Physiotherapy 104 (2018) 1–8

Systematic review

Strategies to translate knowledge related to common

musculoskeletal conditions into physiotherapy practice: a
systematic review
Marie-Ève Bérubé a , Stéphane Poitras a,∗ , Marc Bastien a , Lydie-Anne Laliberté a
, Anyck Lacharité a , Douglas P. Gross b
a School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H
8M5, Canada
b Department of Physical Therapy, University of Alberta, 2-50 Corbett Hall, Edmonton, Alberta T6G 2G4, Canada

Abstract
Background Many physiotherapists underuse evidence-based practice guidelines or recommendations when treating patients with muscu-
loskeletal disorders, yet synthesis of knowledge translation interventions used within the field of physiotherapy fails to offer clear conclusions
to guide the implementation of clinical practice guidelines.
Objectives To evaluate the effectiveness of various knowledge translation interventions used to implement changes in the practice of current
physiotherapists treating common musculoskeletal issues.
Data sources A computerized literature search of MEDLINE, CINHAL and ProQuest of systematic reviews (from inception until May 2016)
and primary research studies (from January 2010 until June 2016).
Study selection and eligibility criteria Eligibility criteria specified articles evaluating interventions for translating knowledge into physio-
therapy practice.
Data extraction and data synthesis Two reviewers independently screened the titles and abstracts, reviewed full-text articles, performed
data extraction, and performed quality assessment. Of a total of 13 014 articles located and titles and abstracts screened, 34 studies met the
inclusion criteria, including three overlapping publications, resulting in 31 individual studies.
Results Knowledge translation interventions appear to have resulted in a positive change in physiotherapist beliefs, attitudes, skills and
guideline awareness. However, no consistent improvement in clinical practice, patient and economic outcomes were observed.
Limitations The studies included had small sample sizes and low methodological quality. The heterogeneity of the studies was not conducive
to pooling the data.
Conclusions and implication of key findings The intensity and type of knowledge translation intervention seem to have an effect on practice
change. More research targeting financial, organizational and regulatory knowledge translation interventions is needed.
© 2017 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Keywords: Physical therapists; Back pain; Neck pain; Occupational injuries; Knowledge

Introduction
It has been shown that most primary care physiothera-
pists underuse evidence-based clinical practice guidelines or
recommendations when treating patients with musculoskele-
∗ Corresponding author.
E-mail address: stephane.poitras@uottawa.ca (S. Poitras).
tal problems, even though the majority of them are aware
of such guidelines [1,2]. This results in inadequate practice
and could potentially increase the risk of chronic disability
[3,4]. Since individuals with chronic musculoskeletal health
problems are characterized by greater comorbidity and eco-
nomic burden when compared to healthy individuals [5], it
is important for physiotherapists to implement interventions

https://doi.org/10.1016/j.physio.2017.05.002
0031-9406/© 2017 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
2 M.-È. Bérubé et al. / Physiotherapy 104 (2018) 1–8
whose effectiveness has been clearly demonstrated and are
in line with established guidelines.
Use of knowledge, including guidelines, is complex due
to a number of competing factors, some of which are beyond
the immediate control of clinicians [6]. The main barri-
ers to physiotherapists using guidelines are, among others,
lack of time and personal skills in searching and evaluat-
ing research evidence, and lack of autonomy and authority
to implement guidelines in practice [1,7]. Concerning mus-
culoskeletal disorders specifically, guidelines generally state
that the focus should move from a biomedical to a biopsy-
chosocial approach, in order to evaluate and manage factors
associated with chronic disability [8]. Research has also
shown the challenges of physiotherapists moving from a
biomedical to a biopsychosocial model when trying to imple-
ment guidelines into practice [9].
Knowledge translation aims to integrate the findings of
research into practice [10] and enhance patient outcomes
[11]. It is a dynamic process that involves the synthe-
sis, dissemination, and exchange of knowledge based on
the best available evidence in hopes of improving health
[12]. Previous systematic reviews have assessed the efficacy
of knowledge translation interventions within rehabilita-
tion professionals [6,10,13–15]. However, these systematic
reviews included broad and non-specific clinician and patient
populations and failed to offer clear conclusions to guide the
implementation of clinical practice guidelines specifically for
physiotherapists treating musculoskeletal conditions. Also,
to our knowledge there is no documented evaluation of the
quality of past systematic reviews, making it difficult to
draw conclusions from these reviews. To account for this
knowledge gap, this systematic review seeks to review the
effectiveness of various knowledge translation interventions
used to implement changes in clinical practice, patient out-
comes, and economic variables for physiotherapists treating
common musculoskeletal conditions including, but not lim-
ited to, back and neck pain. This will help to develop effective
knowledge translation interventions needed to implement
guidelines into practice.
