{"paper_id":"8efcb0d6-08ca-49c0-b246-a2c35965601e","body_text":"Wissing et al. BMC Women’s Health          (2025) 25:272  \nhttps://doi.org/10.1186/s12905-025-03782-4\nRESEARCH Open Access\n© The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 \nInternational License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long \nas you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if \nyou modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or \nparts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated \notherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not \npermitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To \nview a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.\nBMC Women’s Health\nAssessing use of eau recommendations \nin diagnostic and therapeutic strategies \nfor chronic pelvic pain syndrome: a case \nvignette study on dutch pelvic floor \nphysiotherapists practices\nMyrthe Wissing1*, Marian Rombouts2, Monique Steegers3, Kris Vissers2, Selina van der Wal2 and Kim Notten1 \nAbstract \nBackground Chronic Pelvic Pain Syndrome (CPPS) presents as pain located in the pelvic area lasting for at least \nsix months, often with a multifactorial aetiology. The International Continence Society divides CPPS in multiple \ndomains; one is the musculoskeletal domain. Pelvic floor physiotherapy is a recommended treatment and is advised \nin the European Association of Urologist (EAU) guidelines. However, in the Netherlands, it is unclear which treatment \nstrategies are used by pelvic floor physiotherapists (PFPs) for CPPS patients due to the lack of a Dutch evidenced-\nbased guideline for physiotherapists. This study provides an overview of the adherence to the EAU guideline by PFPs \nin managing CPPS patients.\nMethods A case vignette study using two case vignettes and a general questionnaire defining contextual data. \nParticipants were PFPs treating patients with CPPS in primary care. We contacted 550 qualified PFPs registered \nin the Dutch national quality registry for physiotherapy. Main outcome measure: first, adherence to EAU guidelines \nand second, the adherence compared to level of education and caseload.\nResults Of the invited participants, 198 completed the survey. Of these, 29 (14.6%) scored higher than 80% \nfor both case vignettes; fifty-four (27%) scored 80% for the male case vignette and 30 (15%) scored 80% for the female \ncase.\nConclusions Our findings show low adherence to the EAU guideline’s proposed diagnostic and treatment criteria. \nPFPs should become more familiar with implementation of this guideline.\nKeywords Guideline adherence, Pelvic floor disorder, Pelvic pain, Physical therapy\nBackground\nChronic pelvic pain syndrome (CPPS) is pain in the pel -\nvic region characterized by either continuous or intercur-\nrent episodes of pain for over six months without clear \nevidence for clinical pathology [1]. CPPS is a syndrome \nfound in both men and women with a prevalence in \nmen ranging from 1.9—9.6% compared to 5.7—26.6% in \nwomen [2–6]. CPPS often presents with symptoms of \n*Correspondence:\nMyrthe Wissing\nmyrthe.wissing@radboudumc.nl\n1 Department of Obstetrics and Gynaecology, Radboudumc Nijmegen, \nGeert Grooteplein Zuid 10, Nijmegen, GA 6525, The Netherlands\n2 Department of Anesthesiology Chronic Pain and Palliative Medicine, \nRadboudumc, Nijmegen, The Netherlands\n3 Department of Anesthesiology, Amsterdam UMC, Amsterdam, The \nNetherlands\n\nPage 2 of 7Wissing et al. BMC Women’s Health          (2025) 25:272 \nthe lower urinary tract and lesser pelvis inducing sexual, \nbowel and gynaecological dysfunction. The exact aetiol -\nogy of CPPS remains unknown, but a high interference \nwith gynaecologic, urologic, gastrointestinal, musculo -\nskeletal and psychosocial comorbidities is observed [1]. \nIn 22%—94% of CPPS cases, myofascial pelvic pain is \ninvolved [7]. Ideally, CPPS should be treated at a dedi -\ncated multidisciplinary centre specialized in chronic pain \nin the area of the lesser pelvis [8, 9].