Awareness, agreement, adoption, and adherence to low back pain guidelines: A survey of outpatient physical therapists

Background: Despite widespread dissemination of clinical practice guidelines (CPGs), physical therapists (PTs) often use ineffective interventions for low back pain (LBP), suggesting a lack of knowledge translation. The transition from awareness to adherence is a complex process and not well understood. Objective: To evaluate outpatient PTs’ progression from awareness to adherence to LBP CPGs using Pathman’s model of clinical behavior change. Methods: A cross-sectional survey was conducted in 18 outpatient physical therapy clinics across eight health systems. Seventy-three PTs who routinely manage patients with LBP were invited to participate. The survey assessed awareness, agreement, adoption, and adherence to CPG-recommended interventions and included three clinical vignettes representing distinct LBP subgroups. Proportions of PTs meeting successive adherence steps were calculated. Spearman’s rank correlations examined associations among awareness, agreement, adoption, and adherence. Differences across subgroups were analyzed to identify variation in guideline uptake. Results: Sixty PTs completed the survey. Awareness was 78.3%, agreement 85%, adoption 65% and adherence 10%. Among those who agreed with the CPGs, 80% were aware. Of those who adopted the guidelines, 69% were aware and 84% agreed. All adherent PTs met criteria for awareness, agreement, and adoption. Awareness (r_s = 0.379, P =.001), agreement (r_s = 0.395, P <.001), and adoption (r_s = 0.284, P =.030) were significantly correlated with mean adherence. While adoption did not differ significantly across vignettes (P =.879), the mean adherence for LBP with associated affective disorder was 26% lower (P <.001) Conclusion: Adherence to LBP CPGs among PTs remains low despite high awareness and agreement. While strengthening earlier stages of guideline uptake is critical, persistent gaps in adoption and adherence indicate this alone is insufficient. Targeted strategies are urgently needed, particularly for patients with affective disorders, where adherence is notably poor.