A systematic review of the effectiveness of knowledge translation interventions for chronic noncancer pain management

1Institute of Health Economics, Edmonton; 2Departments of Psychiatry, Medicine and Oncology, Faculty of Medicine, University of Calgary, Calgary; 3Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta; 4School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario; 5Faculty of Nursing, University of Calgary, Calgary, Alberta; 6McMaster University, Hamilton, Ontario Correspondence: Maria B Ospina, Suite 1200, 10405 Jasper Avenue Northwest, Edmonton, Alberta T5J 3N4. Telephone 780-448-4881, fax 780-448-0018, e-mail mospina@ihe.ca Chronic noncancer pain is a poorly understood condition in which the patient experiences pain for prolonged periods of time, often despite the healing or complete absence of demonstrable tissue damage. More complex in nature than acute pain, chronic noncancer pain is often intertwined with multiple physical and psychosocial complications, and accompanied by other medical disorders that further increase the burden of this disease. Issues such as immobility, wasting of muscle and joints, depression of the immune system, poor appetite and nutrition, dependence on medication, overuse and/or inappropriate use of the health care system, poor job performance or inability to work, and anxiety have all been reported in the chronic pain literature, along with chronic comorbidities such as heart disease, depression and sleep disorders (1-4). As a result of these issues, studies have shown that the health-related quality of life of chronic noncancer pain patients is among the lowest observed for any medical condition (5). Chronic noncancer pain in Canada, as well as in many other parts of the world, is a widespread and burdensome problem for individuals, the health care system, the economy and society as a whole (1). Some studies indicate that large numbers of Canadians (upwards of 20% [6] to 30% [7]) report some form of chronic persistent pain, lasting an average of 10.7 years. Chronic noncancer pain results in significant suffering, disability and reduced quality of life (8), and significant personal (9) and societal economic burdens, estimated to exceed $6 billion annually (10). review

Pain Res Manag Vol 18 No 6 November/December 2013 e130 Not surprisingly, it has been further identified that chronic noncancer pain places a significant strain on the health care system.For instance, it has been found that these individuals make more physician and emergency room visits and experience longer hospital stays than those without such disorders (11)(12)(13)(14).High resource use by chronic noncancer pain patients leads to high direct costs for care (13,15,16) in addition to high indirect costs related to significant decreases in work productivity and disability payments (14,(17)(18)(19)(20).The scientific literature overwhelmingly points to the significant burden that chronic noncancer pain, a disease and health care problem in its own right, places on the individual, the health care system and society as a whole.
Despite the fact that reliable evidence exists (eg, guidelines, systematic reviews, etc) detailing effective treatments and management practices for chronic noncancer pain, evidence-based treatments and practices are often not used by practitioners, leading to these conditions being undertreated and mismanaged (1,(21)(22)(23)(24).
The answer advocated by many to this dilemma lies in the area of knowledge translation (KT) because the problem encompasses the gap between the knowledge that exists about managing chronic noncancer pain and current health care practices (1).KT has been defined in Canada as: The exchange, synthesis and ethically-sound application of knowledge -within a complex system of interactions among researchers and users -to accelerate the capture of the benefits of research for Canadians through improved health, more effective services and products, and a strengthened health care system (25).
KT is based on the notion that the quality of care and the health of the population will increase when relevant research findings and evidence are applied to everyday practice (26,27).KT, however, is not a simple, straightforward process.Multiple factors, such as the everincreasing volume of literature, lack of resources, and other individual and organizational constraints, often complicate and impede attempts to incorporate evidence into practice (26,(28)(29)(30).KT research attempts to identify effective interventions that address these barriers and lead to evidence uptake and improvement in patient outcomes (30).
Little is known about which KT interventions are specifically effective in the area of chronic noncancer pain management (1).The aim of the present systematic review was to systematically locate and assess the evidence regarding the effectiveness of KT interventions for chronic noncancer pain management.