\nThe International Continence Society (ICS) has divided \nCPPS in nine different domains based on different organ \nsystems. The fifth domain is the Musculoskeletal domain; \nthis involves pain originated from the pelvic muscles, fas-\ncia, ligaments, joints, or bones. This subdivision of the \ndomain chronic pelvic muscle pain (CPMP) is especially \nrelevant for pelvic floor physiotherapists (PFPs) as they \nhave expertise in diagnostic and treatment modalities for \npelvic floor muscle dysfunctions [10]. Therefore, patients \nwith CPMP are often referred to PFPs [1].\nCurrently, several CPMP treatment strategies are \navailable, including myofascial manual techniques and \nbiofeedback therapy as recommended in the annually \nupdated, evidence based European Urology Association \n(EAU) guideline (see Table  1) [1, 11–14]. In the Neth -\nerlands, no national evidence-based physiotherapeutic \nguideline is available for Chronic Pelvic Pain, although \nusing the general Chronic Pelvic Pain guidelines is taught \nand recommended in the master’s degree (MSc)-curricu-\nlum of PFPs. In recent years, the level of PFP training has \nevolved. Historically, PFPs were educated to the bache -\nlor’s degree level (BSc). Since 2014, they can be awarded \na master’s degree (MSc), which applies a different level of \nthe European Qualifications Framework (level 7 instead \nof level 6), resulting in a higher qualification standard for \nPFPs. [15–17].\nWe conducted a case vignette study to provide an over-\nview of the adherence to EAU guideline by Dutch PFPs in \nmanaging CPPS patients. Moreover, we compared PFPs’ \nlevel of education and workload with the adherence to \nEuropean guidelines.\nMethods\nParticipants\nThe participating PFPs were accredited professionals \nwith a sufficient case load and were all members of the \nDutch Association of Pelvic Floor Physical Therapy. Eli -\ngible participants met the inclusion criteria if they had \ncompleted a licensed course in pelvic floor physiotherapy \nin the Netherlands and were registered in the National \nQuality Register for Physiotherapists (NQRP).[18].\nDue to privacy constraints of the Dutch Association \nof Pelvic Floor Physiotherapists, we were unable to con -\ntact all PFPs directly via email. An online search pro -\nvided contact information of 87% of PFPs, who were \nsent an email requesting for their participation. This \nemail included the study’s background and a request for \ninformed consent. Once informed consent was received, \nPFPs were sent a link to the online survey, and further \ncontact remained by email. The online survey was admin-\nistered using the database Castor EDC. PFPs completed \nthe surveys in between February 2020 and May 2020. \nDuring this period, three reminders were sent.\nDesign\nA case vignette study consisting of case vignettes and \na general questionnaire containing baseline questions \n(contextual data, patient load and educational level) \nwere developed based on the current EAU guidelines \nfor Chronic Pelvic Pain [1]. Our study was approved by \nthe Central Committee on Research Involving Human \nSubjects of Arnhem and Nijmegen (file number: \n2023–16474).