level of severity of infants with CMT. Classification of any sort was performed frequently and always by 3% of respondents prior to publication, and by 57% after publication. It is assumed that the increase was due to the provision of a classification schema based on 7 grades of severity. Although this is a significant increase, more than 40% of respondents have not implemented this recommendation from the CMT-CPG. This action statement is rated “P” for best practice due to a lack of psychometric evidence on the severity grades; thus, the level of obligation for implementation is based more on expert opinion than evidence.5 Studies are currently underway to establish the psychometrics of the grades; however, the lack of implementation by 40% suggests a lack of confidence with classification, or a need for clinician education on its application in practice, including its use with parents for prognosis of the episode of care or for explaining treatment intensity.
Action statement 16 recommends follow-up after the initial episode of care. Reported implementation shifted from 40% to 55% after publication. Respondent comments about this lower implementation level included difficulty reevaluating a child who has been discharged from services without initiating another referral; parents disinterested in returning if they think the condition is resolved, and lack of reimbursement for a reevaluation after discharge. The importance of this follow-up examination is to screen for recidivism of asymmetries, as the child initiates more activity against gravity, such as crawling and walking, and to screen for developmental delays that have been correlated with CMT in longitudinal studies.25 Parent education about these concerns may need to be stressed at the time of discharge.
There was considerable variability in the respondents' self-identified KB activities. There were differences of more than 15% between individuals who have attempted to implement KB activities within their practices and those who have attempted to facilitate the uptake of the CMT-CPG by professional colleagues in the nearby geographic region. In addition, more than 40% of respondents reported that they have not attempted to facilitate implementation of action statements related to early referral/screening and long-term follow up procedures, and two-thirds have not attempted to disseminate the CPG to physicians and other providers. This suggests that many practitioners lack the time, strategies, motivation, training, and/or resources to effectively share the recommendations of the CMT-CPG with key constituencies. This may limit the effect of the CPG. For example, dissemination to those health care providers most likely to identify infants with CMT about the importance of early referral to and treatment by PTs may reduce the age of treatment onset, which can reduce the episode of care. In addition, educating third-party payers to recognize and value the importance of long-term follow-up for infants with CMT may promote changes in reimbursement.
Considerations for Guideline Developers
On the basis of the survey results, multifaceted strategies should be considered to increase uptake of CPGs.21,26 Professional organizations need to facilitate development of KB skills and networks of knowledge brokers to assist with the introduction of new guidelines.14 The creation of companion documents, such as documentation templates or clinical summaries, may make it easier for clinicians to document adherence or share recommendations with consumers or other health professionals. Developing a variety of easily accessible materials to share with relevant stakeholders, including parents/caregivers and referral sources, regarding new CPGs will be critical to influence on practice. The APPT is addressing this through its Knowledge Transition committee, which will develop parent summaries, brochures, or educational materials for consumers, physicians, and academic faculty. A documentation template for CMT has already been published,27 and the APTA Outcomes Registry will facilitate standardized documentation of measures and interventions. Training workshops or online educational modules may be needed when a CPG requires a substantial change in practice. Publicity, through annual meeting presentations and newsletter announcements, can keep awareness high so that members anticipate and plan for the publication of a CPG.
Limitations of the Study
It is difficult to specifically identify therapists who treat CMT; thus, survey participants were solicited from APTA APPT events and through its newsletter. This may have biased the sample toward a more up-to-date or involved audience and may have missed individuals whose experiences differ from the survey sample. This was a self-report survey, without a control group, and respondents may have underestimated their practice behaviors prior to the CPG publication to appear to be improving after its publication. Physical therapists may or may not have realistic perceptions of the extent to which they adhere to guideline recommendations.28 The attrition of about 100 to 120 of the 282 respondents for the questions on KB may be due to survey fatigue29; however, many of the respondents who skipped the KB section did finish the demographic questions at the end of the survey. Those individuals may not have a large caseload related to CMT or do not have the need or opportunity to engage in significant KB. Respondents may have not considered KB activities as their responsibility, which could explain the large number of respondents (66%) who did not try to share the CMT-CPG with referral sources.
The CMT-CPG has successfully aided in aligning practice with evidence among pediatric PTs. A number of CMT-CPG recommendations that were not widely practiced prior to publication of the guideline were reported as being practiced more frequently after publication. Participants identified areas of challenge and success in translating these recommendations into practice and in their KB activities; these can be helpful for the development and implementation of future clinical practice guidelines.
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