Barriers to the implementation of point-of-care ultrasonography by physiotherapists in haemophilia treatment centres in Canada: a modified Delphi approach

Open access


Background: In patients with haemophilia, evidence suggests that the physical examination alone is not sensitive enough to detect small amounts of blood within a joint. Attention has shifted to methods of improving the sensitivity of the physical examination through adding diagnostic modalities such as point-of-care ultrasonography (POC-US). Proficiency with the physical examination and understanding of the role of POC-US are important competencies for physiotherapists. Despite training, implementation of POC-US by physiotherapists in haemophilia treatment centres in Canada has been mixed.

Aim: Using a theory-based approach, the aim of the current study is to achieve expert consensus regarding the barriers to physiotherapy performed POC-US in haemophilia treatment centres in Canada using a modified Delphi approach.

Materials and Methods: Using the Knowledge-to-Action Framework and the Consolidated Framework for Implementation Research (CFIR), a modified Delphi approach was completed using the Modified BARRIERS Scale (MBS). Participants were blinded and consensus was reached over three rounds at the Canadian Hemophilia Society’s annual three-day conference.

Results: Twenty-two physiotherapists participated; 20 participants completed Round 1, and 21 completed Rounds 2 and 3. Four items of the MBS reached consensus: 1) The physiotherapist does not have time to read research related to POC-US; 2) The physiotherapist is isolated from knowledgeable colleagues with whom to discuss POC-US; 3) Administration will not allow POC-US implementation; 4) There is insufficient time on the job to implement new ideas. All four consensus items can be mapped to one domain of the CFIR: the inner setting.

Conclusion: The haemophilia treatment centre within a healthcare organisation appears to be an important target for addressing barriers to the implementation of physiotherapy performed POC-US.

If the inline PDF is not rendering correctly, you can download the PDF file here.

  • 1. Dunn AL. Pathophysiology diagnosis and prevention of arthropathy in patients with haemophilia. Haemophilia 2011; 17(4): 571–8. doi: 10.1111/j.1365-2516.2010.02472.x.

  • 2. Srivastava A Brewer AK Mauser-Bunschoten EP et al. Guidelines Working Group on Behalf of the World Federation of Hemophilia. Guidelines for the management of hemophilia. Haemophilia 2013; 19(1): e1–47. doi: 10.1111/j.1365-2516.2012.02909.x.

  • 3. Pettersson H Ahlberg A Nilsson IM. A radiologic classification of hemophilic arthropathy. Clin Orthop Relat Res 1980; 149: 153–9.

  • 4. Manco-Johnson MJ Pettersson H Petrini P et al. Physical therapy and imaging outcome measures in a haemophilia population treated with factor prophylaxis: current status and future directions. Haemophilia 2004; 10 Suppl 4): 88–93.

  • 5. Melchiorre D Linari S Innocenti M et al. Ultrasound detects joint damage and bleeding in haemophilic arthropathy: a proposal of a score. Haemophilia 2011; 17(1): 112–7. doi: 10.1111/j.1365-2516.2010.02380.x.

  • 6. Aznar JA Abad-Franch L Perez-Alenda S et al. Ultrasonography in the monitoring of management of haemarthrosis. Haemophilia 2011; 17(5): 826–8. doi: 10.1111/j.1365-2516.2011.02538.x.

  • 7. Strike KL Iorio A Jackson S et al. Point of care ultrasonography in haemophilia care: recommendations for training and competency evaluation. Haemophilia 2015; 21(6): 828–31. doi: 10.1111/hae.12767.

  • 8. Canadian Association of Radiologists. Position Statement on the Use of Point of Care Ultrasound. June 2013. Available from (accessed 15 August 2019).

  • 9. Vieira RL Levy JA. Bedside ultrasonography to identify hip effusions in pediatric patients. Ann Emerg Med 2010; 55(3): 284–9. doi: 10.1016/j.annemergmed.2009.06.527.

  • 10. Adhikari S Blaivas M. Utility of bedside sonography to distinguish soft tissue abnormalities from joint effusions in the emergency department. J Ultrasound Med 2010; 29(4): 519–26.

  • 11. Martinoli C Della Casa Alberighi O Di Minno G et al. Development and definition of a simplified scanning procedure and scoring method for Haemophilia Early Arthropathy Detection with Ultrasound (HEAD-US). Thromb Haemost 2013; 109(6): 1170–9. doi: 10.1160/TH12-11-0874.

  • 12. Doria AS Keshava SN Mohanta A et al. Diagnostic accuracy of ultrasound for assessment of hemophilic arthropathy: MRI correlation. AJR Am J Roentgenol 2015; 204: W336–47. doi: 10.2214/AJR.14.12501.

  • 13. Querol F Rodriguez-Merchan EC. The role of ultrasonography in the diagnosis of the musculo-skeletal problems of haemophilia. Haemophilia 2012; 18(3): e215–26. doi: 10.1111/j.1365-2516.2011.02680.x.

  • 14. Moore CL Copel JA. Point-of-care ultrasonography. N Engl J Med 2011; 364(8): 749–57. doi: 10.1056/NEJMra0909487.

