Case Report

Implementation of Measurement
Instruments in Physical Therapist
Practice: Development of a
Tailored Strategy
J.G. Anita Stevens, Anna J.M.H. Beurskens

Background and Purpose. The use of measurement instruments has become

a major issue in physical therapy, but their use in daily practice is infrequent. The
aims of this case report were to develop and evaluate a plan for the systematic
implementation of 2 measurement instruments frequently recommended in Dutch
physical therapy clinical guidelines: the Patient-Specific Complaints instrument and
the Six-Minute Walk Test.
Case Description. A systematic implementation plan was used, starting with a
problem analysis of aspects of physical therapist practice. A literary search, structured
interviews, and sounding board meetings were used to identify barriers and facilitators. Based on these factors, various strategies were developed through the use of a
planning model for the process of change.
Outcomes. Barriers and facilitators were revealed in various domains: physical
therapists competence and attitude (knowledge and resistance to change), organization (policy), patients (different expectations), and measurement instruments (feasibility). The strategies developed were adjustment of the measurement instruments,
a self-analysis list, and an education module. Pilot testing and evaluation of the
implementation plan were undertaken. The strategies developed were applicable to
physical therapist practice. Self-analysis, education, and attention to the practice
organization made the physical therapists aware of their actual behavior, increased
their knowledge, and improved their attitudes toward and their use of measurement
instruments.

J.G.A. Stevens, PT, MSc, is Researcher and Teacher, Center of

Research Autonomy and Participation of People With Chronic Illnesses, Department of Physiotherapy, Zuyd University, Nieuw
Eyckholt 300, PO Box 550, 6400
AN Heerlen, the Netherlands. Address all correspondence to Ms
Stevens at: [email protected].
A.J.M.H. Beurskens, PT, PhD, is Associate Professor, Center of Research Autonomy and Participation of People With Chronic
Illnesses, Department of Physiotherapy, Zuyd University.
[Stevens JGA, Beurskens AJMH.
Implementation of measurement
instruments in physical therapist
practice: development of a tailored strategy. Phys Ther. 2010;
90:953961.]
2010 American Physical Therapy
Association

Discussion. The use of a planning model made it possible to tailor multifaceted

strategies toward various domains and phases of behavioral change. The strategies
will be further developed in programs of the Royal Dutch Society for Physical
Therapy. Future studies should examine the use of measurement instruments as an
integrated part of the process of clinical reasoning. The focus of future studies should
be directed not only toward physical therapists but also toward the practice organization and professional associations.

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Implementation of Measurement Instruments

onitoring the health status

of patients through the use
of outcome measures is considered to be an aspect of good clinical practice in physical therapy.13
The clinical guidelines of the Royal
Dutch Society for Physical Therapy
recommend the use of measurement
instruments. Until now, this recommendation has been implemented in
a passive way by mailing the clinical
practice guidelines containing the
measurement instruments. Despite
the overall positive attitude of physical therapists, the daily use of outcome measures in physical therapist
practice is remarkably low.2,4 8
In Europe and Australia, implementation is a common term for what in
the United States is called knowledge translation or exchange. In this
article, the term implementation,
which means a systematic process
in which innovations or changes of
proven value become structurally
embedded in professional practice,
was used. It is well known that passive implementation strategies are
not effective.9,10 Systematic reviews
of the effectiveness of implementation interventions have shown that
strategies should be targeted toward
specific barriers to and facilitators of
change that have been assessed in a
thorough problem analysis of the target group and setting.9,1118 Although
education is an important strategy,
implementation should not be restricted to educational interventions
for individual health professionals
only. Factors concerning practice
policy and organization, patients,

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and the measurement instruments

themselves also are important.4,12
The Dutch Scientific College of Physiotherapy of the Royal Dutch Society
for Physical Therapy has made a systematic approach to the implementation of outcome measures in daily
practice a focal point of its policy.
The aims of this case report were to
develop and evaluate a systematic implementation plan for the use of 2
measurement instruments frequently
recommended in Dutch physical
therapy clinical guidelines: the PatientSpecific Complaints (PSC) instrument,19 which is comparable to the
Pain-Specific Functional Scale,20 and
the Six-Minute Walk Test (6MWT).21
To meet our aims, we sought answers
to 2 questions:
1. Which barriers and facilitators
contribute to the use of the PSC
and 6MWT in physical therapist
practice?
2. Which implementation strategies
can be tailored to these barriers
and facilitators and applied to
physical therapist practice?

