Design and Registration
This study will be conducted by a multidisciplinary team with proven expertise in clinical PT, health services research and rehabilitation sciences. The study design is following the Arksey and O’Malley framework [13] and comprises five consecutive steps: (I) Identification of the research question, (II) Identification of relevant studies, (III) study selection, (IV) data charting, and (V) compiling and reporting of results. Study execution will be reported in concordance with the established reporting guidelines for Scoping Reviews (PRISMA P; PRISMA ScR) (see supplementary file 1 for reporting checklist of the study protocol PRISMA P) [14, 15]. In terms of research transparency, this protocol has been registered on the Open Science Framework database.
Stage 1: Identifying the research question
The rationale of this scoping review is directed by the following research questions:
RQ1: How is medical overuse of PT services in LBP management being measured?
RQ2: To what extent are domains of the medical overuse typology equally approached and represented?
RQ3: Which methods fit the legal conditions of the German healthcare system?
Stage 2: Identifying relevant studies (Eligibility criteria)
Eligibility criteria of this scoping review will follow the Population-Concept-Context (PCC) framework recommended by the Joanna Briggs Institute [16]. The PCC framework of this protocol is shown in Table 1 and is extended by the additional domain of “types of evidence”.
Table 1
Criteria | Characteristics |
Population | - LBP patients (ICD: M54.3; M54.4; M54.5; M54.8; M54.9) - All stadiums of LBP |
Concept | - All studies aiming to detect of medical overuse of physiotherapy care in low back pain management regarding effectiveness, treatment efficacy and alignment of care |
Context | - Physiotherapy care across all sectors of health services (inpatient, outpatient and rehabilitation healthcare settings) |
Types of evidence | - All types of empirical studies - Studies across all countries - Articles published in English or German language - Published and unpublished studies |
The scoping review will include LBP patients according to the International Classification of Diseases (ICD) Version 10 (M.54). Specifically, diagnostics of ischialgia (M54.3), lumboischialgia (M54.4), back pain (M54.5), other back pain ((M54.8) and unspecified back pain (M54.9) will be included. Studies investigating medical overuse of PT care for specific back pain events containing nerve compressions, fractures, spinal cancer, traumata, infectious diseases or musculoskeletal birth anomalies will be excluded. According to classifications of time or severity of pain, all stadiums of LBP (acute, sub-acute, chronic, and recurrent) [17] and all grades of chronic pain severity established by von Korff et al. [18] will be included.
Regarding the concept of medical overuse, all studies aiming to detect overuse of low-value PT care in LBP management will be included and subsequently categorized to domains of the continuum of care model introduced by Michaleff et al. [7]. This model represents a tailored and continued development of the overuse typology of Verkerk et al. [8] fitting the context of PT care for musculoskeletal health conditions. Given the objective to provide an overview of existing evidence of medical overuse measures, studies of all sectors of PT care (inpatient, outpatient, and rehabilitative care settings) will be included. The time period of included publications will not follow any restrictions and will reach up until October 2021. Despite, the authors will include articles of all regions and countries in the world.
This review will include all types of experimental studies, quasi-experimental studies, analytical observational studies, cross-sectional studies, and all types of systematic or non-systematic review studies. To avoid publication bias, available preprint studies, will be included. Additionally, grey literature such as health insurance reports or other reports of governmental entities will be included. Opinion paper, editorials, commentaries and case reports will be excluded as these article types do not provide requested information on conducted research designs and instruments. A comprehensive overview of eligibility criteria for included articles is listed below.
Inclusion criteria
To be eligible for this review, articles must comply the following criteria:
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Population of LBP patients (ICD-10: M54 group)
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Studies investigating any aspect of medical overuse in the context of PT care
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Studies conducted in any health care sector
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Articles published at any time until 10/2021
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Studies conducted in any country or region of the world
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Studies reported in English or German language
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Any studies, regardless of their study design
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Health insurance reports or reports of governmental entitites
Exclusion criteria
Articles meeting the following criteria will be excluded:
Stage 3: Study selection (search strategy)
Databases for the selection of eligible studies will be Medline (PubMed), Web of Science, CINHAL and Google Scholar. The search strategy will contain keywords and subject headings from referring domains of the PCC framework. Within domains, keywords and index terms will be combined with the Boolean operator “OR”. If applicable, keywords and index terms will be truncated. To connect domains, the operator “AND” will be applied. The search strategy will follow a three-step study selection approach and is led by the Joanna Briggs Institute’s (JBI) Reviewer Manual [16]. In step one, an initial, limited search of set databases will be conducted with predefined keywords and index terms (see supplementary file 2) which will be used to screen retrieved articles for additional keywords and index terms. In step two, a second search including all identified keywords and index terms will be performed. In terms of a snowball principle, reference lists of included articles will be screened for additional sources in step three. The study selection process will be peer reviewed by applying the Peer Review of Electronic Search Strategies (PRESS) checklist [19]. Retrieved articles will be imported to Endnote20 (Philadelphia, USA).
