Clinical practice guidelines are an important tool that aims at bridging the gap between best evidence and clinical practice. Although our study highlighted an overall good level of knowledge of the core first-line intervention, adherence to CPGs was low. Many physiotherapists did not advise losing weight, but advised rest, while often including secondary treatments (e.g. manual therapy) supported by low-level evidence.
Most physiotherapists (> 90%) participating in the survey were aware of the importance of therapeutic exercise, education and enhancing patients’ adherence to the treatment, in the caretaking process of people with hip or knee osteoarthritis. These results are in line with the ones reached by other physiotherapists worldwide [16,17,18,19]. Despite this, 56% of the physiotherapists participating in the survey considered it essential to include manual therapy (e.g. manual mobilisation, massage) in the treatment. Current evidence shows that when manual therapy is compared with exercise therapy alone, it provides only short term benefits in reducing pain, improving function, and physical performance [35]. However, this conclusion on manual therapy is gathered from low-quality evidence, and therefore CPGs rated it as lower quality when compared to the evidence supporting exercise, which makes manual therapy only a conditional treatment [3, 4]. In line with this, prioritising manual therapy in patients’ management may reduce the time allocated to exercise. However, we did not ask the participants whether they considered manual therapy more effective than exercise, or which treatment they would prioritise, thus leaving uncertainties regarding the clinical impact of this finding. Future studies, with a mixed-method design are needed to better understand how different treatments are weighed by clinicians in the management of people with osteoarthritis.
Furthermore, we found an insufficient level of knowledge in three distinct areas: a) the criteria for the clinical diagnosis of osteoarthritis, b) the role of other non-surgical interventions that could enhance therapeutic exercise benefits (e.g. topical anti-inflammatory drugs and TENS), c) the number of sessions needed to ensure an optimal outcome. As far as the clinical diagnosis and drug prescription are concerned, this lack of knowledge might be due to the fact that, in Italy, physiotherapists are not allowed to perform clinical diagnosis and prescribe drugs. However, they are often the first health care professionals that people with osteoarthritis refer to. Thus, they should be aware of the recommended pharmacological management to facilitate the integration of drug therapy with physiotherapy and the proper clinical diagnostic criteria in order to refer patients to relevant healthcare professionals, when necessary.
Our study showed that only 10% of the respondents considered being 45 years old or older, having pain, and joint stiffness for less than 30 min in the morning, sufficient criteria for the diagnosis of osteoarthritis, as recommended by the NICE CPGs. These seemed to be the most appropriate criteria to ensure that even younger patients with osteoarthritis woul receive appropriate care in line with CPGs [36]. The lack of agreement regarding clinical diagnostic criteria may partially explain the relatively high percentage (> 40%) of physiotherapists who considered radiographic findings necessary to express a clinical diagnosis of osteoarthritis. This data is consistent with the findings of a similar survey conducted by Ayanniyi et al. [19]. Radiographic findings should be taken into account only when other diseases are the suspected cause of the symptoms (e.g. infection, cancer, rheumatoid arthritis) or when surgical intervention is planned [4]. These recommendations are based on evidence that shows a weak association between the severity of radiographic findings and pain and disability levels [37, 38]. Furthermore, basing clinical decisions on imaging fosters the perception of osteoarthritis as a wear-and-tear disease which may, in turn, induce fear-avoidance behaviours [38, 39]. However, since physiotherapists in Italy are unable to prescribe radiographic investigations, the impact of this finding on the clinical management of the patients is uncertain.
The second section of the survey showed mismatching between the knowledge of CPGs and their application in clinical practice. Although most physiotherapists showed adequate knowledge of first-line interventions, only a minority (25%) wholly adhered to CPGs, whereas more than 50% included at least one non-recommended strategy or treatment.
One of the challenges in the implementation of CPGs seems to be the fact that health care professionals view osteoarthritis as a “non-serious” disease. This may depend on inadequate preparation at undergraduate level [11, 20, 40]. These erroneous beliefs might be carried on in post-graduate degrees, since the percentage of “Non-Delivering” did not change throughout the different levels of academic degrees achieved (> 50%). Moreover, in Italy, there are no MSc degrees available, specifically on musculoskeletal and rheumatic conditions, and PhD curricula are very specific, therefore, if not focussed on osteoarthritis, they cannot bridge the pre-existingevidence-to-practice gap. In addition, implementing osteoarthritis CPGs in the complex setting of clinical care can be challenging [20] since clinicians have to face several barriers among which patients’ preferences, resource availability, discrepancies between CPGs, lack of English knowledge and limited access to information [22].
