Current use of patient-reported outcome measures by musculoskeletal physiotherapists in Portugal

Abstract

BACKGROUND:

Musculoskeletal conditions are the leading cause of disability, requiring continuous outcome measurement, including the utilization of patient-reported outcome measures (PROMs).

OBJECTIVE:

The aims of the study were a) to characterize the use PROMs by Portuguese physiotherapists in patients with musculoskeletal conditions; b) to analyze the associated factors of their use and; c) to identify the barriers and facilitators to their implementation.

METHODS:

A cross-sectional online survey was carried out with musculoskeletal physiotherapists working in Portugal. Closed questions were used to describe the use of PROMs. The factors associated with the non-use of PROMs were analysed through logistic regression models ( $p=$ 0.05). Barriers and facilitators were assessed through open questions and analyzed using thematic analysis.

RESULTS:

One hundred and fifty-six physiotherapists answered the online survey. Most physiotherapists do not use outcome measures consistently and physical tests are often chosen (70.5%) over PROMs (17.3%). The work sector ( $p=$ 0.01; $p=$ 0.015; $p=$ 0.009). the workplace stimulus ( $p=$ 0.001) and the physiotherapists’ knowledge about PROMs ( $p=$ 0.017) were identified as factors associated with the non-use of PROMs. Barriers and facilitators to the use of PROMs are related to physiotherapists’ skills, the patients’ characteristics, the workplace conditions, and the instruments’ characteristics.

CONCLUSION:

This study showed the poor use of PROMs by musculoskeletal physiotherapists and identified the associated factors, barriers, and facilitators that should be considered to increase its future use by musculoskeletal physiotherapists in Portugal.

Keywords

Outcome measurement patient reported outcome measures musculoskeletal pain

1. Introduction

Musculoskeletal (MSK) conditions are the most frequent cause of long-term pain and disability, reducing individuals’ ability to work and participate in social activities [1, 2]. The prevalence of MSK conditions differs according to age and to a specific condition, but it is estimated that about 20–33% of the world’s population live with a chronic MSK condition [1]. Identical data has been reported in Portugal. According to Branco et al. [3], about 21.2% of the Portuguese adult population presents at least one rheumatic and musculoskeletal disease (RMD). Current literature shows that the costs associated with MSK conditions can be reduced if patients are encouraged to participate in an adequate rehabilitation programme [4]. Physiotherapy modalities such as therapeutic exercise, manual therapy or education are widely recommended and first-line options to reduce pain, disability or absenteeism, as well as to prevent the development of chronicity [5, 6].

A core element in modern musculoskeletal physiotherapy is the regular use of measurement instruments (MIs) and the continuous evaluation of health outcomes, namely through patient-reported outcome measures (PROMs) [7, 8, 9]. This assessment helps to increase the patient’s involvement in his/her rehabilitation, justify and/or change the chosen treatment, improve the physiotherapist’s perception of the achieved progress, and promote communication between different health professionals [9, 10, 11, 12, 13].

The use of PROMs has received particular importance in the last decade as they allow patients to self-report their own health status, without the interpretation or influence in their response by a health professional [11]. PROMs can be more reliable than clinician-centered instruments because they are not affected by inter-observer variability and, at the same time, they assess some health problems and outcomes that would otherwise be impossible to measure. For example, the assessment of psychosocial aspects is not possible with another type of instruments [11, 12]. They can be applied to obtain a diagnosis, determine a prognosis and measure clinical outcomes, and some of them can be applied for all three purposes [14].

