Journal of Rehabilitation Medicine 51-11 | Page 25

Implementation tools for rehabilitation guidelines
an advantage, and provided the opportunity to get to
know each other. In addition, the interactive part of
sessions was acknowledged. Interventions may have
a different effect on different professionals. There is a
lack of evidence on whether any single active know-
ledge transfer intervention improves the knowledge
of physiotherapists, but there is strong evidence to
suggest that an active multi-component knowledge
transfer intervention leads physiotherapists to change
their practice behaviour, compared with passive dis-
semination (14).
The use of opinion leaders alone or in combination
with other interventions may successfully promote evi-
dence-based practice, but effectiveness varies between
studies (15). These results are based on heterogeneous
studies that differ in terms of the type of intervention
included, the setting and outcomes measured. In most
of the studies the role of the opinion leader was not
clearly described, and it is therefore not possible to
determine the best way to optimize the effectiveness
of opinion leaders.
Commitment from management is essential for suc-
cessful implementation (16, 17). One of the reasons for
piloting this project in Päijät-Häme was, that primary
and specialized healthcare, including rehabilitation,
were parts of the same organization, so it was easy to
obtain commitment to the project from administration
and management. However, the fusion of 3 different
primary healthcare organizations and specialized healt-
hcare into a single large organization was carried out
in 2017. This resulted in difficulties in keeping to the
planned timetable. In addition, a new electronic health
record system caused several problems in clinical work.
Professionals (both physiotherapists and physicians)
had multiple new factors to adapt to. This may have
disadvantaged the implementation of the CC Guideline
on shoulder tendon disorders. On the other hand, the
new organization enhanced the possibilities of uniting
care pathways, as all physiotherapists were under the
same management. Bekkering et al. found, in 2003
in a study of physiotherapy guidelines on low back
pain, that the most important discrepancies between
current practice and recommendations of guidelines
were problems in co-operation between referring phy-
sician and physiotherapists, and knowledge or skills
of the physiotherapists. In order to create permanent
change in how shoulder tendon disorders are rehabi-
litated, more extensive education of physiotherapists
on musculoskeletal diseases may be needed. This was
started in 2018 and continued up to the Spring of 2019.
In addition to good co-operation with physicians, who
should refer patients to physiotherapy when needed,
a seamless shoulder tendon disorder care pathway
requires knowledge and commitment from other pro-
839
fessionals, such as nurses who conduct the triage of
patients when patients contact healthcare.
The current study has several limitations. It is a case
study, a description of our project. The implementa-
tion of rehabilitation of shoulder tendon problems in
Päijät-Häme district is continuing and the final results
are not yet available.
Implementation of rehabilitation has distinctive
features. A multidisciplinary team includes several
professionals and the process may take place at one
or multiple levels, as well as in different organiza-
tions. Rehabilitation is often a long process, but it is
dependent on the right timing, good collaboration,
continuing assessment and evaluation, clear goals
and commitment from the rehabilitee. It is essential
to understand that implementation of rehabilitation is
not easy, and requires enough time. There is limited
evidence to recommend one knowledge translation
strategy over another among allied health professions
(19), working together for a common goal. However,
it is evident that RCTs will never be able to produce
evidence of effectiveness of implementation for dif-
ferent rehabilitation contexts. Therefore observational
effectiveness data from clinical registers, including
electronic health records, will also be needed (20,
21). High competence of staff and the use of the best
available scientific evidence will probably lead to the
best implementation results in a particular clinical and
organizational context.
ACKNOWLEDGEMENT
This study was funded by the Social Insurance Institute of
Finland.
The authors have no conflicts of interest to declare.
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