\nThe case vignette and general questionnaire\nTwo case vignette studies and a general questionnaire \nwere developed by the research group (abbreviations of \nthe researchers: MR-SW-KN-KV-MS),describing the case \nof a male and female CPPS patient (Figs.  1 and 2). A case \nvignette is a validated and generally accepted method for \nassessing the diagnostic steps and clinical reasoning of \nhealth care professionals [19–22]. Both cases consisted \nof six questions: two on the diagnostic strategy, two on \nthe therapeutic options, and two on the number of treat -\nment sessions needed. The multiple choice questions \n(questions 2–4 for each case) contained three or four \nanswer options; the first question on diagnostic strategy \nTable 1 Recommended strategies for assessing and managing \na CPPS patient by Pelvic Floor Physiotherapists by the EAU \nguidelines\nDiagnostic modalities\n- Vaginal and rectal examination\n- Broad musculoskeletal evaluation (including muscles outside the pelvis)\nTreatment modalities\n- Myofascial trigger point release\n- Myofascial stretching and relaxation\n- Transvaginal manual therapy of the pelvic floor musculature\n- Biofeedback treatment\n- Electromagnetic therapy\n- Microwave thermotherapy\n- Extracorporeal shockwave therapy\n- Acupuncture\n- Posterior tibial nerve stimulation\n- Transcutaneous electrical nerve stimulation\n\nPage 3 of 7\nWissing et al. BMC Women’s Health          (2025) 25:272 \n \nhad seven answer options. The respondents were asked \nto give the three most applicable options for each case.\nThe general questionnaire included questions on con -\ntextual data, educational level (BSc or MSc), years of \nwork experience, case load of patients in their practice, \nand different CPPS diagnostic and interventional strate -\ngies available in their practice.\nValidation and pre‑test\nThe case vignettes were developed by a group of experts \nincluding three accredited pain specialists (KV-MS-\nSW), a urogynaecologist (KN), and two PFPs (MR-LS). \nThe case vignettes were developed based on real clinical \ncases and on the EAU guidelines for CPPS presented in \nthe guideline [1]. The case vignettes were pilot tested by \na panel of 5 PFPs (SS-CO-SH-SSp-MD). The results of \nthe pilot were discussed in the research group and altera -\ntions were made if needed. The final versions of both case \nvignettes are presented in Additionl file 1: Appendix 1.\nThe scoring system\nAn expert group consisting of a PFP , urogynaecologist and \npain specialist (MR-KN-SW) reviewed the results of both \nvignettes and compared the answer options with the EAU \nguidelines [1 ]. They divided 10 points for each answer \noption based on a consensus in the complete research \ngroup (MR-SW-KN-KV-MS-MW) and established the \ndefinite scoring system (see Additionl file 1: Appendix  1 \nand 2). The maximum score for both cases was 43 points \n(= equal to 100% agreement with the guideline). Based \non expert consensus, we determined the cut-off value for \nsuccess at 80% (i.e., 34 points). Secondly, we were inter -\nested whether a high case load or educational level of the \nPFPs would improve guideline adherence. A sufficient \ncase load was defined at > 1 new patient per week and a \nhigh case load was defined at > 5 new patients per week.\nData analysis\nThe statistical analysis was performed with IBM SPSS \nStatistics for Windows, version 25. The general question-\nnaire and multiple choice questions were analysed using \ndescriptive statistics and presented in frequencies, mean \nand standard deviation.\nA Chi-square test was used to determine if there was \na statistical significant association between educational \nlevel and case vignettes scores, and between case load \nand case vignettes scores, with a significance level of 0,05.\nFig. 1 Male vignette\nFig. 2 Female Vignette\n\nPage 4 of 7Wissing et al. BMC Women’s Health          (2025) 25:272 \nResults\nContextual data\nOf the 635 registered PFPs in the Netherlands, 550 PFPs \nwere approached based on availability of internet contact \ninformation and were invited to take part in this study. \nOf these 550 PFPs, 277 PFPs returned the survey (41%). \nSeventy-nine surveys were excluded as they were incom -\nplete, leaving a total of 198 completed surveys (36%) for \nanalysis (Fig. 3). The contextual data of the PFPs are sum-\nmarised in Table 2.