The screening process of included articles will be performed in two consecutive steps: First, two reviewers (LK, LL) will independently conduct a title and abstract screening by consensus. To solve disagreements, it will be referred to a third party (AC). Primary reasons for article exclusion will be recorded. Secondly, a full text screening will be conducted following the principles of step one. To manage the study selection process, the online application RAYYAN Version 2021 (Cambridge, USA) will be used. A comprehensive flow of the study selection process will be illustrated by the PRISMA-ScR flowchart.
Stage 4: Data charting (data extraction)
To guarantee an appropriate illustration of study characteristics, a preliminary data extraction chart tailored to objectives of this review is illustrated in Table 2. The chart is developed in concordance with JBI’s Reviewer Manual [16]. Chart elements are complemented by associated questions which is inspired by recently published Scoping Review Protocols [20–22]. The data extraction process will be performed in Microsoft Excel. The chart will be piloted by two researchers (LK, LL) and adjusted if necessary. As this is an iterative process, further adjustments at later points in time will also be taken into account. One researcher (LK) will take the lead in data extraction and will be checked by a second reviewer (LL).
Table 2
Preliminary data extraction chart
Chart elements | Associated questions |
Publication details |
Author(s) | Who wrote the article? |
Year of publication | When was the article published? |
Country of origin | Where was the study conducted and published? |
Type of PT access | How are the legislative conditions for PT services in the country of origin? How is the access to PT services regulated? What occupational rights do therapists have? |
Publication type | What type of publication is this? (empirical study, grey literature) |
Study details |
Aims/purpose | What were the aims of the study? |
Methodological design | What methodological design was applied? |
Population and sample size | Who was the target population and how many were included in the study? |
PT services | Which PT services were of primary interest? |
Conceptualization and measurement details |
Medical overuse definition | How is medical overuse of PT services in LBP-management conceptualized? |
Conceptual framework | Is the concept based on a practical/theoretical framework, theory or typology? |
Domains and perspectives of the low-value care typology | Which domains of the low-value care typology introduced by Verkerk et al. [8] are investigated? (domains: ineffective care, inefficient care, misaligned care; perspectives: provider, society, patient) |
Number of domains and perspectives | How many domains and perspectives of the low-value care typology were included? |
Measurement | What research instrument was used for measurement (e.g. quality indicators, scaling, questionnaire, interview guide)? What level of measurement was used (nominal, ordinal, interval, ratio)? Were measures of direct or indirect nature? |
Instrument psychometric properties | If applicable: Was the instrument validated? What was the reliability statistic? What was the content validity? Which guidelines or evidence synthesis were referenced to set thresholds |
Limitations and challenges | Were there any reported limitations or quality issues (not a critical appraisal)? |
Recommendations for further studies? | Were there any recommendations for further studies? |
Stage 5: Collating, summarizing and reporting results
To guide the report of results, this stage will contain four consecutive steps. In the first step, a narrative summary comprising a numerical table about generic details of included articles will be provided. The table will be led by the domains of the PCC framework and will further contain information about the number of included articles, study designs, instruments and measures, investigated PT services, LBP stadiums and referred guideline recommendations.
In step 2, the first research question (RQ1: How is medical overuse of PT services in LBP management being measured?) will be addressed. An in depth narrative description of identified measures and instruments will be provided. In an illustrative form (bubble chart or comparable figure), trends of methodical approaches for specific aspects of PT overuse, specific PT services or specific healthcare settings will be visualized. Result reporting of RQ1 will be completed by a narrative summary connecting research trends with reported limitations and recommendations (with special focus on instrument validity for overused low-value PT services exposure) for future research intends.
In step 3, result reporting of RQ2 (To what extent are domains of the medical overuse typology equally approached and represented?) will be approached by a narrative description of the numerical distribution of domains. Additionally, the development of a pie chart is intended to illustrate results. The chart also aims to highlight distributional differences in relation to specific PT services (e.g. diagnostics, treatments, prescriptions, advice) and healthcare settings (primary and secondary care). This is to identify potential trends of researched domains and perspectives of the medical overuse typology with referral to specific services and contexts. Thus, this potentially shows in which situations scientific methods measuring overuse domains are insufficient or not available.
In step 4 of the analysis, findings will dichotomously be mapped to health systems in which PT services are provided in primary or secondary care. Since this review particularly focuses on overuse measures for secondary care conditions, the German health system setting will serve as an exemplary context to pragmatically tailor and collate results. In this regard, a framework will be developed which assigns identified measures and results of this review to the occupational law of German PT’s. In this way, we attempt to answer RQ3 (Which methods fit the legal conditions of the German healthcare system?).