Although the use of MIs is strongly recommended, current evidence shows its poor application by physiotherapists [8, 13, 15] and that those who use them continue to mainly apply physical tests instead of PROMs [12, 16]. Given the low usage of MIs, sociodemographic and/or clinical practice factors that influence their use by physiotherapists have been analysed, as well as the associated barriers [8]. These issues have already been studied in countries like Australia, Germany, Saudi Arabia, the Netherlands and the United States of America, where it was possible to verify that the physiotherapists’ greater knowledge, higher academic degree, years of work experience as well as the fact of working in inpatient settings makes them more likely to use these instruments [7, 8, 15, 16, 17, 18]. The lack of time in physiotherapy sessions and the utility of measurement tools in the identification of yellow flags were also reported as barriers and facilitators to use PROMs, respectively [10, 12]. This knowledge has been used to modify potential barriers and design strategies to facilitate the use of MIs and, in particular, PROMs.

However, information about the use of PROMs in Portugal is still scarce, which reflects the need to investigate this topic in the Portuguese context. This knowledge can be an important contribution to define and implement strategies aiming at a greater use of PROMs in the context of musculoskeletal physiotherapy in Portugal, namely through behavioral change strategies targeting physiotherapists and influencing factors. The main objective of this study was to characterize the use of patient-reported outcome measures by musculoskeletal physiotherapists in Portugal. Secondly, we hypothesized that certain sociodemographic and clinical characteristics of physiotherapists could be associated with the non-use of PROMs. Thirdly, we aimed to identify the barriers and facilitators to its implementation, regarding the physiotherapists’ perspective.

2. Methods

2.1 Study design

A cross-sectional study was conducted using an online survey. The study protocol was previously submitted and approved by the Specialized Committee on Ethics for Research – Polytechnic Institute of Setúbal, Portugal (46A/AFP/2019). This study followed the recommendations of the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) [19].

2.2 Participants and recruitment

This study included physiotherapists working in Portugal, either in the public and/or private sector, who were invited via email. Inclusion criteria were having at least 50% of their weekly patients with MSK conditions and the patients’ age equal to or greater than 18 years [20]. An exclusion criterion was not working professionally in Portugal. The recruitment process started with the effective members of the Musculoskeletal Physiotherapy Interest Group, a member organization of the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT). Additionally, the former students of the master in musculoskeletal physiotherapy from the Polytechnic Institute of Setúbal – also recognized by IFOMPT, were invited to participate. After finishing the questionnaire, physiotherapists were asked to identify other potential participants who met the eligibility criteria (snowball method).

A letter explaining the study was given to all participants who contributed anonymously and voluntarily, by previously filling out and signing an informed consent form. The required sample was calculated based on the percentage of physiotherapists currently working with MSK conditions in Portugal (6071) [21] and an expected value of 361 (CI 95%) participants was obtained (www.surveysystem.com/sscalc.htm).

2.3 Data collection

Data was collected through the LimeSurvey platform using a questionnaire based on previous studies [8, 10, 12, 13, 15, 21, 22] and which has previously undergone a pilot study, in order to obtain the participants feedback about the survey items and the chosen software [15, 23]. The final version of the online questionnaire was composed of four sections: 1 – Socio-demographic characteristics of the participants (e.g., age, academic degree, PROMs related formation); 2 – Characterization of the participants’ clinical practice (e.g., years of MSK practice, number of different diagnoses per week, patient’s injury phase); 3 – Use of measurement instruments and; 4 – Barriers and facilitators. The first three sections constituted the quantitative component of the study, with closed questions in which data was collected through Likert scales, questions with “yes” or “no” answers and questions in which a numerical value was requested. In turn, the fourth section was the qualitative component, with open questions, in which participants were able to freely expose the factors that influence their use of PROMs, without any word limit. Data collection took place between February and July 2020. Two electronic reminders were emailed 2 and 3 weeks after the initial invitation to maximize the response rate.