Methods
This systematic review followed the PRISMA (Preferred
Reporting Items for Systematic reviews and Meta-Analyses)
Statement [16]. It consists of a 27-item checklist and a four-
phase flow diagram established to improve the reporting
of systematic reviews and meta-analyses, ensuring clarity
and transparency [17]. It has been shown that endorsing the
PRISMA Statement results in the increase of reporting and
methodological quality [18].
A protocol and search strategy was designed to synthesize
research evidence prior to this systematic review (Appen-
dices 1 & 2, Supplementary data). It was refined during the
research by adding relevant keywords to expand and cover
more literature in order to achieve saturation. As per the
PRISMA Statement; “Authors may modify protocols during
the research; and readers should not automatically consider
such modifications inappropriate” [17].
Data sources and searches
To begin, the search strategy (Appendix 1, Supplementary
data) was applied in two electronic databases (MEDLINE,
CINHAL) to identify systematic reviews using language
(French and English) and date restrictions (from inception
until May 2016). These two databases have been shown to
exhaustively cover the physiotherapy research field [19]. This
process allowed for the identification of the literature covered
so far by systematic reviews and their end date of coverage,
which was determined to be January 2010. Therefore, the
same search strategy (Appendix 2, Supplementary data) was
applied in two electronic databases (MEDLINE, CINHAL)
using language (French and English) and date restrictions
(January 2010 to June 2016) for individual studies. Grey liter-
ature was also searched in one electronic database (ProQuest)
using language (French and English) and date restrictions
(January 2010 to June 2016). Finally, verifying reference
lists and communicating with experts, if needed, is an effec-
tive process of ensuring that all relevant publications were
included [20]. Coupled with the search strategy, a “snowball”
method was used, which can be described as using the refer-
ence list of a publication and the citations of the reference to
identify additional papers [21]. Snowball sampling has been
shown to be powerful for detecting high quality sources in
obscure locations [22].
Study selection
Systematic reviews and individual studies were included
if they met the criteria presented in Table S1 (Supplemen-
tary data). Publications were excluded if the population
consisted of physiotherapy students. Two reviewers indepen-
dently screened the titles and abstracts of search results for
the systematic reviews and individual studies, and reviewed
the full-text of potentially relevant publications using the pre-
determined inclusion criteria. Individual studies found in the
systematic reviews were also screened for eligibility. Diver-
gences in study selection were resolved through discussion
between both reviewers. In the event where consensus could
not be obtained, a third person adjudicated. Authors were
contacted whenever an article could not be accessed.
Data extraction
Study data were extracted using a modified version of
the Data Collection Checklist available from the Cochrane
Effective Practice and Organisation of Care Review Group
(EPOC) [23]. Quality improvement research has shown that
EPOC has established methods and tools supporting reviews
of quality improvement strategies [24]. Data were extracted
as per the predetermined items of PICOS; population con-
sisting of physiotherapists treating back pain, neck pain
or work-related musculoskeletal disorders; the interventions
 M.-È. Bérubé et al. / Physiotherapy 104 (2018) 1–8
were at a professional, financial, organizational or regulatory
level; included any empirically assessed change in health pro-
fessional outcomes/process measures, patient outcomes or
economic variables; and research design. Data were extracted
by two independent reviewers. In the event where a consensus
could not be obtained, a third person adjudicated.
Quality assessment
The measurement tool used to assess the methodological
quality of systematic reviews was the AMSTAR [25]. This
11-item tool has been shown to have good agreement, reli-
ability, construct validity and feasibility [26]. Quality was
determined using three levels: a score from 8 to 11 is consid-
ered as high quality, 4 to 7 is medium quality, whereas 0 to 3
is low quality [27].
The quality of individual studies was assessed using the
PEDro scale from the Physiotherapy Evidence Database. The
reliability of the total PEDro score has been shown to vary
from fair to good, whereas the reliability of ratings of PEDro
scale items varied from fair to substantial [28]. This tool has
been shown to be valid using Rasch analysis [29]. Since it
is difficult to blind therapists or subjects in physiotherapy
studies, it has been suggested to adopt a modified cut-off
point of 5/10 [30]. In the context of this systematic review,
a publication with a score of 5/10 or more on the PEDro
scale and random allocation (criteria #2) was considered as
good quality. Validated scores of studies in the Physiotherapy
Evidence Database were used. Two independent reviewers
assessed the methodological quality of systematic reviews
and included studies. In the event where a consensus could
not be obtained, a third person adjudicated.
