Emphasis on improving patient care and optimizing care delivery has led to an increase in clinical practice guidelines (CPGs). As part of a strategic effort to increase the quality, consistency, and evidence base for physical therapy, the APTA has supported development and distribution of CPGs.1 In parallel, the APTA Academy of Pediatric Physical Therapy (APPT) strategic plan supports the development of 5 CPGs in 5 years.2 The first CPG developed addressed physical therapists' (PTs) management of infants with congenital muscular torticollis (CMT) and was updated in 2018.3,4
CMT is a common musculoskeletal deformity seen in infants at or shortly after birth,5 characterized by a lateral head tilt to one side and neck rotation to the opposite side from postural preference, tightness, and/or fibrosis of the sternocleidomastoid muscle.6 Some speculate that the increased incidence in CMT referrals is a consequence of infants' positioning throughout the day. The American Academy of Pediatrics' recommendations to put babies to sleep on their backs to reduce the risk of sudden infant death syndrome7 may not be balanced enough by an emphasis on “tummy time while awake.” As many as 44% of new parents report that they received no information on awake positioning.8
The 2013 CMT CPG was developed to support PTs' services provided to infants and families. Prepublication APTA and APPT conference presentations described the CPG development process to raise awareness. A guideline draft was available for public review in May 2013. Stakeholder and public feedback influenced the final version that was disseminated in Pediatric Physical Therapy,3 listed on the National Guideline Clearinghouse (www.guidelines.gov) and PEDro (www.pedro.org.au/) databases and announced through APPT newsletters. Presentations at the 2013 Section on Pediatrics Annual Conference and the 2014 APTA Combined Sections Meeting promoted awareness to facilitate implementation.
Publication and continuing education are passive knowledge translation (KT) strategies, effective for improving knowledge but not attitudes or behaviors.9 Clinicians may face challenges incorporating recommendations into practice10,11 even when attitudes about CPGs are positive.12 When knowledge brokers (KBs) assist with translating CPGs into practice, research evidence can be successfully integrated.13
A 2014-2015 quantitative survey described the CMT CPG implementation by pediatric PTs.14 It focused on action statement implementation before and after publication, and KT experiences. Results indicated successful action statement implementation, with most implemented by 90% or more of respondents, although KT was more challenging.14 Complementing the quantitative survey, this qualitative study aimed to gather more complete understandings of CMT CPG implementation by PTs.
In this qualitative study, semistructured in-depth telephone interviews were conducted with pediatric PTs who provide care to infants with CMT. After completing the quantitative survey,14 respondents who volunteered for a follow-up interview were asked about CPG perceptions, implementation experiences, and ideas for future CPGs. The first author, a pediatric PT, conducted the interviews; she neither wrote the CMT CPG nor assisted with the quantitative survey. She had no prior contact or professional relationships with the participants and made a conscious effort not to engage in clinical discussions about personal experiences treating infants with CMT. Chatham University's Institutional Review Board approved the study.
Participants were selected from volunteers using a purposive sampling technique. This subset of pediatric PTs had completed the quantitative survey14 and either read the CMT CPG or attended APTA or APPT presentations about the CPG; all had experience treating infants with CMT.
Procedure and Data Collection
One-on-one, semistructured telephone interviews were recorded with an online conference audio-recording system and later transcribed for data analysis. Randomly assigned code numbers maintained participant anonymity. Questions were derived from iterative discussions by the authors (Table 1) to explore participants' CMT CPG knowledge, perceptions, implementation, and recommendations for future CPGs.
DATA REDUCTION AND ANALYSIS
The transcribed interviews were analyzed using an inductive phenomenological approach in which the researcher is immersed in data, reflects on the data, and generates descriptions that facilitate deep understanding.15,16 Initial codes were developed to organize and sort interview content based on the CMT CPG, the quantitative survey data, and literature on CPG development and KT.3,11,14 Analysis began with an open-coding strategy, allowing for independent interview data analysis, followed by content thematic analysis to identify emerging themes using an axial coding process.15,17 This iterative data analysis process via thematic analysis identified 3 main themes.