2.4 Data analysis

Quantitative data was analysed using the Statistical Package for the Social Sciences (SPSS), version 25.0. Descriptive statistics were used to systematize the participants’ sociodemographic and clinical practice data, as well as their use of MIs, including PROMs. Logistic regression models were used to analyse the relationship between the participants’ sociodemographic and clinical practice characteristics (independent variables) and the non-use of PROMs (dependent variable). The independent variables were aggregated (if needed) into categorical variables while the dependent variable was dichotomized into ‘yes’ or ‘no’ according to the participants’ answers to the question on the use of PROMs. Firstly, a univariate analysis was performed through a logistic regression model (method: Enter), in order to verify which independent variables were statistically associated with the dependent variable (non-use of PROMs). Secondly, the significant variables ( $p<$ 0.2) were then submitted to a multivariate analysis using the Backward Stepwise (Conditional) method. The relationship between the independent variables and the dependent variable was assessed by the Odds Ratio (OR) and Nagelkerke R2 values. Chi-square goodness-of-fit test (Hosmer and Lemeshow test) was used to assess the quality of adjustment of the chosen model. $P$ -values $<$ 0.05 were considered significant.

For the open questions (Section 4), an inductive thematic analysis was performed according to the six stages recommended by Bolarinwa [24]. The main researcher (RS) was responsible for conducting the analysis. He is a physiotherapist with 5 years of clinical practice in MSK conditions, had a degree in physiotherapy and interest in MSK conditions. The second researcher (DP) supervised and reviewed all stages of qualitative analysis. He is a physiotherapist with 10 years of clinical practice and research in MSK conditions, PhD in Epidemiology and experienced in conducting qualitative studies.

3. Results

From a total of 543 invitations sent, we were able to obtain 156 (28,7%) responses for the quantitative component and 140 (25,8%) responses for the open questions (qualitative component). Thirty-eight responses were excluded by incomplete data, as they were not suitable for any statistical analysis regarding PROMs use. The data collection process is detailed in Fig. 1.

3.1 Sociodemographic and clinical practice characteristics of participants

Table 1
Sociodemographic and clinical practice characteristics of the participants

Variable	Categories	$n$ (%)
Gender	Female	87 (55.8%)
	Male	69 (44.2%)
Age ( $\overline{\text{x}}$ and $\sigma)$		29.35 years ( $\pm$ 6.97 years)
Age (min/max)	–	22 years	65 years
Academic degree	Licenciate	98 (62.8%)
	Master	36 (23.1%)
	Post-graduation	20 (12.8%)
	Doctorate	2 (1.3%)
Academic formation	Public education	98 (62.8%)
	Private education	58 (37.2%)
Complementary formation (in MSK area)	Yes	143 (91.7%)
	No	13 (8.3%)
PROMs related formation	Yes	50 (32.1%)
	No	106 (67.9%)
Years of experience ( $\overline{\text{x}}$ and $\sigma)$		7.00 years ( $\pm$ 6.62 years)
Years of experience (min/max)		1	40
Years of MSK practice ( $\overline{\text{x}}$ and $\sigma)$		6.66 years ( $\pm$ 6.02 years)
Years of MSK practice (min/max)		1 year	33 years
Number of different diagnoses (per week)	1–10	83 (53.2%)
	11–20	56 (35.9%)
	21–30	13 (8.3%)
	$>$ 30	4 (2.6%)
Injury phase^*	Acute ( $<$ 6 weeks)	67 (42.9%)
	Subacute (6–12 weeks)	50 (32.1%)
	Chronic ( $>$ 12 weeks)	39 (25.0%)

$n$ – Frequency; % – Percentage; $\overline{\text{x}}$ – Mean; $\sigma$ – Standard-deviation; MSK – Musculoskeletal; ^*Injury phase in which participants intervene more frequently.

Figure 1.

Study flowchart.

Physiotherapists’ mean age was 29.35 years ( $\pm$ 6.97 years). Most of them had only a licentiate degree (62.8%) and reported no training related to PROMs (67.9%). Participants have an average of 7 years ( $\pm$ 6.62 years) of professional experience, most of them work in the private sector (68.6%) and 42.3% treat only 1 patient per hour. The participants’ sociodemographic and clinical practice characteristics are shown in detail in Table 1.