MeThOdS identification of studies
The protocol of the present study was registered in the PROSPERO international prospective register of systematic reviews (2011:CRD42011001379).The methodology followed the standards recommended by the Cochrane Effective Practice and Organisation of Care Review Group (EPOC) guidelines for conducting systematic reviews of interventions designed to improve the delivery, practice and organization of health care services (31).Comprehensive searches of psychological, sociological and biomedical electronic databases (The Cochrane Library, MEDLINE, EMBASE, Centre for Reviews and Dissemination Database, Cumulative Index to Nursing and Allied Health, Web of Science, PsycINFO, Sociological Abstracts, SocINDEX, Social Services Abstracts, ABI Inform, Business Source Complete, Health-evidence.ca,KT+, Campbell Collaboration, Knowledge Utilization -Utilisation des Connaissances, Canadian Research Index) were conducted from database inception date to September 2011 with no date limits applied.The search strategy was designed by an information specialist and comprised both selected subject headings and keywords relating to chronic pain conditions and KT (the full search strategy is available upon request).In addition, the Cochrane EPOC Register was searched for studies not identified in previous electronic searches.Reference lists of reviews and retrieved articles were checked for relevant studies.Scientific meeting proceedings, clinical trial registries, government documents, theses and dissertations were sought to identify unpublished studies.Language restrictions were not imposed in the searches.

inclusion and exclusion criteria
Randomized controlled trials (RCTs), controlled clinical trials (CCTs) and controlled before-and-after studies (CBAs) of KT interventions targeting health care providers working with chronic noncancer pain patients, or individuals with chronic noncancer pain were included.Both individual and cluster designs were considered.A KT intervention was defined as the act of transmitting specific evidence-based knowledge about chronic noncancer pain.To include any given study, it was necessary to be able to identify the source and content of the information transmitted, and to confirm that the information was indeed based on evidence.For example, an experiment to test the effectiveness of informing providers or patients about what the investigators regarded to be best practice in a particular pain condition would not have been included unless it could be verified that the content of the program was entirely derived from scientific evidence and not from opinion or conjecture.An experiment to test the effectiveness of an evidence-based treatment guideline, on the other hand, would have been eligible for inclusion.This stance was taken to restrict the focus of the present study to true KT interventions and, thus, to distinguish it from reviews of the effectiveness of patient and provider education in general, in the belief that KT studies, while less plentiful, deliver a higher quality of factual information.
Outcomes of interest were primary outcomes related to patients (eg, health status, pain intensity and relief, knowledge, satisfaction with care, adverse events, work-related measures), to health providers (eg, changes in practice, knowledge, satisfaction) and to the organization or system (eg, staff turnover, patient workload).Studies were not excluded on the basis of language of publication.Two pairs of reviewers independently screened the titles and abstracts generated from the search strategies to identify potentially relevant articles.The full text of articles deemed relevant and those whose abstracts and titles provided insufficient information were retrieved for a closer inspection by two independent reviewers who determined study eligibility for the review.Disagreements about inclusion and exclusion of studies were resolved through discussions among reviewers until consensus was reached.

Risk of bias assessment
Two reviewers independently assessed the risk of bias of individual studies using the criteria developed by the Cochrane EPOC group (31).Briefly, RCTs, CCTs and CBAs were assessed for adequacy with regard to 10 validity criteria: sequence generation; allocation concealment; baseline outcome measurement; baseline characteristics; blinding of participants and personnel; blinding or objective assessment of the primary outcome; completeness of follow-up; completeness of outcome reporting; protection against contamination; and other potential threats to validity.Discrepancies in risk of bias assessment between reviewers were resolved by consensus.Risk of bias summaries were reported in relation to the primary outcome reported in the individual studies (32).Studies were not excluded from the analysis because of poor methodological quality.

data extraction and analysis
Details regarding study characteristics (ie, design, country, clinical topic, units of allocation and analysis), type of KT intervention, sample size, primary study outcomes and associated statistical significance were extracted from individual studies using a pretested data extraction form and summarized in evidence tables.Studies were grouped according to target audience (ie, health professionals, patients, miscellaneous groups) and then classified according to the Cochrane EPOC taxonomy of interventions (31) into: professional (eg, distribution of educational material, educational meetings and outreach visits, use of local opinion leaders, and audit and feedback), organizational (eg, revision of professional roles, communication systems or equipment availability), financial (eg, various methods of remuneration or payment systems), regulatory interventions (eg, any health service change introduced by regulation or law) and those related to patients and consumer communication (eg, information, health promotion, skills training, coordination of care, supportive environments).