Data synthesis and analysis
To analyze and synthesize study data, stratification was
used to group the studies by pathology (back pain, neck
pain, and other musculoskeletal pain). Each set of studies
was subsequently aggregated according to the type of inter-
vention strategy: health professional interventions, financial
interventions, organizational interventions or regulatory
interventions. Health professional interventions included,
as described in the EPOC checklist [23], distribution of
educational materials, educational meetings, local consen-
sus processes, educational outreach visits, local opinion
leaders, patient mediated interventions, audit and feedback,
reminders, marketing and mass media. As for the financial
interventions, they included provider interventions such as
fee-for-service, incentives or grant allowance and patient
interventions such as user-fee, incentives, penalty or co-
payment. Organizational interventions included provider and
patient oriented interventions as well as structural inter-
ventions. Finally, regulatory interventions comprised any
intervention that aimed to change health services delivery or
costs by regulation or law. A subanalysis was also performed
on health professional outcomes/process measures, patient
outcomes and economic variables. A descriptive analysis
3
of the included studies was completed in hopes of identi-
fying patterns in terms of interventions and outcomes and
ultimately explore which interventions were successful or
not. Recommendations were developed based on high qual-
ity individual studies whereas poor quality studies were used
as potential avenues for future research. Meta-analyses were
planned if homogeneity of the studies was established.
Results
Of the 2822 systematic reviews screened, six reviews met
the inclusion criteria and one review was identified using the
snowball method (Fig. S1, Supplementary data). The seven
systematic reviews [6,10,13–15,31,32] were used to extract
individual studies published before January 2010. A sum-
mary of the quality assessment score using the AMSTAR
scale is presented in Table S2 (Supplementary data). Of
the seven systematic reviews, only one systematic review
received a good quality score, and the remaining six were
considered of medium quality.
Of the 13 014 studies screened, 34 individual studies met
the inclusion criteria (Fig. S2, Supplementary data). 21 of
them were identified by the primary search strategy; four from
the snowball strategy; one from expert opinion, and eight
studies were included from the systematic reviews. Included
studies consisted of interventions to implement treatment
guidelines for back pain (n = 24), neck pain (n = 5) and mus-
culoskeletal disorders (n = 5). 15 studies were randomized
controlled trials (RCT), 18 were a controlled before-and-after
(CBA) design and one interrupted time series. A summary of
the 34 studies, including study elements such as the aim,
PICOS question and the quality assessment score using the
PEDro scale is presented in Supplementary Tables1–4. Tables
are organized by the type of intervention and musculoskele-
tal condition, such as professional interventions targeting
the back pain population, organizational interventions with
the back pain population, professional interventions with the
neck pain population, and professional interventions for other
musculoskeletal conditions. Of the 34 manuscripts, three
studies produced two manuscripts each [33–38], resulting in
31 individual studies. As for methodological quality, 13 of the
34 individual studies received a higher rating, (cut-off point of
5/10 on the PEDro scale and random allocation) considered
as good quality publications [35,36,39–49], and the remain-
ing 21 articles received a lower rating [33,34,37,38,50–66].
Meta-analyses and evaluation of publication bias could not
be conducted due to methodological outcome heterogeneity
of the studies.
Interventions
Following the EPOC classification, the predominant
knowledge translation interventions were done at a profes-
sional level for 31 studies [33–36,39,66,40–45,65,46–62,64].
Only three studied used organizational interventions
4 M.-È. Bérubé et al. / Physiotherapy 104 (2018) 1–8
[37,38,63] and there were no studies located on financial or
regulatory interventions.
Health professional knowledge
28 studies evaluated outcomes at the health professional
level [33–35,37–39,66,40,42,43,65,46–51,53–55,57–64].
Although a variety of outcome measures were used, the
beliefs, attitudes, skills, guidelines awareness, and knowl-
edge of physiotherapists improved in 23 of the 28 studies
[35,37–39,66,40,43,65,46–50,53,54,57–64].
Health professional clinical practices
15 studies assessed impact at the clinical practice level
[33,34,38,42,46–49,51,54,55,57,62–64]. 10 of these reported
increased guideline adherence [38,46–49,54,57,62–64],
while five reported no change in practice [33,34,42,51,55].
From these 15 studies, only four were considered of good
quality, with three reporting practice improvements [46–48]
and no significant change in the other [42]. The three stud-
ies demonstrating improvements used either self-reported
measures [46,48] or audio recordings of patient encounters
accomplished in the context of research [47], while the study
demonstrating no change used patient records [42].