3.2 Use of patient-reported outcome measures

Table 2
Use of PROMs by the participants

Variable	Categories	$n$ (%)
Measurement instruments use	Never/rarely/ocasionally	71 (45.5%)
	Frequently/always	85 (54.5%)
Clinician-centred instruments use	Never/rarely/ocasionally	46 (29.5%)
	Frequently/always	110 (70.5%)
PROMs use	Never/rarely/ocasionally	129 (82.7%)
	Frequently/always	27 (17.3%)
Age group in which PROMs are mostly applied	18–30 years	36 (23.1%)
	30–40 years	34 (21.8%)
	40–50 years	20 (12.8%)
	50–65 years	19 (12.2%)
	$+$ 65 years	10 (6.4%)
Workplace stimulus to use PROMs	Never/rarely/ocasionally	132 (84.6%)
	Frequently/always	24 (15.4%)
Necessary knowledge to apply PROMs	Yes	106 (67.9%)
	No	50 (32.1%)
Purposes for using PROMs	Diagnosis	56 (35.9%)
	Prognosis	43 (27.6%)
	Outcome measurement	134 (85.9%)
% of patients in whom PROMs are used (média e desvio padrão)		36.72% ( $\pm$ 29.73%)

$n$ – Frequency; % – Percentage.

Fifty-five percent of participants reported using MIs often/always. However, the majority (82.7%) reported a poor use of PROMs (never/rarely/occasionally) and consider themselves not to be motivated to use them in the workplace (84.6%). In addition, most participants claim to use PROMs to measure outcomes (85.9%) and consider having the necessary knowledge to apply them (67.9%). The remaining data are detailed in Table 2.

Figure 2.

Outcome domains measured by the participants. ^*frequency ( $n$ ).

PROMs’ utilisation was considered a practice of moderate to high importance by 78.9% of the physiotherapists, most of them are reasonably satisfied with their use (65.4%) and their choice of PROMs is mostly based on its easiness for the patient (71.2%), psychometric properties (65.4%) and time of application (60.3%). Regarding the outcome domains used (Fig. 2), most physiotherapists use PROMs frequently/always to measure pain intensity (81.4%) while domains such as depression, anxiety and sleep disorders are never/rarely/occasionally assessed (91.7%, 89.1% and 89.1%, respectively).

3.3 Factors associated with the use of PROMs

Table 3
Results of the multivariate regression analysis

Variable	$p$ -value	Odds ratio (OR)	95% CI
			Lower	Upper
Work sector
Public^*	–	1	–	–
Private	0.001	21.156	4.704	95.148
Conventioned	0.015	11.312	1.004	80.461
Mixed	0.009	19.009	2.164	171.722
Workplace stimulus
Frequently/always^*	–	1	–	–
Never/rarely/ocasionally	0.001	0.082	0.026	0.254
Physiotherapist knowledge
Yes^*	–	1	–	–
No	0.017	6.331	1.397	28.687

^*Reference class.

Through the univariate analysis, it was possible to verify a $p$ -value $<$ 0.2 in 11 independent variables. These variables were then submitted to a multivariate analysis and the final statistical model retained 3 of the 11 variables ( $p<$ 0.05). The variables work sector ( $p=$ 0.015), the stimulus at the workplace ( $p=$ 0.001) and physiotherapists’ knowledge ( $p=$ 0.017) were independently associated with the non-use of PROMs. This means that physiotherapists who work in the private, conventional and mixed sectors were more likely not to use PROMs (OR $=$ 21.156; OR $=$ 11.312 and OR $=$ 19.009 respectively), comparing to those who work in the public sector. These results also show that participants who believe that they do not have the necessary knowledge to use PROMs and have lacked stimulus in the workplace to apply them, are more likely not to use them (OR $=$ 6.331 and OR $=$ 0.082 respectively), comparing to physiotherapists who considered themselves to have that knowledge or stimulus in the workplace. The results of this analysis are detailed in Table 3. The chi-square goodness-of-fit test (Hosmer-Lemeshow test: chi² (9) $=$ 2.165; $p=$ 0.826) and Nagelkerke R2 coefficient (R2 $=$ 0.379) indicate that these 3 factors explained 37.9% of the variance in the regression model. The area under the ROC curve (AUC $=$ 0.826) showed a good ability to distinguish the use from the non-use of PROMs by the physiotherapists.