Knowledge translation for chronic noncancer pain
Pain Res Manag Vol 18 No 6 November/December 2013 e131 Details about implementation of the interventions (ie, delivery format, manual availability and training of providers) were obtained.The level of action to support research implementation into practice was classified according to a taxonomy that focuses on the primary goal of KT (33) as: increase awareness of the problem or knowledge gap; acquire new knowledge; evaluate/synthesize new knowledge; make a decision; adaptation of evidence to context; implement/operationalize specific actions (implementation fidelity); facilitate the process of change; and quality/outcome evaluation/monitoring.
Substantial diversity in study designs, methodological quality, KT interventions and outcomes across studies precluded combining individual results into a meta-analysis.Instead, a narrative synthesis of effectiveness outcomes across KT interventions was undertaken according to the guidelines suggested by Popay et al (34).Subgroups were created to guide the exploration of outcomes within classes of KT interventions in the narrative synthesis.The focus of the analysis was the effect of KT interventions on primary outcomes (ie, clearly defined as such by the authors of individual studies or those first listed in the results section).Outcome reporting was divided into patient-related, professional and system outcomes.The timeframes for outcome assessment were grouped into short-(ie, <3 months), medium-(ie, between three and six months) and long-term (ie, >6 months) outcomes.The initial phases of the review (study screening and eligibility) were managed using the Early Review Organizing Software (35,36); risk of bias assessment, data extraction and narrative synthesis were managed using Excel (Microsoft Corporation, USA).

Risk of bias
The risk of bias in individual studies is reported in Table 2.The high risk of bias components across the studies included inadequate (or lack of) random sequence generation (37,(48)(49)(50)(51)(52)(53)(54) and allocation concealment (49-54), differences at baseline measurement (22,43,45,46,52,54) and inadequate account for losses to follow-up (38)(39)(40)45,51,54).Due to poor quality of reporting in some individual studies, the effects of bias related to the lack of blinding of participants and outcome assessment, and selective outcome reporting were unclear.One study was judged to have incomplete outcome reporting (41).Another study was likely to be affected by threats to validity derived from participants' bias (42).The results of the risk of bias assessment presented in Table 2 suggest that a small proportion of studies (22,41,44) were likely to be at low risk of bias.

effects of kT interventions
More than one-half of the studies (38)(39)(40)45,46,48,50,51,53,54) assessed primary outcomes related to the health providers.They included short-term assessments of change in knowledge about pain and pain management (39,51,54), and appropriateness or improvement in prescription behaviour (assessed at medium- [46,50] and long-term [45]).Other health provider outcomes included medium-(48,53) and shortterm (38) changes in clinical management (such as time spent providing advice to patients, or case notes documenting chronic noncancer pain) and assessments of the level of confidence regarding certain therapeutic options (evaluated at short-term [40]).Patient-related outcomes were assessed in nine studies (22,37,(41)(42)(43)(44)47,49,52).They included short-, medium-and long-term evaluations of patients' function (43,44), medium-and long-term assessments of knowledge acquisition (41) and beliefs about pain (52), long-( 49) and medium-term ( 22) work-related  outcomes such as restrictions in work duty rate and return to work, and medium-term assessments of pain complaints (47) or discussion of painrelated topics during the clinical encounter (42).Primary outcomes addressing changes at the organization or system level were not identified.Table 3 summarizes the characteristics of intervention groups and KT effectiveness outcomes according to the target population in the individual studies.The main results of each study are reported in natural units extracted from the studies.The identification of a small number of studies reporting comparable outcome measures precluded the visual assessment of potential publication bias using funnel plots.kT interventions targeting health professionals: 12 studies assessed the effect of KT professional education-mediated interventions on health provider outcomes (ie, changes in knowledge about pain and pain management [39,51,54], clinical management [38,48], prescription behaviour [45,46], confidence in therapeutic options [40]) and patient-related outcomes (ie, function [43,44], pain complaints [47] and changes in work duty rate [49]).Professional education-mediated interventions, such as electronic learning education based on clinical practice guidelines (38), and educational packages that involved the participation of opinion leaders (48) were evaluated in one RCT (38) and in one cluster RCT (48).Individual study results did not show a consistent and statistically significant effect on clinical management as a result of the KT intervention.
Evidence from two cluster RCTs (43,44) showed that, compared with passive dissemination of clinical practice guidelines, KT interactive education interventions directed to health providers had a positive effect on patients' function at short and medium term.Statistically significant effects resulting from education-mediated KT interventions to health providers were not reported for other patient-related outcomes (ie, pain complaints, changes in work duty rate).There were inconsistent results regarding the effects of education-mediated KT interventions on other health provider outcomes such as knowledge about pain and pain management (reported as not statistically significant in one RCT [39] and one CBA [54] but statistically significant in one CCT [51]) and prescription behaviour (statistically significant in one cluster RCT [45] while not statistically significant in another cluster RCT [46]).One RCT (40) that compared the provision of written empirical evidence with a no-intervention group found a statistically significant improvement in health providers' confidence on therapeutic options derived from the KT intervention.
One CBA study (53) evaluated the effect of a professional intervention targeting physiotherapists that involved structural changes in the organization and delivery of care (ie, quality improvement) for low back pain.The study did not report statistically significant changes in clinical management, as evidenced by the number of clinical reports in which key assessment and management factors were documented.kT interventions targeting patients: Three RCTs (37,41,42) evaluated the effect of information/education and consumer decision aids (ie, written materials, oral and Internet-based education) offered to patients with low back pain (37,41) and migraine (42) compared with usual care.Statistically significant results were reported for short-term changes in patients' function (37) and medium-and long-term changes in knowledge acquisition (41).Alternatively, no statistically significant differences were found between a patient-oriented KT education intervention and a nointervention group in the number of migraine-related complaints (42).
One RCT ( 22) evaluated a multifaceted patient-oriented KT intervention consisting of a coordination of care approach.Compared with usual care, the KT intervention did not have a statistically significant effect on the medium-term return-to-work rate.kT interventions targeting combined groups: Two studies evaluated multifaceted KT interventions that targeted composite groups of health providers, patients and the community.One CCT (50) evaluated an interactive KT educational intervention whereas one CBA (52) assessed a mass media campaign.Both studies reported statistically significant effects on the medium-term appropriateness of prescription behaviours among health providers (50) and long-term beliefs about back pain in the community (52).

