The transmission of evidence contained in clinical practice guidelines through curriculum, student knowledge, and physiotherapy practice to the experience of the final consumer (the patient) using lateral ankle ligament sprains as the case study.

Abstract

Background: The theory and practice of knowledge translation underpins evidence-based practice (EBP). There is significant concern that translation of research-based evidence into clinical practice is slow and incomplete. This thesis investigates evidence for this concern in the case of a common injury, (which is managed by a variety of clinicians) the acute lateral ankle ligament sprain (LALS), and a tool frequently used to enhance EBP, the clinical practice guideline (CPG). The aim of this research is to sequentially investigate the pathway for transmission of evidence contained in CPGs through curriculum, student knowledge, and physiotherapy practice to the experience of the final consumer (the patient) using LALS as the case study. Methods: Initially, a systematic review of LALS CPGs was conducted. CPGs were critically appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument online version, My AGREE PLUS. A qualitative study of educators involved in teaching LALS curricula for the Australasian College of Sports and Exercise Physicians, St John Ambulance first aid, pharmacy, nursing, and physiotherapy was performed using thematic analysis. Three online surveys completed the five studies. A survey of students to determine what they learn about LALS, a survey of clinicians to investigate their clinical practice in relation to LALS and, a survey of patients who have had a LALS to determine what treatment they received. The components of management found in the studies were compared with the most recent 2018 CPG for LALS. Results: This study found that generally, CPGs for physiotherapists (USA and Netherlands), athletic trainers (USA), physicians (Netherlands and USA) and nurses (USA, Canada, and Australia) are of poor quality. Educators, physiotherapy students, and physiotherapists prefer textbooks to CPGs to inform EBP. Across the five groups investigated, there was no common curriculum. As they practiced only triage management, the nurses, pharmacists and first aid trainers had little concept of the importance of severity of injury. In contrast, the physician and physiotherapy educators establish severity to guide management. The physicians and physiotherapists derive their judgement from their own research and reflective EBP. Australian physiotherapists and physiotherapy students are generally following the recommendations from the 2018 LALS CPG; specifically, medication advice, functional support, optimal loading, rest, ice, compression, elevation, exercises, and manual therapy and are not using electrophysical agents for LALS. Physiotherapists and physiotherapy students may be compromising safety by advising nonsteroidal anti-inflammatory drugs (NSAIDs), despite there being no curriculum that teaches them about drug interactions and the effects of these medications in delayed healing. This may be a scope of practice problem and requires further research. Four hundred and thirty-two patients with LALS completed the survey. LALS patients reported that they received recommendations from their treating physiotherapist; specifically, ice, compression, ultrasound, exercises, protection (crutches) and manual therapy. Conclusions LALS CPGs are of poor quality. Generally educators, physiotherapy students and physiotherapists do not use them to inform EBP and prefer text books. Possibly, LALS patients may not be receiving optimal EBP. Further research is needed to determine why CPGs are not used and which interventions may be useful in enhancement of knowledge transfer thereby improving patient outcomes.