3.4 Barriers and facilitators to the use of PROMs

Nine themes related to the factors that limit or promote the use of PROMs (barriers and facilitators) were obtained from qualitative data.

3.4.1 Barriers

Theme 1: Physiotherapists’ skills

Participants considered that their reduced work experience and limited access to contents about PROMs in their formation, makes them less able to apply these instruments.

Theme 2: Patients’ characteristics

The older age and low literacy of many patients seem to contribute to the incomprehension of PROMs and to the need for help from the physiotherapist to fill them.

Theme 3: Working conditions

The high affluence of patients at the workplace and the consequent lack of available time for them to complete PROMs was stand out. The non-use of PROMs by work colleagues was also identified, which seems a consequence of lack of acceptance and encouragement by the employer to its use.

Theme 4: Limitations of the instruments

Perceived subjectivity, limited reliability, and lack of validation of some PROMs for the Portuguese population were highlighted. Their large dimensions and consequent longer time to complete them was also mentioned.

3.4.2 Facilitators

Theme 1: Access and value given to PROMs at the workplace

The mandatory use of PROMs by the employer and the importance given by co-workers were identified as facilitators. It was also suggested the presence of a digital platform, shared with patients, where it would be easier to record data and calculate PROMs scores.

Theme 2: Physiotherapists’ knowledge

Participants’ academic and/or complementary education about PROMs was identified as important to increase the recognition of its usefulness. The effective management of the available time by physiotherapists was reported as critical to allow their greater use.

Theme 3: Active role of patients

Patients’ motivation was identified as a key factor to increase the success of PROMs use. The patients’ younger age (with a higher literacy), their perceived value of PROMs, as well as their request regarding the condition prognosis, were also mentioned as enhancers.

Theme 4: Benefits of patient-reported instruments

The most reported aspect was PROMs’ usefulness since they are filled out by the patient, allowing an increase in its motivation. It also allows individuals to take responsibility for their recovery and the promotion of a more empathetic relationship with the physiotherapist. The characterization of the pathology behavior over time was also highlighted.

Theme 5: Physiotherapists’ availability

The most reported aspect regarding the clinical practice was the available time in each physiotherapy session. The freedom in managing the time spent with each patient emerged as an essential factor to apply PROMs.

4. Discussion

This study described the current use of PROMs by musculoskeletal physiotherapists in Portugal, together with the associated factors, facilitators, and barriers of their utilization in clinical practice. A key finding was that Portuguese physiotherapists do not use measurement instruments (and particularly PROMs) regularly. We found that physiotherapists who work in the private, conventional and mixed sectors are more likely not to use PROMs, as well as those who believe they do not have the necessary knowledge to use them and have lacked stimulus in the workplace for its application. The use of PROMs was considered a practice of moderate to high importance by most participants, although only a few apply them consistently. Physiotherapists’ lack of skills was identified as a barrier to use PROMs. Other identified barriers were patients’ age, their lack of interest, PROMs’ limitations and the physiotherapists’ reduced available time in each session. The professional context and intervention model of physiotherapy in Portugal, being mainly based on the number of sessions/interventions, may contribute to less available time and even devaluation of measuring PROMs by the professionals.

On the other hand, the perception of PROMs value by patients, as well as their increased involvement in the rehabilitation process, were mentioned as enhancers of their use. Similarly, PROMs’ usefulness and their valorization by the employer, together with the physiotherapists’ knowledge and availability were identified as facilitators.