diScuSSiOn
The present systematic review summarized the evidence from 19 studies on the effectiveness of a variety of KT interventions for chronic noncancer pain management.The review has revealed that professional KT interventions incorporating interactive education components have a positive effect on patients' function at the short-and medium-term.Evidence of the effectiveness of KT education interventions for health providers is variable for outcomes such as knowledge acquisition, prescription behaviour, clinical management and confidence in therapeutic options, and for other patient-related outcomes such as pain complaints and changes in work duty rates.
There is evidence that education, information and consumer decision aids directed at chronic noncancer pain patients can lead to improvements in functional capacity and knowledge about chronic pain issues.Evidence from one study on professional-oriented KT interventions on chronic noncancer pain issues that involve structural changes and quality improvement processes did not show significant effects on health provider-or patient-related outcomes.Similarly, there is currently little research evidence to support the effectiveness of other KT interventions that involve coordination of care approaches for chronic noncancer pain patients.More studies assessing the effects of KT interventions targeting structural changes and organization of care are needed to address these knowledge gaps.
The results of chronic pain treatment are particularly sensitive to the degree to which patients are prepared to accept the need for often-difficult changes in lifestyle and outlook.Knowledge is an essential component of behavioural change; however, the mere use of evidence-based knowledge about what to do when faced with chronic pain, even if performed effectively, may not result in measurable clinical improvements, simply because behavioural changes are often difficult to make.This is a limitation not of KT, but of the limited role that knowledge plays in influencing the complex nature of health-related behaviours.
The present systematic review included studies that used a variety of research designs (ie, cluster RCTs, RCTs, CCTs and CBAs).Consistent with the results of similar reviews (55), the majority of included studies were considered likely to be at high risk of bias.Although the majority of the research evidence on the effectiveness of KT interventions for chronic noncancer pain management was derived from RCTs or cluster RCTs, the risk of bias assessment was particularly challenging in many instances, due to incomplete or ambiguous reporting of methodological characteristics.A careful consideration and adoption of methods to reduce bias and enhance the transparency of reporting of primary trial research are necessary to expand the evidence base of KT interventions for the management of chronic noncancer pain.
A relatively heterogeneous group of KT interventions was evaluated in the studies, varying widely in their individual components and the level of action to support research implementation into practice.Overall, the poor reporting of details about their implementation (ie, theoretical framework of behaviour change, frequency and duration of the delivered intervention, characteristics and training of intervention providers, and implementation fidelity) across the studies has important consequences for the interpretation of the effectiveness outcomes in the present review.The lack of information from individual studies on how some procedures and other elements of the KT interventions were implemented as planned precluded the evaluation of whether certain KT interventions were ineffective due to an ineffectual intervention strategy or because they were poorly implemented (56,57).For the KT interventions that showed promising results (ie, education approaches for health care providers and patients), the identification of the likely mechanism of action was equally hampered by poor reporting of KT implementation details.An improved reporting of these elements will facilitate a further understanding about what makes certain KT interventions effective, particularly those with multifaceted components, and the applicability and relevance of individual study findings to other situations (58).
Pain Res Manag Vol 18 No 6 November/December 2013 e136   The adoption of theoretical frameworks for KT, such as the Promoting Action on Research Implementation Health Services (PARIHS) model (59)(60)(61), may help to expand our understanding of the role of KT interventions in managing chronic noncancer pain.The PARIHS framework recognizes the complexities and nonlinearity of implementing evidence into practice.The unique aspect of this framework is that it recognizes the complexity of interactions between professionals and the clinical context, and emphasizes the role of process of implementation by facilitation as an important factor.This model has resonance with the 'Knowledge to Action' model introduced by Graham et al (62) which highlights a range of contextual factors that need to be taken into consideration when implementing evidence.
