Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review

Abstract

Objectives: Physicians often refer patients with musculoskeletal conditions to physical therapy. However, it is unclear to what extent physical therapists' treatment choices align with the evidence. The aim of this systematic review was to determine what percentage of physical therapy treatment choices for musculoskeletal conditions agree with management recommendations in evidence-based guidelines and systematic reviews.

Design: Systematic review.

Setting: We performed searches in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine, Scopus and Web of Science combining terms synonymous with 'practice patterns' and 'physical therapy' from the earliest record to April 2018.

Participants: Studies that quantified physical therapy treatment choices for musculoskeletal conditions through surveys of physical therapists, audits of clinical notes and other methods (eg, audits of billing codes, clinical observation) were eligible for inclusion.

Primary and secondary outcomes: Using medians and IQRs, we summarised the percentage of physical therapists who chose treatments that were recommended, not recommended and had no recommendation, and summarised the percentage of physical therapy treatments provided for various musculoskeletal conditions within the categories of recommended, not recommended and no recommendation. Results were stratified by condition and how treatment choices were assessed (surveys of physical therapists vs audits of clinical notes).

Results: We included 94 studies. For musculoskeletal conditions, the median percentage of physical therapists who chose recommended treatments was 54% (n=23 studies; surveys completed by physical therapists) and the median percentage of patients that received recommended physical therapy-delivered treatments was 63% (n=8 studies; audits of clinical notes). For treatments not recommended, these percentages were 43% (n=37; surveys) and 27% (n=20; audits). For treatments with no recommendation, these percentages were 81% (n=37; surveys) and 45% (n=31; audits).

Conclusions: Many physical therapists seem not to follow evidence-based guidelines when managing musculoskeletal conditions. There is considerable scope to increase use of recommended treatments and reduce use of treatments that are not recommended.

Prospero registration number: CRD42018094979.

Keywords: musculoskeletal; non-pharmacological; physical therapy; recommended care; systematic review; treatment choices.

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram. AMED, Allied and Complementary Medicine; CENTRAL, Cochrane Central Register of Controlled Trials; CINAHL, Cumulative Index to Nursing and Allied Health Literature.

Figure 2

Median percentage of physical therapy treatment choices that involved treatments that are recommended, not recommended and had no recommendation. (A) The percentage of physical therapists that report they provide (or would provide) treatments that are recommended, not recommended and had no recommendation for a given condition. (B) The percentage of patients that received treatments that were recommended, not recommended and had no recommendation from a physical therapist for a given condition as determined by audits of clinical notes, audits of billing codes, treatment recording forms, clinical observation or surveys completed by patients. *No treatment choices in this category(s) could be identified. LBP, low back pain; MSK: all musculoskeletal conditions (excluding shoulder pain and knee/hip arthroplasty); OA, osteoarthritis.