Patient outcomes
11 studies evaluated outcomes at the patient level
[36,66,41–46,52,56,63], five of which demonstrated posi-
tive patient outcomes [44,46,52,56,63], while six showed
no improvement [36,66,41–43,45]. Out of these 11 studies,
seven were considered of good quality, with two showing
improvement in patient outcomes [44,46] and five showing
no significant changes [36,41–43,45].
Economic outcomes
Four studies evaluated economic outcomes [41,43,44,52].
Two good quality studies showed no change in cost differ-
ences, cost of absenteeism, annual cost per patient and cost
of care [41,43]. One good quality and one low quality study
demonstrated fewer visits over a shorter duration and lower
physical therapy costs in regards to neck pain [44,52].
Discussion
The primary objective of this study was to establish rec-
ommendations in regards to efficient knowledge translation
interventions aimed at physiotherapists treating muscu-
loskeletal problems. Given the lack of clear evidence on
the subject, this project sought to systematically review cur-
rent literature on the effectiveness of various physiotherapy
knowledge translation interventions used to foster changes
in health professional, patient, or economic outcomes. This
study remained specific to those treating common muscu-
loskeletal conditions, including, but not limited to back and
neck pain. To our knowledge, this is the first systematic
review specifically focusing on physiotherapists.
We identified 34 studies that evaluated knowledge trans-
lation interventions specific to physiotherapists treating
musculoskeletal disorders. Interventions to move knowledge
to physiotherapists consisted of professional (distribution
of educational materials, educational meetings, local con-
sensus processes, educational outreach visits, local opinion
leaders, patient mediated interventions, audit and feedback,
reminders, marketing, and mass medias) and organizational
(revision of professional roles, clinical multidisciplinary
teams, skill mix changes, communication and case discussion
between distant professions, and monitoring mechanisms)
interventions. Findings from this systematic review suggest
that these interventions, whatever the type chosen, tend to
increase guideline awareness and knowledge.
However, results in regards to practice change and
patient outcomes were less clear. Studies demonstrating prac-
tice change tended to use self-reported measures [46–48],
whereas the study showing no change used patient records
[42]. Social desirability bias could explain positive changes
seen in studies using self-reported measures, with physio-
therapists reporting what they believed researchers wanted to
see. It would be preferable in future studies to study patient
records, in order to avoid social desirability bias. When look-
ing at the studies with positive patient outcomes, they tended
to be face-to-face continuing education courses (instead of
online courses or passive dissemination of documents) of
longer duration (generally multiple sessions over a month or
more) that included case studies and practical tools, allowed
clinicians to practice newly acquired competencies in clinic,
and obtained feedback from trainers. Research has demon-
strated that the type and intensity of knowledge translation
interventions have an influence on the amount of change
in practice [14]. In regards to type, it has been shown that
multifaceted intervention tend to lead to significant changes
in practice compared to passive dissemination interventions
[15,67]. Moreover, it has been demonstrated that changes in
practice can take up to eight days of training and close mon-
itoring to be truly integrated into regular practice habits [45]
and that brief interventions can lead to changes in attitudes
and beliefs but not to a change in professional practice [66].
This systematic review suggests that using a knowledge trans-
lation intervention of sufficient length, with practical tools,
and allowing the physiotherapists to provide questions and
feedback to trainers after using the guidelines could improve
physiotherapist practices and patient outcomes.
Lack of impact on practice and patient outcomes could
also be explained by the challenges of physiotherapists
attempting to integrate the biopsychosocial model found in
most guidelines into practice. Even though physiotherapists
generally recognize the contribution of cognitive, psycholog-
ical, and social factors to the experience of pain and disability,
they tend to be more inclined and comfortable associating
 M.-È. Bérubé et al. / Physiotherapy 104 (2018) 1–8
pain with tissue or structural damage, and treat accordingly
[68]. They also report lacking the skills necessary to man-
age patients using a biopsychosocial approach [68]. Future
knowledge translation interventions should aim at increas-
ing skills related to the biopsychosocial model that would be
transferable to the clinical setting. However, some authors
have questioned the ability of individual physiotherapists to
effectively and independently manage risk factors of chronic
disability such as catastrophizing and kinesiophobia, when
limited results have been obtained with multidisciplinary
teams [45].
Use of guidelines can be influenced by beliefs of
colleagues and other health professionals [69], with the
integration of guidelines facilitated by their adoption by
all involved health professionals [6]. However, research
has shown the difficulties experienced by physicians when
implementing guidelines for treating musculoskeletal dis-
orders [70]. Only one study addressed multiple providers
simultaneously [63], with all other studies focused only on
physiotherapists. Future studies should assess knowledge
translations interventions targeting not only the physiothera-
pist, but all involved health care providers [32].