Target Setting
The implementation plan was aimed
at physical therapists in private practice in the community. This group is
the largest group of physical therapists in the Netherlands; they are easily accessible and are not restricted
by complicated and formal institutional rules. It also appears that these
physical therapists use fewer measurement instruments than their colleagues in hospitals and other
institutions.7

Development and
Application of the Process
As a guideline for a systematic approach, the implementation model
of Grol et al10 was used. The 5 steps
in this model and the methods used
in this case report are shown in the
Figure.
Number 6

Step 1: Proposal for

Improvement
We focused on the implementation
of 2 easily applicable measurement
instruments that are frequently recommended in Dutch physical therapy guidelines. The first instrument
was the PSC, a Dutch instrument that
is comparable to the Pain-Specific
Functional Scale.19,20 In both instruments, patients must list 3 activities
and score them. Differences are the
scoring method (visual analog scale
versus numerical rating scale), the
time frame on which the score is
based (1 week versus 1 day), and the
availability of a sample activity list in
the PSC to help patients identify
their main complaint. The second instrument was the 6MWT, which is
used to assess the aerobic exercise
capacity of a patient by measuring
the walking track length in 6
minutes.21
Step 2: Problem Analysis
To obtain a complete and valid overview of relevant barriers and facilitators, we used various methods to collect information. First, a literature
search of the PubMed and Cochrane
databases was carried out to identify
studies about barriers and facilitators
in the use of measurement instruments and clinical guidelines. From
this information a topic list was formulated (the list is available on request from the authors). Second,
physical therapists in several private
practices were interviewed. We
searched for a wide variety in terms
of expertise and number of employees and considered the use of clinimetrics (purposive sampling).
The
semistructured
interviews
(45 60 minutes) were digitally audiotaped, summarized, and member
checked by the physical therapists.
The interviews started with general
inquiries on the following themes:
information about the practice, patient categories, and measurement
instruments used. Thereafter, open
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Figure.
Implementation model of Grol et al10 and the methods used in this case report. KNGFKoninklijk Nederland Genootschap voor
Fysiotherapie (Royal Dutch Society for Physical Therapy).

questions were asked about perceived barriers and facilitators in the

use of measurement instruments in
daily practice. At the end of each
interview, the topic list was presented to the interviewees, and additional relevant items could be indicated. The barriers and facilitators
identified were ordered in various
domains: the physical therapist, the
organization, patients, and the measurement instruments themselves.
The number of interviews was estimated at between 15 and 20, and the
interviews were stopped when a saturation of data was reached.22
Step 3: Development of
Implementation Strategies
The information from step 2 guided
the selection of both the type and
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the specific content of the implementation strategies developed; a

planning model for the process of
change was used.10,16 In addition, a
literature survey on how to select
and tailor strategies to the information from the problem analysis was
performed. Until now, not many implementation studies have been
based on a problem analysis. Therefore, studies about the effect of implementation on general health were
used. The results from both the literature search and the interviews were
discussed with the project group
(experts in the field of guideline implementation) and a sounding board
(the interviewed physical therapists).
Subsequently, implementation strategies were selected and developed.