\nTable  2 presents contextual data of the pelvic floor \nphysiotherapists including information on work experi -\nence and level of education.\nThe case vignettes\nThe complete case vignettes are presented in Additionl \nfile 1: Appendix  1. A great variety of possible answers \nwere given to the questions for both vignettes. The thera-\npists were very divided which diagnostic or therapeutic \nmodality should be used in the case vignettes.\nWhen comparing the responses to the advice in the \nEAU guideline, 29 (14.6%) of the 198 therapists scored \n80% or higher for both case vignettes. Fifty-four (27%) \ntherapists scored 80% for the male case vignette, and \n30 (15%) scored 80% for the female case. Hundred and \ntwenty six (64%) therapists scored for neither of the case \nvignettes 80%.\nThe PFPs’ educational levels are listed in Table  2. A \nschism is seen in educational level compared to the Euro-\npean Qualification Framework. The majority had an \neducational level of BSc (71%), the remainder qualified \nat MSc level (29%). Additionally, four PFPs were a PhD \n(candidate) (2%). Significantly more BSc therapists fol -\nlowed the EAU guidelines compared to MSc therapists; \n27 of 141 compared to 2 of 57 respectively (p = 0,005) \n(Table 3).\nIn addition to the comparisons of education and scor -\ning, the number of patients treated was compared to the \nscoring. The PFP were asked how many new patients they \nadmitted for diagnostic or therapeutic consultation in a \nFig. 3 Flow Chart Inclusion Respondents\n\nPage 5 of 7\nWissing et al. BMC Women’s Health          (2025) 25:272 \n \nweek. A total of 136 PFPs had a high case load (defined as \n5 new patients in a week) (Table 2). Eight of the 61 thera-\npists, with less than 5 new cases a week, scored 80% or \nmore for both case vignettes compared to 21/136 thera -\npists with more than 5 new cases a week. No significant \ndifference was found in adherence to the EUA guide -\nline between therapists with a high or low caseload (p = \n0.680) (Table 3).\nDiscussion\nThis is the first evaluation of the adherence to EAU mul -\ntidisciplinary guidelines by Dutch PFPs, using a case \nvignette study. We assessed the clinical diagnostic and \ntreatment strategies of chronic pelvic muscular pain by \nDutch PFPs on a scoring system based on the EAU guide-\nlines [1]. A poor adherence to the guideline recommen -\ndations was found, based on the answers given by the \nPFPs. There was a significant difference in adherence to \nthe EAU guideline in favour of BSc-educated PFPs. The \ncase load was not associated with adherence to EAU \nguidelines.\nOnly 15% of the therapists answered according to the \nEAU guideline in both case vignettes. Of the respondents, \n26% scored 80% for one of the cases, answering according \nto current guidelines. This shows that, although the cur -\nrent EAU guidelines for CPPS provide a recommenda -\ntion for how to treat a patient, this does not guarantee a \ngood implementation of the guideline and/or a uniform \nphysiotherapeutic approach and treatment. Compared to \nthe literature on adherence to guidelines in general, the \ncompliance wase found low [23]. For example, in a study \namongst primary care physicians in the USA, 70% of the \nphysicians understood that CPPS is a non-infectious dis -\nease; however only 5% referred patients to PFPs while \nantibiotic therapy was the chosen therapy by 72% of the \nprimary care physicians [24]. This indicates that primary \ncare physicians have little awareness of the current guide-\nlines concerning CPPS.\nOther case vignette studies have also described poor \nadherence to current guidelines [25–31]. For example, \nin palliative care of cancer patients, the adherence to the \nnational Dutch guideline on the diagnosis and treatment \nof pain in patients with cancer was inconclusive: in case \nof a pharmacological treatment (99%) or invasive treat -\nment (95%) adherence was high, in contrast to the rec -\nommendations on the use of a one-dimensional pain \nscale (23%) and performing a multidimensional pain \nassessment (15%) [25].