Organizational interventions, such as revision of pro-
fessional roles, clinical multidisciplinary teams, formal
integration of services, and continuity of care, have been
demonstrated as effective for other providers managing other
health problems [71]. Unfortunately, the studies using orga-
nizational approaches in this review all had low quality scores
and showed mixed results for patient and professional out-
comes, therefore, no conclusions could be made on their
effectiveness. Since no studies were done on financial or
regulatory interventions, it is unknown if these types of inter-
ventions would have an impact on physiotherapy practices.
Knowing that financial incentives have been demonstrated
as effective for changing behaviors of physicians and nurs-
ing staff [72], we can hypothesized that the same outcome
could be expected in physiotherapy. However, future studies
are needed to evaluate the impact of financial incentives on
practice change in physiotherapists treating musculoskeletal
disorders.
Several methodological parameters could potentially
explain differences observed between studies in practice
and patient outcome results. As described in the model of
Prochaska et al. [73], behavior change can take more than
6 months until the adoption of a new behavior is com-
plete. It has been suggested that a 2-year follow-up would
be necessary to appropriately assess practice and patient
outcome change following a knowledge translation inter-
vention [51]. In the included studies, outcomes of practice
change were mostly measured at 6 months post interven-
tion [33,34,38,42,49,51,64], while only two studies had
longer follow-ups of 1 [55] and 4 years [63]. Further stud-
ies assessing change of practice over a longer follow-up
period are needed to adequately assess the efficacy of knowl-
edge translation interventions to improve practice. Another
methodological factor that could explain lack of change
5
Key messages
- Knowledge translation interventions in physiotherapy
appear to change beliefs, attitudes and skills as well
as guideline awareness regardless of the type of inter-
vention used. The type and intensity of knowledge
translation interventions seem to have an impact on
changes in practice and patient outcomes.
What the paper adds to current literature/what
new knowledge is added by this study?
- This systematic review adds insights into explaining
the reasons why a change in attitudes and beliefs do
not systematically translate into behavior and prac-
tice change. This study summarizes an exhaustive
list of individual studies and underlines the fact that
knowledge translation aimed at physiotherapists are
currently not appropriate to modify behavior and prac-
tice in the treatment of musculoskeletal conditions.
- This study highlights the fact that more research
targeting financial, organizational and regulatory
interventions is needed to evaluate whether knowl-
edge translation interventions could result in a change
of behavior and practice, and that the type and inten-
sity of the intervention that is being used has an impact
on changes in practice and patient outcomes.
of practice or patient outcomes was physiotherapist selec-
tion bias. Considering that voluntary participation was often
used to recruit physiotherapists, it is possible that phys-
iotherapists already knew and were using guidelines [45].
Future research should use random selection of physio-
therapists, with baseline assessments of knowledge and
practices.
Despite following PRISMA guidelines, limitations of this
review should be noted. Although a wide variety of studies
were included, heterogeneity did not allow for pooling of data
in a meta-analysis. Also, this systematic review is limited by
the quality of the included studies. In fact, there seems to be a
lack of high quality studies in this area as most of the included
articles have moderate to weak methodological rigor. Only 13
of the 34 studies showed a score equal to or greater than five
on the PEDro scale and random allocation. Moreover, 19 of
the 34 studies had a CBA or ITS design and therefore did not
include randomization. Although four studies assessed the
economic impact of the knowledge translation interventions,
with varying results, none assessed the cost of the knowl-
edge translation interventions. It is, therefore, impossible to
determine the cost-effectiveness of the knowledge translation
interventions, i.e. to what extent the savings outweigh the cost
of the intervention.
6 M.-È. Bérubé et al. / Physiotherapy 104 (2018) 1–8
Conclusion
Results of this systematic review suggest that knowledge
and awareness of musculoskeletal guidelines by physiother-
apists tend to improve irrespective of the type of knowledge
translation interventions used. However, the impact of
interventions on physiotherapy practice and patient out-
comes are less clear. Interventions of sufficient length,
with practical tools, and allowing physiotherapists to pro-
vide questions and feedback to trainers after using the
guidelines appear to improve patient outcomes. Since the
cost-effectiveness of knowledge translation interventions
has not been assessed, care should be taken before imple-
mentation. This review also demonstrates the need for
further rigorously designed studies, since most were of
low quality. Finally, this systematic review emphasizes
the need for studies investigating the impact of orga-
nizational, financial or regulatory knowledge translation
interventions.
Conflict of interest: There are no conflicts of interest to dis-
close.
Appendix A. Supplementary data
Supplementary data associated with this arti-
cle can be found, in the online version, at
http://dx.doi.org/10.1016/j.physio.2017.05.002.
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