Interview data were triangulated with the CMT CPG, the quantitative survey results,14 and the authors' clinical expertise. Triangulation processes cross verify the same information to increase the validity and reliability.16,18,19 Triangulation by all authors supported thematic agreement. To ensure rigor, transparency, and trustworthiness, the researcher maintained an audit trail (see Supplemental Digital Content 1, available at: http://links.lww.com/PPT/A269) and was immersed in the data throughout the study. A second trained qualitative researcher coded the data for good-to-excellent percent agreement of 91%.19
Participants included 13 pediatric PTs averaging 21 (range = 3-38) years of clinical experience from a variety of clinical settings: hospital-based outpatient, early intervention, home health care, and school-based. Participants practiced in the following states at the time of the interview: Pennsylvania (2), Maine, Washington, Georgia, California (2), New Mexico, North Carolina, New Jersey (2), Minnesota, and Oklahoma. First professional degrees included certificate/bachelors, masters, and DPT degrees; 10 were APTA members and 8 were APPT members; 4 were American Board of Physical Therapy Specialties-certified pediatric clinical specialists.
Three major themes emerged that reflected the participants' views of the CMT CPGs as well as how participants implemented and used the CPG in clinical practice. The 3 major themes emerged through the axial coding process include:
- Knowledge and evidence for practice
- Education of clinicians about the CMT CPG
- CPG structure and components that influenced practice
Theme 1: Knowledge and Evidence for Practice
The theme of knowledge and evidence for practice emerged from participant interview data, indicating that the CPG provided published evidence to guide the examination, treatment, and discontinuation of infants diagnosed with CMT. Participants reported that the CPG increased use of research evidence to provide the best care for infants and their families, and was generally positively regarded.
Well, I was extremely excited to have all the literature—well, not all the literature, but the majority of the literature... via that clinical practice guideline. I was relieved to be able to say to my families, “This is best practice. You know, there's this practice guideline from the APTA, and this is what the recommendations are.” PT007
Some indicated that evidence-based practice is expected in their practice settings; after the CMT CPG was published, their clinical leadership encouraged and facilitated its use.
I really felt that it was important to make sure that everyone's using the guideline as recommended. I know that most therapists are not APTA members, let alone pediatric section members, so in our facility, we try very hard to make sure our therapists are using recommended practices. So, any time a practice guideline comes out, it's shared. PT005
They are responsible for staying current, and part of our mission is that we're providing evidence-based therapy as much as we can. PT007
Some participants reported they had developed their own treatment strategies or primarily relied on approaches that they felt had promise but were not included in the guideline due to a lack of published evidence. For example, a few participants were frustrated that interventions/techniques such as TMR, myofascial release, positional release, and manual therapies were not included in the guideline.
But I actually ended up going to a Total Motion Release course, which was—I know that it's not recommended because there's no research backing it up, but it kind of gave me a community of other therapists who felt that torticollis isn't just a neck problem; you have to look at the whole body. So, using that kind of approach kind of let me feel comfortable that I could look at the whole body seeing a kid with torticollis. PT005
Despite these concerns, most participants recognized evidence-based CPGs as part of current practice, even though some alternative approaches may not have published evidence.
I think that's where health care is going, and that if we don't do guidelines, then somebody else will. But I think you're going to have a lot of resistance from the current practitioners, because part of the reason people go into PT—and especially peds PT—is for the creativity of it ... PT006
Theme 2: Education of Clinicians
Participants indicated they used the CPG to educate staff and decrease variation in practice. In some settings, practice leadership directed development of educational efforts including in-service presentations to therapists or students, continuing education courses, implementation strategies, and charts and tables with assessment guidelines that clinicians could use in daily practice.
I gave a 3.75-hour continuing education course, which is mostly therapists that I work with in the system, but also was opened up to other therapists from the area who wanted to come ... We really used the guidelines as a basis for the course. PT005
I did an in-service, and just presented the guidelines, presented the research behind it, and we just said, “OK, from here on out, this is what we need to be documenting, and this is what we need to base our clinical decisions on as far as treatment and interventions and duration.” PT009
We did education on it—so, teaching the average clinician what the guideline said, talked about each of the action statements, the recommendations within the documentation changes that were made as a result of them, and then we dialed back and created what we called skills labs for areas that we felt as though were potential knowledge gaps within the guidelines in terms of administration of assessment. PT008
Theme 3: Clinical Practice Guideline Structure and Components That Influenced Practice Applications
Participants described the CMT CPG as organized, objective, and helpful in guiding PTs from examination through discharge planning of infants with CMT. For example, several participants indicated the helpfulness of the CPG CMT classification grades, decision tree, and severity scale for prognosis. Several participants copied and laminated the classification grades and decision trees and used them for reference while treating infants.