Assessing the impact of a KT intervention requires the consideration of how research is used and how it is expected to impact clinical practice (63).More than one-half of the studies in the present review used measures of change in health provider outcomes to assess the effectiveness of KT interventions.Measures of change in patient outcomes were assessed in nine studies and included both measures of actual change in patients' health status (eg, patient function) and surrogate measures of patients' change in health status (eg, knowledge acquisition and beliefs about pain, work duty rate and return to work).The pattern of reporting outcome evaluation measures in health practitioner and patients in the individual studies is similar to that identified in similar reviews (55,64).The complexity of chronic noncancer pain suggests that multiple domains are relevant when evaluating the effects of KT interventions.It is recommended that authors of future studies agree on key domains of outcomes to enable the harmonization of measuring the benefits of KT interventions for the management of chronic noncancer pain across studies.Similarly, it is important that future studies refine measures of the multidimensional aspect of patient-related outcomes to include role vocational, social and emotional aspects as outcome measures, and include the patient perspective on what represents a clinically meaningful change that may be expected as a result of KT interventions.
Overall, the KT interventions for chronic noncancer pain management identified in the present systematic review involved both instrumental and conceptual uses of knowledge for the implementation of research into practice (65).Instrumental use of research included the implementation of clinical practice guidelines and facilitating process of change and quality monitoring.Conceptual uses of research through the KT interventions in the present review supported the acquisition of new knowledge about chronic noncancer pain issues and increased awareness of knowledge gaps through the dissemination of research evidence.
Some results of the present study are consistent with those of previous systematic reviews of KT in the area of cancer pain management (55,66) in which comprehensive educational interventions (eg, information, behavioural instructions and advice in relation to pain management by means of verbal, written, audio-or videotaped or computer-aided modalities) were significantly more likely to have positive results compared with those that did not use this approach.In their review, Cummings et al (55) found that education interventions addressed to health providers were associated with significant decreases in patients' pain intensity, and increases in health providers' knowledge and attitudes about cancer pain.Similarly, they found that more than one-half of the studies involving educational KT interventions targeting patients identified a significant decrease in patients' pain intensity as a result of the intervention.
Bennett et al (66) performed a systematic review and meta-analysis to evaluate the benefit of patient-based educational interventions (eg, information, behavioural instructions and advice) in relation to management of cancer pain, which are given by a health provider or peer.Results of our review are also consistent with overviews of systematic reviews of dissemination and implementation strategies of research findings (58,67,68), which have found a consistent effect across interventions including a combination of educational outreach visits, reminders, audit and feedback, social marketing and interactive educational meetings.
The strengths of the present systematic review pertain to its rigour in searching the literature, the criteria-based selection of relevant evidence, the rigorous appraisal of study validity and the evidence-based inferences.Although the identification of a small number of studies reporting comparable outcome measures precluded visual assessment of potential publication bias using funnel plots, the comprehensive search strategy is likely to have identified most of the available literature on the effectiveness of KT interventions for chronic noncancer pain management.Another important asset of the present systematic review is the control for the impact of multiple-publication bias in the narrative synthesis of the results.Multiple publications from single studies can bias a review in a number of ways.Because studies with significant results are more likely to lead to multiple publications and presentations (69) they are more likely to be located in literature searches and, if not recognized as such, they can lead to an overestimation of the intervention effects in systematic reviews (70,71).Our review identified nine multiple publications, avoiding the inclusion of duplicate publications of data, which may have skewed the evidence base in the analysis of the study results.
The present systematic review has several limitations that must be noted.A variety of KT intervention taxonomies are available in the scientific literature and there is a lack of agreement within the research community on a common theoretical or empirical framework for classifying KT interventions.We used a standard taxonomy of interventions aimed at achieving practice change that has been widely used in similar reviews (55,(72)(73)(74).We recognize that many discrete KT interventions deployed various elements that could be classified in more than one category (eg, educational interventions plus patient reminders, audit and feedback techniques, or local opinion leaders).
Planned KT strategies are more likely to be successful if the choice of the approach is informed by an assessment of the likely barriers and facilitators that can operate at the patient and health care provider level and beyond (eg, structural, organizational, peergroup barriers and clinical encounter barriers).The present systematic review was limited to the analysis of the effectiveness of KT interventions for chronic noncancer pain management and did not evaluate the role of different levels of barriers and facilitators to KT.An examination of these factors is crucial to understand how KT interventions can best be implemented.Such analysis implies going beyond the experimental evidence to incorporate qualitative approaches.