Steps 4 and 5: Testing and

Evaluation of the
Implementation Plan
In the literature, recommendations
were made about testing interventions initially in small groups, in
which active education and professional support seemed to be effective in improving physical therapists
attitudes and adherence.4,23,24 Therefore, pilot testing of the implementation plan was undertaken with 2
groups of physical therapists from 4
physical therapist practices. The
evaluation focused on feasibility and
readjustment of the strategies developed. The results of the first pilot
program were used to make adjustments in the second pilot program. It
was not our intention to evaluate the
effectiveness of the strategies, but the

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Table 1.
Summary of Barriers to and Facilitators of the Use of Measurement Instruments Reported in the Interviews
Domain

Barriers

Facilitators

Physical therapist
Competence

Attitude

Lack of knowledge, education, routine, and

experience

Sufficient knowledge and education

Diagnosis focused on ICFa domain: body

functions

Measurement instruments are already used in

daily routine

Resistance to change

Readiness to change

No conviction of additional value on the plan

of care

Positive attitude toward the use of

measurement instruments

Being overloaded with information

Conviction of contribution to quality of physical

therapy care

Headstrong in own working method

Defining therapy outcome otherwise
Lack of confidence in own skills
Organization
Practice

Takes too much time

Patient computer system

No financial compensation

Colleagues

Patient

Absence of practice policy

Presence of practice policy

Lack of discussions, meetings, and feedback

from colleagues

Regular meetings and feedback from colleagues

No adherence to the agreements made

Innovative team and cooperative colleagues

Different expectations and preferences: needs

no measurement instruments, wants only
therapy, and puts pressure on therapist

Patient wants objectives to evaluate outcome of

therapy

Linguistic problems and lack of understanding

Measurement instrument

Poor availability

Good availability

Difficult choice
Feasibility: extensive, difficult interpretation,
and unclear instructions
a

ICFInternational Classification of Functioning, Disability and Health.

therapists were asked whether their

knowledge, attitudes, and use of measurement instruments had changed.

Outcome
Step 2: Problem Analysis
All of the physical therapists who
were invited for the interviews attended the interviews. After 11 interviews with 13 physical therapists, a
saturation of data was reached, and
the interviewing was stopped. The
physical therapists, whose ages
ranged from 22 to 54 years (median43), were interviewed in the
southern region of the Netherlands.
Their working experience varied
from 2 to 30 years (median21), and
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the number of colleagues in the practice varied from 1 to 11 (median6).

The interviewed physical therapists
specialized in different areas. The report of the interview was sent to
each therapist for member checking, and the reports were all in
agreement.
The 13 therapists indicated that they
were familiar with the PSC and
6MWT, but less than half of them
indicated that they used these measures. Almost all interviewed physical therapists were motivated to use
the instruments and were convinced
of the additional value. Barriers and

Number 6

facilitators reported in the interviews are summarized in Table 1.

In the sounding board, discussions
about the identified barriers and facilitators took place. During these
discussions, some physical therapists
were very honest and admitted that
they did not use the measurement
instruments as often as they claimed.
Because of the gap between claiming
to use and actually using the instruments, the physical therapists made
a commitment to use the PSC and
6MWT for 1 month and then discuss
their experiences in a subsequent
meeting. In the second meeting,
they indicated that the instruments
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Table 2.
Planning Model for the Process of Changea
Domain

Phase of Behavioral Change and

Implementation Goals

Implementation Strategies

Physical therapist
Competence

Orientation:
Awareness, interest, and involvement
Insight:
Increasing knowledge and understanding

Attitude

Insight:
Insight into own working method
Acceptance:
Positive attitude and motivation
Intention and decision to change
Change:
Confirmation of the benefit

Organization

Education:
Homework tasks
Practical training and role playing
Self-analysis list:
Increasing awareness, self-reflection, and insight
into own working method
Education:
Discussions about resistance, advantage, and
added value of clinimetrics
Coaching style, own responsibility, individual
learning goals, and interactions with colleagues

Insight:
Insight into own working method

Self-analysis list:
Insight into practice policy

Acceptance:
Positive attitude and motivation
Intention and decision to change

Education:
Discussions and agreements with colleagues,
development of practice policy, and formulation
of learning and practice goals

Change:
Implementation in daily practice
Preservation of change:
Integration in daily routines
Anchoring in the organization
Measurement instrument