... there was a lot of useful information there. It was also classifying the severity of it, or giving a prognosis based on initial findings, all that stuff. So, I really found the practice guidelines had a lot of information that we could use to make our evaluations, assessments, documentation a little bit stronger, especially giving rationale to insurance companies to why you're doing what you're doing, or why you want to keep a child a little bit longer. PT005
We're using the classification grade scale now, so that's new. The muscle function scale we had kind of started to look at, but we hadn't made it a consistent practice across all of our providers, so I feel like we're consistently making that a part of our ongoing assessment. And then our goals—that was one thing that we change; we kind of found that we were all defining the resolution of torticollis just a little bit different [sic] between providers, so we're using the goals that are listed in the APTA as our guide for discharge. PT015
Participants were motivated to change examination processes by including more objective measures or to develop protocols and documentation templates.
What's really changed for me is how I'm assessing children and how I'm looking at them over time, and how I'm taking data on their improvements. It's changed my evaluation and examination procedures quite a bit. PT0014
Well, we weren't really using a document in the beginning, so once the guidelines came out.... We kind of came up with a general evaluation and then said that these were the measurements we were going to take every visit, and then based on those measurements, this is how we're going to do our clinical reasoning, but also take into account other things, like insurance limitations, copays, and then if the family was actually following through with the HEP. PT009
In contrast, some participants were overwhelmed by the extensive nature of the CMT CPG.
There were complaints about, “There's so much information in here,” and that kind of thing, but there were also positives about, “It's nice to have this; it's nice to be able to refer to this while I'm educating my families or being able to incorporate best practice.” PT007
Some participants condensed the information for presentations or usable tools. Strategies included: developing outlines; creating laminated assessment charts; developing screening and documentation templates to identify red flags; and copying the flowcharts and severity grades for easier referencing.
I went and made charts of the grades of severity, the prognosis, so now every one of my clinicians that I work with has that as a chart. PT005
Finally, the CMT CPG influenced how participants interacted with parents in terms of education and facilitating parents' roles in their child's treatment.
When I've talked about severity, I've talked about the guidelines with parents, to make them understand kind of where they're sitting, and I use that as prognosis. You know, I use the severity rating a lot to help parents, because a lot of parents come in so anxious, so I like to say to them, “So here are our difficulties right now, but let me tell you what we have in the positive column right now.” This would be termed a “mild”; we have this guideline, and this is because these findings are termed a mild congenital muscular torticollis, and generally our research is telling us that you caught this early and this will respond well. So I use it that way to prognosticate with parents, and that one case where I wasn't getting a lot of buy-in and we were starting to think about the tot collar, I also used it to say, “There is a guideline, and we're not making the type of progress on the guideline that I would expect to see at this point.” PT014
CPGs can lead to increased consistency of care and reductions in variation.20 The CMT CPG was designed to assist PTs' management of CMT and to “provide a standard of best practice for pediatric PTs.”3 This qualitative study's results support these intentions.
Participant interviews describe practice before and after the 2013 CMT CPG publication. Implementation varied depending on the KT activities used and the presence of a local champion; however, all participants agreed that some aspect of practice changed to align with some portion of the CPG. Overall, participants were positive about the guideline, indicating that it took a holistic approach to provide an organized, objective process to guide care of infants with CMT.
Participants agreed that pre-CMT CPG publication, infant assessment, and examination varied, discharge planning was inconsistent, and determination of CMT resolution varied. Most participants indicated that the CMT CPG examination and discharge planning recommendations were helpful and informative, inspiring them to revise assessment practices and documentation. The CMT severity classification and decision trees were reported to be useful elements, regularly used to guide determination of CMT severity, the episode of care, intervention goal setting, intervention choice, discharge planning, and parent education.
