German physiotherapy is faced with the challenge of establishing solid structures that ensure evidence-based methods in medical practice.
For that to happen, all those involved in the system need to work together. The importance of evidence-based therapy is growing. The number of scientific publications is continuously expanding. But are the findings actually being transferred into practice?

Mr Huber, you have been tackling the question of how evidence-based therapy reaches patients. How do things look today, in terms of practical implementation?

Many clinics advertise the fact that the therapy is aligned with the latest scientific findings. But that is not always the case. As I pointed out in my article, early mobilisation, for instance, is very important following a stroke, and has proven positive effects on recovery of function. Despite this, even today therapists still cling to outdated guidelines and treat patients in the early phase very cautiously and hesitantly. As a result, valuable time is wasted.

What makes it so difficult to pass this knowledge down to the front line of treatment?

It’s to do with the complexity of the processes. They are difficult to control, since many actors are involved at various interfaces.

Can you give an example?

In physiotherapy there are researchers, trainees in schools, apprenticeships and continuing training, knowledge users in medical practice, employers, professional associations, health care politicians and health insurance providers involved in the processes. Only if all these actors communicate with one another and work together in a closely-connected way at the interfaces is it possible to ensure that new knowledge reaches the patient. But for that to happen, a lot of things still need to change.

And presumably not just at one of the interfaces?

That’s right. If you look at the efforts to date by actors in physiotherapy, it is clear some things are still needed before everyone is pulling in the same direction.
For example, the training and examination regulations for physiotherapists are now over
20 years old. You will search in vain for subjects such as “scientific working” or “evidence base”.

Can knowledge be passed on following training, for example via CPD and advanced professional training?

Even that’s problematic. There is no body regulating the CPD and advanced professional training market. It’s true there is an obligation to undertake CPD, and there are certain quality criteria, but there is no monitoring body examining the curricula of the respective CPD providers for their evidence. The CPD providers are not required to pass on current knowledge or at least to clarify which content is backed by scientific evidence and which is based on an empirical approach. Therapists may potentially invest a lot of time and money in CPD with outdated content.


Are there any pioneers showing the way forward?

Of course, there are schools and clinics which are driving knowledge transfer forward. Particularly in the in-patient context, a fair amount has happened in recent years. Device-based therapy, backed by good evidence, is also increasingly on the rise here. By contrast, things are more problematic in the out-patient sector. Here, the problem is the health insurance providers. In relation to treatment for people with neurological disorders, the catalogue of treatments provides traditional approaches to treatment, such as Bobath, Vojta. Therapists receive more money for them per treatment unit than for normal physiotherapy. More modern, evidence-based procedures such as task-oriented training are, on the opposite, not mentioned in the catalogue of treatments and certainly do not result in any higher financial compensation. This skewed situation also blocks evidence-based procedures from becoming established in the CPD market. The catalogue of treatments is no incentive for therapists to use contemporary methods. This is where the professional associations should engage with the health insurance providers and push for updates in the joint Federal committee.

What steps are needed to improve the situation?

Physiotherapy in Germany needs a superior body to coordinate the exchange between the interfaces. At the moment, “knowledge translation” is more or less a personal matter for each individual. Of course, there are schools and clinics which are driving knowledge transfer forward and implementing it in practice. And there definitely is process change – for instance, the new possibility of studying physiotherapy in Germany at undergraduate level – but at the broader level a vacuum continues to exist.

How do physiotherapists react to the increasing changes? Their day-to-day work must surely change as new findings emerge.

Certainly – not least the therapists need to critically examine their work “on the test bench”, if the results from research are to reach the patient. Some applications where the evidence is lacking have become favoured habits. Changing one’s own behaviour is, naturally, a process that provokes resistance. Motivated physiotherapists urgently need to overcome this hurdle if they want to treat patients efficiently.


The talk in the research field is about “knowledge translation”. What are the latest findings being offered on this subject

For actors in vocational training and in the CPD market, science offers recent findings on how they can support the change process. In randomised controlled studies, researchers have investigated which knowledge translation interventions are the most effective. In a large-scale work of review, for instance, Jeremy Grimshaw has identified that passive interventions – i.e. articles, presentations, conference attendance and training material – are not sufficiently effective on their own to change the behaviour of users. The approach is only meaningful in generating an awareness of the problem. Learning with the aim of changing behaviour, however, contains several critical steps: with regard to physiotherapy, the learner needs to acquire the knowledge, to apply it firstly in the practice situation and later with patients, and to integrate it into their day-to-day therapeutic work. This is a complex path, which learners can only accomplish through active involvement.

What is your own personal summary of the situation?

Knowledge translation is a complex process, and in German physiotherapy it is still in its early days. Active and diverse measures provide effective support for it, but require motivation, time and money - these are daunting obstacles, but not insurmountable. All actors should communicate with one another for the patient’s benefit and to professionalise the status of the profession, and to move the process forward together.

Mr Huber, thank you for this interesting interview.