The reduced outcome measurement by physiotherapists is not surprising and may be related to their uncommon habit to perform clinical records in their daily practice, compared to what is recommended [25, 26, 27, 28]. Also, the low use of PROMs that was found is common to similar studies and may reflect their predominant biomedical reasoning, through which a structuralist and clinician-centred practice is performed [16, 29]. The wide use of clinician-centred instruments and outcome domains such as pain intensity or physical function, which, although measured through PROMs, represent the priorities of physiotherapists more than those of patients, seems to corroborate this hypothesis.

Likewise, physiotherapists rarely use psychosocial domains which may be related to the professional’s lack of confidence (and biomedical profile) in assessing these factors. As reported by Östhols, Boström and Eva [30], they may avoid PROMs including sensitive topics as they feel it is an intrusive approach that goes beyond their area of intervention. Yet, patients value the physiotherapists’ attention to the psychosocial aspects of their pain, which highlights the physiotherapists’ difficulties in applying patient-centred care [31]. Despite strong recommendations for the use of patient-relevant outcome domains, namely using PROMs [32, 33], healthcare services are often conditioned by the value of certain outcomes for which physiotherapists are paid, with the overvaluation of physical domains (e.g. range of motion or strength), without including patients’ perspectives [34, 35].

As in the study by Meerhoff et al. [16], the participants’ higher knowledge about PROMs was associated with their greater self-reported use. Previously, other studies also showed that having better academic qualifications is directly related to a greater use of outcome measures by physiotherapists [8, 17, 22]. As described by Main, Foster and Buchbinder [36], physiotherapists should know how to interpret PROMs’ psychometric properties, namely validity, reliability and ability to detect changes, which usually does not happen, as mentioned by Deshpande et al. [37]. This suggests that physiotherapy as a profession in Portugal (as in other countries) may be falling short of evidence-based practice recommendations regarding PROMs’ use when managing MSK conditions. As described by Olsen et al. [38], completing a higher academic level can be a critical step to overcome the lack of knowledge about this subject.

Furthermore, a mismatch was observed regarding the participants data, since most of them considered the use of PROMs as a practice of moderate to high importance but only a small percentage reported their consistent application. This seems to indicate that physiotherapists only value and acknowledge PROMs’ importance in a theoretical way. Our findings were similar to those reported by Olsen et al. [38] and Richoz et al. [29], who found that the lack of clear guidance about PROMs’ suitability for each health condition may inhibit physiotherapists from incorporating them in their daily practice. This suggests that more educational strategies are needed regarding these instruments’ purpose, so that their use can be more widespread, since most professionals do not recognize any additional usefulness of PROMs in their decision-making process, showing resistance to a behavioral change [12]. To enhance the effect of those actions, several authors have advocated the role of opinion leaders and/or knowledge translators, including dialogues and problem solving among colleagues with greater clinical experience [41].

Generally, these findings allowed us, therefore, to understand that to increase PROMs’ use, actions on different levels/domains are required. In line with previous studies, our results point to the potential usefulness of a digital platform in which physiotherapists can record and analyze scores in a more practical way. Employers and co-worker’s valorization of PROMs together with physiotherapists’ continuous professional development (through workshops, conferences, e-learning or idea sharing) seem also good strategies to increase their use [38]. It remains important, however, that these actions are concomitant with changes in healthcare policies and employers’ attitudes regarding outcomes measurement.

4.1 Limitations

The findings of this study should be interpreted considering some limitations. First, it was not possible to obtain a representative sample of MSK physiotherapists in Portugal. The fact of conducting this study during the first wave of the COVID-19 pandemic may explain part of the difficulty experienced in reaching the expected sample size. Secondly, professionals’ self-reported data may have led to the presence of a social desirability bias. Therefore, the results that we found may even be underestimated regarding the low use of PROMs. Thirdly, the young age sample may also be a limitation, since our methodological options may have facilitated the participation of physiotherapists that were more proficient in digital content and inhibited the answers of those who are older or who work in places without internet access. However, it is important to point out that Portuguese physiotherapists are mostly young, below 40 years old. Finally, this study’s qualitative analysis was carried out by only one researcher and reviewed in parallel by another researcher, which made it more suitable to errors and biases. Future studies should include multiple reviewers, allowing for different perspectives when analyzing the data and ensuring a more objective analysis.