CPG implementation and adherence are challenging. Guidelines may be viewed as categorical, prescriptive, and constraining.21 Professional barriers include lack of awareness, skills, self-capacity, and motivation,22 and difficulty with changing habits of practice.23 However, the majority of study participants viewed the CPG as a helpful tool. While it did little to change intervention choices, it seems to have had a strong effect on examination and discharge practices. Participants noted that the CPG provided helpful information and evidence about interventions and validation of their current approaches. Practice validation increased participants' confidence that they were providing appropriate levels of care by including the recommended examination and intervention components. These findings align with the quantitative survey, which indicated that more than half of respondents were implementing all of the CPG recommendations.14 Specifically, the study found that 91% of PT respondents used passive stretching and 97% provided parent education before publication of the CMT CPG,14 leaving little room for improvement. In contrast, significant increases were noted for assessment strategies, including infant screenings, requesting images, classifying severity, and determining prognosis.14
A few participants expressed frustration that the CPG intervention section contained limited or no information on treatment approaches that they felt improved CMT outcomes but lacked published evidence in support. These individuals indicated that some routinely used interventions were included in a “not recommended” category, and that such a category devalued these approaches due to a lack of research evidence, even though the published CMT CPG does not have a “not recommended” category.
Some evidence suggests that a lack of understanding about CPG development may hinder implementation and these participants' frustrations may be such an example. While the CMT CPG public review draft had “not recommended” language, the final version removed this category. Public feedback appropriately influenced a rewording that provided a process for PTs to document deviations from the CPG recommendations. This reinforces the need for greater education on CPG development processes, including the role of public review and subsequent revision prior to final publication. Evidence-based CPGs are by definition based on systematic reviews of peer-reviewed articles; if no articles exist, the approach is not discussed. This is not a devaluation of missing approaches, but rather should be viewed as a reflection of the state, the evidence, and a need to adhere to international standards for evidence-based CPGs. Promoters of alternative approaches should publish their results for inclusion in future CPG updates.
Most KB activities were aimed at other PTs and occupational therapists within the PTs' own clinics or organizations. There was no mention of sharing the CPG with physicians or other health care providers, though several had such plans. More often, the CPG was used to inform parents about the plan of care. Supplemental tools have subsequently been developed to facilitate CPG sharing with physicians, parents, and other stakeholders, and their effect needs to be studied.
An initial aim of both the quantitative survey14 and this qualitative study was to determine whether APPT resources supporting CPG development are justified. Results of both studies indicate that unwarranted variation in practice can decrease as a result of publishing evidence-based CPGs. For CMT, variations decreased as to what characteristics to assess, how to measure them, and what discharge criteria to use. The consistency and degree with which participants changed some practice aspects to align with CPG recommendations is commendable and not typical of CPG uptake.21
Another study aim was to understand more completely how PTs use the CMT CPG, what makes it useful, and what would improve future CPGs. It is clear that more education is needed on CPG structure, development, how evidence-based CPGs differ from primary research and consensus guidelines, and on strategies that PTs can use to disseminate CPG recommendations. Regardless, the referral process and classification decision tree graphics were widely used by respondents for clinical decision-making and parent education. See Table 2 for facilitators and barriers and Table 3 for a list of ideas that might further facilitate CPG implementation. Information in Tables 2 and 3 emerged during the semistructured interviews with all participants.
Limitations and Future Research
While the interview data provided rich details and descriptions of participants' perceptions that expanded and complemented the quantitative survey results,14 there were several limitations. Since participants self-selected to volunteer for the quantitative study and the qualitative interviews, and many took on KB roles to share the CPG with colleagues, the sample may be positively biased and not represent all pediatric PTs who have read the CMT CPG. Alternatively, some may have participated to express their challenges with the CPG. Second, all interviews were conducted by telephone without the opportunity for direct, in-person interactions. Opportunities to interact with the participants face to face may have added to the richness of their responses and led to more probing questions. The inherent bias within the phenomenological approach used in this article precludes the ability of the researchers to completely set aside their own biases. Finally, the time lapse between the participants' exposure to the CPG and when interviews occurred may have influenced their perceptions.
This qualitative study describes pediatric PTs' perceptions about the usefulness of the 2013 CMT CPG, and implementation facilitators and barriers. The findings may not represent the views of all pediatric PTs who work with infants with CMT, but they do provide rich descriptions of perceptions and experiences of those with CMT CPG familiarity. Results are consistent with a prior quantitative study, justifying the continued development of pediatric PT CPGs and providing direction for KT products and education. Participants' recommendations about the CMT CPG, and CPGs in general, may facilitate future CPG dissemination and implementation.
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