Although the patient in the clinical vignette was overweight and presented with moderate symptoms, the interviewed physiotherapists often excluded advising weight loss, whilst rest was often considered. In fact, recommending weight loss may be considered by some physiotherapists as beyond their clinical scope [41]. This data is in line with other studies showing that both Australian and British physiotherapists recommended muscle strengthening exercises, but seemed less confident in prescribing aerobic exercise and recommending weight loss [18, 41]. Providing physiotherapists with additional specific training aimed at dealing with overweight patients may enhance the patients’ outcomes and increase the overall level of adherence to CPGs.
The interpretation of the relatively high inclusion of rest as well as the load reduction in the treatment is difficult to explain, especially in light of the good level of knowledge shown in the first part of the questionnaire. However, the CPGs available do not specify how to adapt the therapeutic exercise in those cases with severe osteoarthritis symptoms, where pain can be easily triggered by joint movement or weight-bearing activities. This is also highlighted by the fact that about 50% of the physiotherapists in the “Non-Delivering” group declared to have read at least one osteoarthritis CPG. Thus, in light of these results, it can be hypothesised that physiotherapists may feel unsure and unprepared when having to deal with this pain condition [42]. Discrepancies between CPGs knowledge and application may also depend on factors that are external to the physiotherapist, and they may vary by country. Regarding osteoarthritis CPGs, this is the first study that pointed towards this discrepancy, starting from several CPGs and by considering a plethora of treatments.
Beneath the differences between the three groups, a transversal trait was found regarding the application of manual therapy which was delivered by more than 70% of the sample. From a cultural perspective, manual therapy is a core competence of physiotherapy, which set the basis of this professional figure in the past, and patients often expect this type of treatments from physiotherapists [40]. Meeting patients’ expectations is thought to foster a positive clinician-patient relationship while enhancing the treatment outcome by inducing analgesia, regulating patients’ emotions, and reorganising the body’s mental representations [43, 44]. Therefore, this data may reflect the contrast between treatments recommendations and patients’ expectations, which can be itself the results of a specific cultural belief that needs to be investigated.
Some limitations of this study need to be discussed. Firstly, our sample was mainly based on physiotherapists who completed a post-graduate degree, therefore our results might overestimate the real level of knowledge of and adherence to osteoarthritis CPGs. Secondly, we did not investigate the participants’ clinical practice setting (e.g. private practice, public care etc.) which might have had an impact on the participants’ level of adherence to CPGs.
Our findings revealed that Italian physiotherapists are aware of the core treatments for patients with osteoarthritis. However, they showed a low level of knowledge of the clinical diagnostic criteria and of the usefulness of other non-surgical treatments that can support first-line intervention (e.g. TENS and non-steroidalanti-inflammatory medications). Moreover, an adequate level of adherence is yet to be reached. These results identify an evidence-to-practice gap which may lead to non evidence-based practice behaviours for the management of the patients with hip and knee osteoarthritis.
Finding new strategies to bridge the gap between evidence and clinical practice appears to be necessary, therefore providing physiotherapists with CPGs in their native language and fostering their use through university programmes could be one of the possible solutions proposed. Moreover, the use of recognised manuals aimed at developing CPGs is advocated. These should ascertain that all search stages are documented for transparency and reproducibility and that the most important elements for a real practical implementation, such as algorithms for clinical decision-making for complicated cases, and patients’ inclusion-exclusion criteria, are included [45].
Finally, the professional image of physiotherapists within society should be reconceptualised. In particular, we should continue to foster a new vision of physiotherapists, as no longer anchored to treatments that are mainly based on physical and manual therapy, but as figures whose treatment paradigm focusses on improving the patient’s individual functioning by specific treatment strategies, such as exercise and education, that take into account scientific evidence conveyed into specific contexts.