cOncluSiOnS
Professional KT interventions in the area of chronic noncancer pain that incorporate interactive education lead to positive effects on patients' function in the short-and medium-term.The benefits of these interventions on other outcomes are not consistent.Patientbased educational interventions can result in benefits in function and knowledge about pain.There is little research evidence to support the effectiveness of KT interventions that involve structural changes and quality improvement processes or coordination of care approaches for chronic noncancer pain patients.Future studies in the area of KT for chronic noncancer pain management should provide better details of the interventions implementation and use consistent theoretical frameworks to inform appropriate choices for dissemination and implementation strategies and to improve their estimate of the effectiveness of such interventions.

Figure 1 ) 5 Unique
Figure 1) Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.KT Knowledge translation

Inadequate random sequence generation Components of risk of bias criteria: 1 =
Sequence generation; 2 = Allocation concealment; 3 = Baseline outcome measurement; 4 = Baseline characteristics; 5 = Participants and personnel blinding; 6 = Blinding or objective assessment of primary outcome; 7 = Completeness of follow-up; 8 = Complete outcome reporting; 9 = Protection against contamination; and 10 = Other potential threats to validity.CBA Controlled before-and-after study; CCT Controlled clinical trial; cRCT Cluster randomized controlled trial; H High risk of bias; L Low risk of bias; RCT Randomized controlled trial; U Unclear risk of bias Knowledge translation for chronic noncancer pain Pain Res Manag Vol 18 No 6 November/December 2013 e135

3 P
-based computer program (n=NR) G2: No intervention (n=NR) Patient; migraine Unit of analysis: Clinical encounter Number of migraine-related topics discussed during the visit (single score from survey) (mean number) between groups = NR Continued on next page Pain Res Manag Vol 18 No 6 November/December 2013 e138

Table 1 Knowledge translation intervention types evaluated in individual studies author (reference), year ePOC classification Intervention characteristics and target group level of action to support moving evidence into practice 1 2 3 4 5 6 7 Health professionals
Knowledge translation for chronic noncancer painPain Res Manag Vol 18 No 6 November/December 2013 e133

Table 1 -COnTInued Knowledge translation intervention types evaluated in individual studies author (reference), year ePOC classification Intervention characteristics and target group level of action to support moving evidence into practice 1 2 3 4 5 6 7 Health professionals -Continued
7f evidence to context (processes/tools designed to make evidence applicable to a given context; includes assessment of needs/barriers; modification of evidence to context); 6 = Implementation fidelity (tools/processes that focus on the operational aspects of implementing/executing specific new actions that are defined by best evidence; and ensuring implementation follows specifications defined by evidence);7= Facilitate process of change and quality/outcome evaluation/ monitoring.CME Continuing medical education; EPOC Cochrane Effective Practice and Organisation of Care Review Group; GP General physician; FP Family physician; NA Not applicable; NR Not reported Pain Res Manag Vol 18 No 6 November/December 2013 e134
*P between groups <0.05 *Statistically significant difference between groups.CBA Controlled before-and-after study; CCT Controlled clinical trial; CME Continuing medical education; CPG Clinical practice guideline; cRCT Cluster randomized controlled trial; G Group; GP General physician; FP Family physician; IQR Interquartile range; LBP Low-back pain; MD Mean difference; NOA Nonopioid analgesic; NR Not reported; OP Occupational physician; PT Physical therapist; RCT Randomized controlled trial; ref Reference; TOA Time of outcome assessment; VAS Visual analogue scale Pain Res Manag Vol 18 No 6 November/December 2013 e139