\nAs noted above, a significant difference was found in \nguideline adherence in favour of BSc-educated PFPs. \nThe EAU Chronic Pelvic Pain guideline is taught in its \nfull extent in the MSc-curriculum, and the clinical rea -\nsoning is practiced with a patient case in small study \ngroups. Therefore, a higher adherence was expected to \nthe guideline in MSc-educated PFPs. We also expected a \nhigher caseload would improve guideline adherence, but \nthis was not confirmed by our results. This may be due to \nthe extended interests of MSc-educated PFPs; their focus \nmay shift from clinical practice to research or additional \ntasks, as would be expected of level 7 EQF educated PFPs \n[15–17]. Additionally, MSc-educated PFPs might choose \nfor individualized treatments, as recommendations in \nguidelines are not always suitable for every patient and \nsubsequently match the treatment with the patients’ \nneeds [32]. Altered management strategies may be due to \nprevious positive experiences or the attitude and beliefs \nof a PFP [33, 34].\nTable 2 Contextual data of the pelvic floor physiotherapists\n* One therapist did not mention the caseload\nCharacteristic Number of \nparticipants\nMean (SD)\nTotal 198\nAge in years 49.4 (10.8)\nGender female 196\nYears’ experience 12.7 (7.7)\nHours per week working 24.4 (7.9)\nWorking in primary health care 177\nSelf-confident with simple pain patients 188\nSelf-confident with complex pain patients 145\n > 5 new patients a week 136*\nBSc pelvic floor physiotherapy 141\nMSc pelvic floor physiotherapy 57\nPhD or PhD candidate 4\nTable 3 Overview adherence to the guideline based on education and caseload\n* P-value determined by using the chi-square test, α = 0.05; n = number of participants\nScored < 80% (n) Scored > 80% (n) Adherence guidelines \n(%)\nTotal of participants \n(n)\nP-value*\nEducation BSc level 114 27 19 141 0.005\nMSc level 55 2 4 57\nCaseload High case load 53 8 13 61 0.680\nLow case load 115 21 15 136\n\nPage 6 of 7Wissing et al. BMC Women’s Health          (2025) 25:272 \nStrengths\nThe majority of Dutch PFPs were invited to participate. \nMoreover, the study was supported by the board of the \nDutch Association of Pelvic Floor Physiotherapists. Fur -\nthermore the case vignettes were developed and recon -\nstructed by an expert group based on EAU guidelines \nfor Chronic Pelvic Pain. The response rate of 41% was \ngood, similar to other chronic pain studies with case \nvignettes (24–43%) [25–27]. Another strength is the \ninvolvement of an expert-based scoring system in which \nmultiple experts participated. Despite the absence of \nformal validation, the expert-based approach offers sev -\neral advantages. It leverages the specialized knowledge \nand experience of professionals who are deeply familiar \nwith the subject matter, ensuring that the scoring reflects \nnuanced and contextually appropriate judgments. They \nreached consensus for the scoring system in comparing \nthe case vignettes with the EAU guidelines. The expert \ngroup verified their consensus within the research team \nfor validation and reached agreement for the practice \nbased scoring system based.