  • 15. Rhon DI Deyle GD Gill NW. Clinical reasoning and advanced practice privileges enable physical therapist point-of-care decisions in the military health care system: 3 clinical cases. Phys Ther 2013; 93(9): 1234–43. doi: 10.2522/ptj.20120148.

  • 16. Boyles RE Gorman I Pinto D Ross MD. Physical therapist practice and the role of diagnostic imaging. J Orthop Sports Phys Ther 2011; 41(11): 829–37. doi: 10.2519/jospt.2011.3556.

  • 17. Brandon M. The use of ultrasonography in a physiotherapy-led one stop hand clinic. Rheumatology 2013; 52: i25.

  • 18. Brandon M Frield L Budai S et al. FRI0474-HPR Ultrasound imaging and the therapeutic planning of targeted corticosteroid injections for symptomatic hand osteoarthritis. Ann Rheum Dis 2013; 71: 749.

  • 19. Moss D Wilson H McEntegart A. Retrospective audit of a physiotherapist-LED shoulder clinic. Rheumatology 2010; 49: I126-I127.

  • 20. Solomon SD Saldana F. Point-of-care ultrasound in medical education – stop listening and look. N Eng J Med 2014; 320(2): 1083–5. doi: 10.1056/NEJMp1311944.

  • 21. Strike K Uy M Lawson W et al. Point-of-care ultrasonography in haemophilia care: Training and competency for muscular haematomas. Haemophilia 2018; 24(3): 335–7. doi: 10.1111/hae.13417.

  • 22. Eccles M Grimshaw J Walker A Johnston M Pitts N. Changing the behavior of healthcare professionals: The use of theory in promoting the uptake of research findings. J Clin Epidemiol 2005; 58(2): 107–12.

  • 23. Straus S Tetroe J Graham ID (eds.). Knowledge Translation in Health Care: Moving Evidence to Practice. 2009. Oxford: Blackwell.

  • 24. Damschroder LJ Aron DC Keith RE et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009; 4: 50. doi: 10.1186/1748-5908-4-50.

  • 25. Consolidated Framework for Implementation Research. Available from: (accessed 15 August 2018).

  • 26. Tabak RG Khoong EC Chambers DA Brownson RC. Bridging research and practice: models for dissemination and implementation research. Am J Prev Med 2012; 43(3): 337–50. doi: 10.1016/j.amepre.2012.05.024.

  • 27. Hsu CC Sandford BA. The Delphi technique: making sense of consensus. Practical Assessment Research and Evaluation 2007; 12(10): 1–8.

  • 28. Skulmoski GJ Hartman FT Krahn J. The Delphi method for graduate research. Journal of Information Technology Education 2007; 6: 1–21. Available from (accessed 15 August 2019).

  • 29. Okoli C Pawlowski SD. The Delphi method as a research tool: an example design considerations and applications. Information & Management 2004; 42(1): 15–29. doi: 10.1016/

  • 30. Keeney S Hasson F McKenna H. The Delphi Technique in Nursing and Health Research. 2011. Oxford: Wiley-Blackwell.

  • 31. Kajermo KN Boström AM Thompson DS et al. The BARRIERS scale – the barriers to research utilization scale - a systematic review. Implement Sci 2010; 5: 32. doi: 10.1186/1748-5908-5-32.

  • 32. Funk SG Champagne MT Wiese RA Tornquist EM. BARRIERS: the barriers to research utilization scale. Appl Nurs Res 1991; 4(1): 39–45.

  • 33. Canadian Physiotherapists in Hemophilia Care. Constitution. Revised May 2016. Available from (accessed 15 August 2019).

  • 34. Nilsagård Y Lohse G. Evidence-based physiotherapy: A survey of knowledge behaviour attitudes and prerequisites. Adv Physiother 2010; 12(4): 179–86.

  • 35. Dannapfel P Peolsson A Nilsen P. What supports physiotherapists’ use of research in clinical practice? A qualitative study in Sweden. Implement Sci 2013; 8: 31. doi: 10.1186/1748-5908-8-31.

  • 36. Grimmer-Somers K Lekkas P Nyland L Young A Kumar S. Perspectives on research evidence and clinical practice: a survey of Australian physiotherapists. Physiother Res Int 2007; 12(3): 147–61.

  • 37. Stevenson K Lewis M Hay E. Do physiotherapists' attitudes towards evidence-based practice change as a result of an evidence-based educational programme? J Eval Clin Pract 2004; 10(2): 207–17.

  • 38. Giguere A Légaré F Grimshaw J et al. Printed educational materials: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012; 10: CD004398. doi: 10.1002/14651858.CD004398.pub3.

  • 39. Dobbins M Robeson P Ciliska D et al. A description of a knowledge broker role implemented as part of a randomized controlled trial evaluating three knowledge translation strategies. Implement Sci 2009; 4: 23. doi: 10.1186/1748-5908-4-23.

Journal information
All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 21 21 5
PDF Downloads 15 15 2