KNGF:
Dissemination by publications
Offering education possibilities

Insight:
Increasing knowledge and understanding
Acceptance:
Positive attitude and motivation
Change:
Implementation in daily practice

KNGF:
Embedding in future electronic patient dossier

Adjustments in PSC and 6MWT:

Increasing feasibility and simplifying instructions
Extending PSC activity lists
Education:
Practical training and homework tasks
Formulation of practice policy

Preservation of change:
Integration in daily routines
Anchoring in the organization
a

The developed implementation strategies are based on various domains and phases of behavioral change, each with specific implementation goals.10,16
KNGFKoninklijk Nederland Genootschap voor Fysiotherapie (Royal Dutch Society for Physical Therapy), PSCPatient-Specific Complaints instrument,
6MWTSix-Minute Walk Test.

were useful in daily practice. For

example, 1 therapist previously
thought that he could not use the
instruments because his patients
only wanted therapy and no measurements; however, the patients appreciated the use of the measurement instruments and asked him to
use them regularly to monitor their
progress. These experiences led to
the identification of new barriers and
facilitators, which made the implementation a cyclic process.

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Step 3: Development of
Implementation Strategies
There is no consensus about the
best general implementation strategy.9,17,25,26 It is clear, however, that
active, multifaceted strategies tailored to a problem analysis are the
most effective.13,16,18,24 In addition,
different models of behavioral
change are recommended, but there
is no agreement about which model
should be used.10,12,14 16 Grol and
colleagues10,16 described a planning
model for the process of change in

which different theories of behavioral change are integrated to induce

changes in professional behavior. Table 2 shows various domains, phases
of behavioral change (orientation, insight, acceptance, change, and preservation of change), and specific implementation goals. On the basis of
this information, we tailored the outcome of the problem analysis to the
appropriate implementation strategies. The definitive strategies, resulting from the project group and
sounding board discussions, were

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critically evaluated and readjusted
several times. An overview of these
strategies is shown in Table 2.
To improve the feasibility of using
the PSC and 6MWT, we made several
adjustments:
The instructions were slightly adjusted to improve interpretation.
The original PSC was developed for
patients with low back pain, and
the sample activity list contained
activities with which only those patients would have difficulties. A list
of sample activities was made for
patients with other disorders.
The visual analog scale of the original PSC was replaced with an 11point numerical rating scale. Practical use by the physical therapists
and information from the literature
revealed that this scoring method
was more feasible for some (older)
patients.27 Changing the visual analog scale to a numerical rating scale
did not change the principle of the
test; the scoring methods are highly
correlated.28 A numerical rating
scale also is used in the PainSpecific Functional Scale.20

A self-analysis list was developed to

provide insight into and selfawareness of barriers and phases of
behavioral change. This list was
based on a questionnaire on the selfreported use of outcome measures in
physical therapy and was obtained,
along with other items, from the
problem analysis.7 It contained 3 sections with questions concerning the
phases of change for the physical
therapist, the organization and its
policy, and an inventory of the actual
use of measurement instruments in
daily practice. A few examples of
questions from sections 1 and 2,
rated on a Likert scale, are shown in
the Appendix. The self-analysis list
was pretested by the physical therapists of the sounding board and was
used as a guide for the education
module.
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An education module focusing on