\nLimitations\nDue to privacy constraints, we were unable to communi -\ncate with the Dutch Association of Pelvic Floor Physiother-\napists about PFPs’ email-addresses and therefore we were \nunable to reach all PFPs, however the overall response rate \nwas good (41%). A further limitation was the use of case \nvignettes as this may cause bias related to socially desir -\nable answers. However, case vignettes are the best option \nto represent clinical reality without case variety. We did \nnot include a question in our questionnaire to determine \nknowledge about the (inter)national guidelines to avoid \nbiased answers. Another limitation is the lack of an vali -\ndated scoring system for the case vignettes. An evidence \nbased scoring is not available and only a practice based \nscoring based on expert opinion was possible to review the \nresults of the case vignettes as seen in other literature[25, \n29, 30, 35]. We recognize the inherent limitations of using \nan unvalidated scoring system however expert-based scor-\ning remains a valuable method for obtaining informed and \ncontextually relevant evaluations of case studies.\nThe lack of adherence to the EAU guidelines for CPPS \nseen in our study marks the cruciality to enhance edu -\ncational efforts and clinical training focused on EAU \nguidelines for PFPs. Strategies should be developed to \nimprove implementation of EAU guideline among all \npracticing PFPs. A Dutch CPPS guideline specifically for \nPFPs might help for an improved adherence to the guide-\nlines. However, more prospective randomized clinical \ntrials are needed to provide evidence for the guidelines \nin recommendations in diagnostic and treatment modali-\nties for CPPS by PFPs. Future research should explore \nthe barriers and facilitators influencing guideline adher -\nence among PFPs in different practice settings. This could \ninform tailored interventions aimed at optimizing guide -\nline implementation and improving patient outcomes in \nthe management of chronic pelvic pain.\nConclusion\nAdherence to EAU guidelines is low resulting in a vari -\nety of CPPS diagnostic and treatment modalities used \nby PFPs; only 15% adhered to the guidelines in the case \nvignettes. To conclude, a minority of the Dutch PFPs fol -\nlow the EAU CPPS guideline recommendations. Based \non these results more attention should be paid to imple -\nmenting the EAU guidelines in the Netherlands and \ndeveloping a Dutch CPPS guideline.\nAbbreviations\nBSc  Bachelor of Science\nCPMP  Chronic Pelvic Muscular Pain\nCPPS  Chronic Pelvic Pain Syndrome\nEAU  European Association of Urology\nICS  International Continence Society\nMSc  Master of Science\nNQRP  The National Quality Register for Physiotherapists\nPFP  Pelvic Floor Physiotherapist\nSupplementary Information\nThe online version contains supplementary material available at https:// doi. \norg/ 10. 1186/ s12905- 025- 03782-4.\nAdditional file 1.\nAcknowledgements\nWe are grateful to all the PFPs who participated. We would like to specifically \nthank the PFPs that helped develop the case vignettes (LS-SS-CO-SH-SSp-MD)\nAuthors’ contributions\nMW and MR wrote the main manuscript. MR and MW collected the data. MW and \nMR analyzed the data. MW prepared all figures. All authors were contributors of \nthe project development and manuscript editing. MW and MR are joint authors.\nFunding\nThis work was supported by the Dutch Association of Pelvic Floor Physiothera-\npists to stimulate scientific research in the field of pelvic floor physiotherapy in \nChronic Pelvic Pain Syndrome.\nData availability\nThe datasets generated and/or analysed during the current study are not \npublicly available due to privacy restraints but are available on request.\nDeclarations\nEthics approval and consent to participate\nThe Central Committee on Research Involving Human Subjects of Arnhem \nand Nijmegen approved this study (file number 2023–16474). All participants \ngave written informed consent before data collection was initiated.\nConsent for publication\nConsent for publication was included in the informed consent.\nCompeting interests\nThe authors declare no competing interests.