4.2 Strengths and implications

To the authors’ knowledge, this was the first study carried out on this topic in the context of MSK physiotherapy in Portugal. This study allowed us to identify the profile of the physiotherapists who do not use these instruments consistently, which can be an important contribution to future actions to minimize this professional behavior. It was also possible to obtain and analyze qualitative data from a large number of participants. Through the open questions, participants identified a wider spectrum of factors related to the barriers and facilitators for using PROMs that can be used to design behavioral change strategies aimed at a consistent use of PROMs in clinical practice.

Our findings should promote a reflection on how the content and skills related to outcome measures are transmitted in physiotherapy education, given that the biomedical profile and the lack of knowledge about patient-centred practice may possibly be contributing to this behavior. In the work context, awareness-raising programs regarding PROMs’ implementation seem also important. Time and resources investment by employers may increase the professionals’ confidence, as well as their commitment to provide quality healthcare. Therefore, new ways of measuring outcomes should also be made available such as electronic software for clinical and outcomes’ records. Further qualitative studies with different methodologies need to be conducted in the future to identify other barriers and define effective strategies for a behavioral change in physiotherapists in Portugal (regarding the use of PROMs).

5. Conclusion

MSK physiotherapists in Portugal present a poor use of PROMs in their clinical practice, as well as a lack of habit when it comes to measuring outcomes in general. Physiotherapists who practice outside the public sector, have no stimulus to use these instruments in the workplace and consider themselves as not having the necessary knowledge to apply them are more likely not to use PROMs consistently. PROMs are considered important tools by professionals, although rarely applied by them, which suggests that this topic is not yet fully understood by physiotherapists. The main barriers and facilitators to the use of PROMs were related to the physiotherapists’ skills/knowledge, the patients’ receptiveness, the working conditions and the psychometric properties of some of these instruments. The results of this study can act as a basis for educational and professional actions to promote outcome measurement through self-reported instruments.

Author contributions

RS: Conceptualization, data collection, data analysis, and writing.

DP: Conceptualization, data analysis, supervision, writing review, and editing.

Data availability

The data supporting the findings of the present study are available from the corresponding author upon reasonable request.

Ethical approval

The study protocol was previously submitted and approved by the Specialized Committee on Ethics for Research – Polytechnic Institute of Setúbal, Portugal (46A/AFP/2019).

Funding

This study was financially supported by the Polytechnic Institute of Setúbal.

Informed consent

All participants provided written informed consent for their inclusion in the study.

Footnotes

Acknowledgments

The authors have no acknowledgements.

Conflict of interest

The authors declare that they have no conflict of interest.

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Current use of patient-reported outcome measures by musculoskeletal physiotherapists in Portugal

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Methods

2.1 Study design

2.2 Participants and recruitment

2.3 Data collection

2.4 Data analysis

3. Results

3.1 Sociodemographic and clinical practice characteristics of participants

Table 1 Sociodemographic and clinical practice characteristics of the participants

Table 2 Use of PROMs by the participants

Table 3 Results of the multivariate regression analysis

3.4.1 Barriers

3.4.2 Facilitators

4. Discussion

4.1 Limitations

4.2 Strengths and implications

5. Conclusion

Author contributions

Data availability

Ethical approval

Funding

Informed consent

Footnotes

Acknowledgments

Conflict of interest

References

Table 1
Sociodemographic and clinical practice characteristics of the participants

Table 2
Use of PROMs by the participants

Table 3
Results of the multivariate regression analysis