the physical therapist and the practice organization was developed.
The aims of the education module
were to provide insight into the use
of measurement instruments and
phases of behavioral change, to optimize the use of the PSC and 6MWT
in the process of clinical reasoning,
and to fit the use of the PSC and
6MWT to practice policy. The education module consisted of 3 sessions of 2.5 hours. The first 2 sessions were planned to take place
within 1 month, and the last session
was planned to take place after 2
months. The program was not completely determined in advance but
was tailored to the professionals. Active teaching methods, such as discussion and role playing, were used
in a coaching style instead of a teaching style. We expected the attendees
to show an active learning attitude,
initiative, and responsibility.
Steps 4 and 5: Testing and
Evaluation of the
Implementation Plan
Pilot testing and evaluation of the
implementation plan were undertaken. The adjusted instruments, the
self-analysis list, and the education
program were tested with 2 groups
of physical therapists from 4 private
practices in the community. The first
group consisted of colleagues from
the same practice (n11); the second group consisted of colleagues
from 3 different practices (n10).
After each session, the process and
the program were evaluated orally;
after the third session, an evaluation
form was filled out.
The strategies developed could be
applied to physical therapist practice. The evaluation of the adjusted
measurement instruments was positive. The adjusted instructions were
easier to interpret, and the additional
activity lists were useful for determining treatment goals. The selfanalysis list appeared to be valuable

Number 6

because physical therapists became

aware of their own barriers in daily
practice. The link with their phases
of behavioral change was revealing
and stimulated them to use the instruments in daily practice. Working
with heterogeneous groups made it
difficult to accommodate the individual barriers of the physical therapists
but, on the other hand, they could
learn from one another.
After the evaluation of the first pilot
education program, the second program was adjusted at several points.
The program became more fixed in
advance. In the first session, attendees began to devise a practice policy.
Individual learning goals were discussed, and homework tasks were
checked. More time was allocated
for practical rehearsal of the tests.
The outline of the final education
program is shown in Table 3.
All of the physical therapists appreciated the active teaching methods,
discussions, and role playing during
training. Developing a practice policy was an issue of major importance, especially for the preservation
of change. During busy daily practice, the therapists never took the
time to discuss these matters.
The physical therapists indicated
that they were interested in practicing with other instruments besides
the PSC and 6MWT and would appreciate sets of short, feasible, and
methodologically sound instruments. At the last meeting, most
physical therapists indicated that
they actually used both instruments.

Discussion
In this report, we have shown that it
is possible to develop and evaluate a
systematic implementation plan for
the use of 2 measurement instruments. A thorough analysis was used
to identify practical barriers and facilitators. In the interviews and discussions, we could continue asking
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Table 3.
Outline of the Education Programa
Day
1

Main Issues

Goals

Working Methods

Introduction

Explicating expectations of therapists:

active learning attitude, responsibility,
initiative, active teaching methods, and
coaching style

Plenary

Self-analysis list

Insight into own working method and

phase of behavior

Individual

Individual learning goals and practice

policy

Responsibility for own learning process in

professional and practice organization
domains

Working group of 3 or 4 people

Advantages and disadvantages of

PSC and 6MWT

Insight and acceptance

Plenary

Training on PSC: clarification of the

patients main complaint

Increasing knowledge and practical skills

Working group of 3 or 4 people

Homework on PSC

Using PSC in practice for the next month

Plenary

Evaluation of the session

Reflection

Plenary

Results of self-analysis list

Insight on working method and phase of

behavior

Presentation

Evaluation of homework task

Insight and acceptance

Plenary

Training on 6MWT: standardization

and interpretation

Knowledge and practical skills

Working group of 3 or 4 people

Use of measurement instruments in

practice policy

Integration in the practice organization to

obtain (or preserve) change

Working group of 3 of 4 people

Homework on 6MWT

Using 6MWT in practice for the next 2 mo

Plenary

Evaluation of the session

Reflection

Plenary

Evaluation of homework task

Insight and acceptance

Plenary

Theory of clinimetrics

Insight and knowledge

Lecture

Step-by-step plan to search for other

measurement instruments

Transfer to the use of other instruments

Lecture

Evaluation of practice policy

Integration in the practice organization to

obtain (preserve) change

Working group of 3 or 4 people

Integration of instruments in clinical

reasoning and daily practice

Preservation of behavioral change

Plenary

Written and oral evaluations of total

education module

Reflection

Plenary and individual

PSCPatient-Specific Complaints instrument, 6MWTSix-Minute Walk Test.