\n\nPage 7 of 7\nWissing et al. BMC Women’s Health          (2025) 25:272 \n \nReceived: 28 November 2023   Accepted: 6 May 2025\nReferences\n 1. D. Engeler APB, B. Berghmans, , J. Birch JB, A.M. Cottrell, , P . Dinis-Oliveira \nSE, J. Hughes, , E.J. Messelink RAP , M.L. van Poelgeest VT, Williams ACdC. \nEAU Guidelines. Edn. presented at the EAU Annual Congress Milan 2023. \nhttp:// uroweb. org/ guide lines/ compi latio ns- of- all- guide lines/: EAU \nGuidelines Office, Arnhem, The Netherlands. ; 2023.\n 2. Ahangari A. Prevalence of chronic pelvic pain among women: an \nupdated review. Pain Physician. 2014;17(2):E141–7.\n 3. Ferris JA, Pitts MK, Richters J, Simpson JM, Shelley JM, Smith AM. National \nprevalence of urogenital pain and prostatitis-like symptoms in Australian \nmen using the National Institutes of Health Chronic Prostatitis Symptoms \nIndex. BJU Int. 2010;105(3):373–9.\n 4. Häuser W, Schmutzer G, Hinz A, Brähler E. [Prevalence and predictors of \nurogenital pain in men. Results from a survey of a representative German \npopulation sample]. Schmerz. 2012;26(2):192–9.\n 5. Hedelin H, Johannisson H, Welin L. Prevalence of the chronic prostatitis/\nchronic pelvic pain syndrome among 40–69-year-old men residing in a \ntemperate climate. Scand J Urol. 2013;47(5):390–2.\n 6. Wehbe SA, Fariello JY, Whitmore K. Minimally invasive therapies for \nchronic pelvic pain syndrome. Curr Urol Rep. 2010;11(4):276–85.\n 7. Ross V, Detterman C, Hallisey A. Myofascial Pelvic Pain: An Overlooked \nand Treatable Cause of Chronic Pelvic Pain. J Midwifery Womens Health. \n2021;66(2):148–60.\n 8. Baranowski AP , Mandeville AL, Edwards S, Brook S, Cambitzi J, Cohen M. \nMale chronic pelvic pain syndrome and the role of interdisciplinary pain \nmanagement. World J Urol. 2013;31(4):779–84.\n 9. Grinberg K, Sela Y, Nissanholtz-Gannot R. New Insights about Chronic \nPelvic Pain Syndrome (CPPS). Int J Environ Res Public Health. 2020;17(9).\n 10. Doggweiler R, Whitmore KE, Meijlink JM, Drake MJ, Frawley H, Nordling \nJ, et al. A standard for terminology in chronic pelvic pain syndromes: A \nreport from the chronic pelvic pain working group of the international \ncontinence society. Neurourol Urodyn. 2017;36(4):984–1008.\n 11. Anderson RU, Wise D, Sawyer T, Nathanson BH, Nevin SJ. Equal Improve-\nment in Men and Women in the Treatment of Urologic Chronic Pelvic \nPain Syndrome Using a Multi-modal Protocol with an Internal Myofascial \nTrigger Point Wand. Appl Psychophysiol Biofeedback. 2016;41(2):215–24.\n 12. Cornel EB, van Haarst EP , Schaarsberg RW, Geels J. The effect of biofeed-\nback physical therapy in men with Chronic Pelvic Pain Syndrome Type III. \nEur Urol. 2005;47(5):607–11.\n 13. Grinberg K, Weissman-Fogel I, Lowenstein L, Abramov L, Granot M. How \nDoes Myofascial Physical Therapy Attenuate Pain in Chronic Pelvic Pain \nSyndrome? Pain Res Manag. 2019;2019:6091257.\n 14. Loving S, Nordling J, Jaszczak P , Thomsen T. Does evidence support physi-\notherapy management of adult female chronic pelvic pain? A systematic \nreview Scand J Pain. 2012;3(2):70–81.\n 15. The European Qualifications Framework: Europass European Union; \n[Available from: https:// europ ass. europa. eu/ en/ europ ass- digit al- tools/ \neurop ean- quali ficat ions- frame work#: ~: text= The% 20EQF% 20cov ers% \n20all% 20typ es,and% 208% 20the% 20hig hest% 20lev el.\n 16. The Dutch Qualification Framework: NLQF; [Available from: https:// nlqf. \nnl/ engli sh.\n 17. Europass. EQF en NLQF, het Europees kwalificatieraamwerk [Available \nfrom: https:// www. europ ass. nl/ eqfnl qf/.\n 18. KNGF AVvh. REGLEMENT CENTRAAL KWALITEITSREGISTER FYSIOTHERAPIE \n1997 [updated 28–09–2016. Available from: https:// www. kngf. nl/ binar \nies/ conte nt/ assets/ kngf/ onbev eiligd/ vakge bied/ kwali teit/ ckr/ regle ment- \ncentr aal- kwali teits regis ter- fysio thera pie- 28- septe mber- 2016. pdf.\n 19. Bachmann LM, Mühleisen A, Bock A, ter Riet G, Held U, Kessels AG. Vignette \nstudies of medical choice and judgement to study caregivers’ medical deci-\nsion behaviour: systematic review. BMC Med Res Methodol. 