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Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? Systematic review
  1. Joshua Zadro,
  2. Mary O’Keeffe,
  3. Christopher Maher
  1. Institute for Musculoskeletal Health, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
  1. Correspondence to Joshua Zadro; joshua.zadro{at}


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.

  • non-pharmacological
  • musculoskeletal
  • physical therapy
  • treatment choices
  • systematic review
  • recommended care

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  • Contributors All authors critically revised the manuscript for important intellectual content and approved the final manuscript. JZ: conception and design, analysis and interpretation of data, drafting and revision of the manuscript, and final approval of the version to be published. MO and CM: conception and design, interpretation of data, drafting and revision of the manuscript and final approval of the version to be published. The corresponding author (JZ) attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests All authors declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work; no other relationships or activities that could appear to have influenced the submitted work.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

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