about underlying thoughts and possible solutions and strategies. In this

way, the problem analysis produced
a larger amount of information than
earlier reports, in which only written
inquiries were used.4 8,29 31 The revealed factors matched the barriers
and facilitators described in the
literature.4,6 8,29,30,32
Many studies2,4 8,14,29 32 have focused on identifying the extent of
use of measurement instruments as
well as factors that affect that use.
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We took the additional steps of developing various strategies based on

these factors and evaluating their applicability in a pilot program in several physical therapist practices. The
involvement of a sounding board
during the development phase guaranteed interest in and acceptance of
the implementation strategies by the
target group.12,14,15
Starting education with self-analysis
provides therapists with the opportunity to formulate their own learn-

ing goals, and trainers can tailor strategies to the professionals as well as
the organization. This approach
has been recommended in other
studies.13,18
Using the planning model of Grol
and colleagues10,16 for the process of
change, we were able to tailor multifaceted strategies to various barriers and phases of behavioral change.
In this way, a change in behavior was
initiated. The physical therapists indicated that they used the measure-

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ment instruments more often, and
they were convinced that doing so
contributed to the process of clinical reasoning. For the preservation
of change, more time is needed.
It is evident that quality improvements should start with small, simple
projects.23 This case report involved
a small group of selected physical
therapists in the southern region of
the Netherlands; therefore, generalization of the results is unjustifiable.
Further studies and additional designs with other measurement instruments are needed to evaluate the
effects of implementation strategies.
Our recommendations for the policy
of the Royal Dutch Society for Physical Therapy are as follows. First, information about measurement instruments should be disseminated
through publication in professional
journals, newsletters, and guidelines.
This strategy represents the orientation phase, in which awareness of
the existence and use of measurement instruments is an important issue. The information should not be
restricted to the measurement instruments alone but also should focus on
how to use and interpret the results
of the instruments in daily practice.
Second, educational opportunities
should be offered for physical therapists to increase their knowledge
and skills regarding the use of these
and other measurement instruments
in the process of clinical reasoning,
with attention to behavioral change.
This education should be included
in mainstream physical therapist
schools. Third, the measurement instruments should be embedded in
the future electronic patient dossier.
The actual use of measurement instruments should not be the only objective in implementation programs.
The integration of the instruments in
the process of clinical reasoning is of
major importance. Therefore, future
programs should focus not only on
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the physical therapist but also on the

practice organization and professional associations.
Both authors provided concept/idea/project
design, writing, and project management.
Ms Stevens provided data collection and
analysis. Dr Beurskens provided fund procurement and facilities/equipment.
The authors are grateful to members of
the project group (Dr Rob de Bie, Dr Erik
Hendriks, Mr Pieter Wolters, Dr Raymond
Swinkels, Mrs Anja van den Donk, and Mr
John Meijers) and the sounding board (the
physical therapists interviewed).
This work was funded by the Dutch Scientific
College Physiotherapy of the Royal Dutch
Society for Physical Therapy (TD/2008/01).
This work, in part, was presented at the Annual Congress of the Royal Dutch Society for
Physical Therapy; November 9, 2007; Amsterdam, the Netherlands.
This article was received March 30, 2009, and
was accepted February 24, 2010.
DOI: 10.2522/ptj.20090105

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26 Grimshaw JM, Thomas RE, MacLennan G,

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Appendix.
Examples of Questions in the Self-Analysis Lista

Questions

Fully
Disagree

Disagree

Neither
Agree nor
Disagree

Agree

Fully
Agree

Section 1: questions about yourself

I am able to interpret the outcome of measurement
instruments in the right way
I think it is important to document patient data in
an objective way
I think that the use of measurement instruments
does not take too much of my time
The use of measurement instruments is a fixed part
of my methodical approach
Section 2: questions about policy in your practice
In my practice, enough measurement instruments
are available
My supervisor supports employees in using
measurement instruments
The colleagues in my practice use measurement
instruments
a

The complete list is available on request from the authors.

June 2010

Volume 90

Number 6

Physical Therapy f

961

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.