2008;8:50.\n 20. Evans SC, Roberts MC, Keeley JW, Blossom JB, Amaro CM, Garcia AM, et al. \nVignette methodologies for studying clinicians’ decision-making: Validity, \nutility, and application in ICD-11 field studies. Int J Clin Health Psychol. \n2015;15(2):160–70.\n 21. Kathiresan J, Patro BK. Case vignette: a promising complement to clinical \ncase presentations in teaching. Educ Health (Abingdon). 2013;26(1):21–4.\n 22. Finch J. The Vignette Technique in Survey Research. Sociology. \n1987;21(1):105–14.\n 23. Mickan S, Burls A, Glasziou P . Patterns of “leakage” in the utilisation of clini-\ncal guidelines: a systematic review. Postgrad Med J. 2011;87(1032):670–9.\n 24. Calhoun EA, Clemens JQ, Litwin MS, Walker-Corkery E, Markossian T, \nKusek JW, McNaughton-Collins M. Primary care physician practices \nin the diagnosis, treatment and management of men with chronic \nprostatitis/chronic pelvic pain syndrome. Prostate Cancer Prostatic Dis. \n2009;12(3):288–95.\n 25. Besse K, Steegers M, Vernooij-Dassen M, Vissers K, Engels Y. Dutch Pain \nSpecialists’ Adherence to the Multidisciplinary Guideline on Treat-\ning Pain in Patients with Cancer: A Case Vignette Study. Pain Pract. \n2017;17(3):344–52.\n 26. te Boveldt N, Vernooij-Dassen M, Besse K, Vissers K, Engels Y. Adaptation \nof an evidence-based clinical practice guideline in cancer pain manage-\nment by medical oncologists: a case vignette study. Support Care Cancer. \n2015;23(5):1409–20.\n 27. Tucker Edmonds B, McKenzie F, Austgen MB, Ashburn-Nardo L, Matthias \nMS, Hirsh AT. Obstetrical Providers’ Management of Chronic Pain in Preg-\nnancy: A Vignette Study. Pain Med. 2017;18(5):832–41.\n 28. Martinez V, Attal N, Vanzo B, Vicaut E, Gautier JM, Bouhassira D, Lantéri-\nMinet M. Adherence of French GPs to chronic neuropathic pain clinical \nguidelines: results of a cross-sectional, randomized, “e” case-vignette \nsurvey. PLoS ONE. 2014;9(4): e93855.\n 29. Rousseau A, Azria E, Baumann S, Deneux-Tharaux C, Senat MV. Do obste-\ntricians apply the national guidelines? A vignette-based study assessing \npractices for the prevention of preterm birth. BJOG. 2020;127(4):467–76.\n 30. Rousseau A, Rozenberg P , Perrodeau E, Deneux-Tharaux C, Ravaud P . \nVariations in Postpartum Hemorrhage Management among Midwives: A \nNational Vignette-Based Study. PLoS ONE. 2016;11(4): e0152863.\n 31. Glauser TA, Salinas GD, Roepke NL, Williamson JC, Reese A, Gutierrez G, \nAbdolrasulnia M. Management of mild-to-moderate osteoarthritis: a \nstudy of the primary care perspective. Postgrad Med. 2011;123(1):126–34.\n 32. Ford JJ, Hahne AJ, Surkitt LD, Chan AY, Richards MC, Slater SL, et al. Indi-\nvidualised physiotherapy as an adjunct to guideline-based advice for low \nback disorders in primary care: a randomised controlled trial. Br J Sports \nMed. 2016;50(4):237–45.\n 33. Swinkels ICS, van den Ende CHM, van den Bosch W, Dekker J, Wimmers RH. \nPhysiotherapy management of low back pain: Does practice match the \nDutch guidelines? Australian Journal of Physiotherapy. 2005;51(1):35–41.\n 34. Darlow B, Fullen BM, Dean S, Hurley DA, Baxter GD, Dowell A. The associa-\ntion between health care professional attitudes and beliefs and the \nattitudes and beliefs, clinical management, and outcomes of patients \nwith low back pain: A systematic review. Eur J Pain. 2012;16(1):3–17.\n 35. Haring MPD, de Haas RJ, van Vilsteren FGI, Klaase JM, Duiker EW, Blokzijl \nH, et al. Variation in the management of benign liver tumors: A Euro-\npean survey and case vignette study. Clin Res Hepatol Gastroenterol. \n2023;47(3): 102094.\nPublisher’s Note\nSpringer Nature remains neutral with regard to jurisdictional claims in pub-\nlished maps and institutional affiliations.","source_license":"CC0","license_restricted":false}