The effectiveness of interventions designed to increase the uptake of clinical practice guidelines and best practices among musculoskeletal professionals: a systematic review

Musculoskeletal (MSK) disorders are the second leading cause of disability globally and account for 21.3% of the total years lived with disability [1, 2]. About half (49.6%) of the total MSK disability stems from low back pain (LBP), followed by neck pain (20.1%), non-spinal MSK disorders (17.3%), osteoarthritis (10.5%), rheumatoid arthritis (2.3%), and gout (0.1%) [3]. Among people with MSK disorders, pain is the most common reason to consult health care providers in primary care [4‐7]. In addition to the large impact on individuals, MSK conditions are associated with a massive social and economic burden to society [8‐12].

Despite available evidence-based guidelines on the management of patients with MSK disorders [13‐15], numerous professional barriers (e.g., lack of awareness, skills, self-capacity and motivation) impede the routine application of guideline recommendations in clinical practice [16, 17]. The field of knowledge translation (KT) has produced a plethora of tools and methods to address these barriers and enhance the uptake of guidelines by clinicians. The field of KT is focused on closing the gap between what is known to work best and what is routinely done in practice [18]. The closure of this gap can be achieved through developing and implementing KT interventions [19].

Most systematic reviews on the effectiveness of KT interventions to increase the uptake of clinical practice guidelines or best practices have targeted physicians [20‐24] and nurses [25‐28]. More recently, five systematic reviews focused on allied health professionals’ uptake of guidelines [19, 29‐32]. Two of the reviews [29, 30] concluded that multifaceted KT interventions among physiotherapists can improve professional outcomes. However, one review failed to show improvement of patient outcomes [30]. In 2012, Scott et al. [19] conducted a review targeting five allied health professions (dietetics, occupational therapy, pharmacy, physiotherapy, and speech-language pathology). The search was later updated by Jones et al. (2015) [31] targeting three allied health professions (occupational therapists, physical therapists, and speech-language pathologists). These two reviews suggested that generally the studies were of poor methodological quality which precluded any decision about the effective KT intervention. A fifth review [32] evaluating the effectiveness of KT interventions to change clinical practice of physiotherapists managing common MSK disorders found equivocal effects for professional and patient outcomes.

To date, no single review has targeted other MSK professionals working in orthopedics, rheumatology, manual therapy, chiropractic, osteopathy, athletic therapy, sports medicine, acupuncture, among other areas. Thus, the goal of this review was to summarize and evaluate evidence about the effectiveness of KT interventions to improve the uptake and application of clinical practice guidelines and best practices for MSK disorders among MSK professionals.

This review addressed the following question: among MSK professionals, to what extent do KT interventions impact on (i) uptake of clinical practice guidelines or best practices for MSK disorders, and (ii) patient outcomes? For the purpose of this review, MSK professionals are health care providers whose nature and scope of practice primarily involves managing MSK disorders.

This review followed the recommendations of Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [33].

This review summarized the evidence from eleven studies that investigated the impact of various KT interventions on MSK professional and patient outcomes for MSK disorders. Nine studies involved physiotherapists, one chiropractors, and one a mixed of physiotherapists, chiropractors, and osteopaths. The targeted behaviors were the general management of MSK disorders (nine studies), diagnostic spine imaging, and professional-patient communication. Five studies were on LBP, two on neck pain and whiplash, one on spinal disorders, and two others on OA of the hip and knee.

Although this review included only RCTs, the majority of the included studies were considered to have moderate-to-high risk of bias. This is consistent with the findings of similar reviews [19, 29, 57, 58]. The assessment of the risk of bias was challenging due to poor or incomplete reporting of methodological characteristics in several studies. The small number of eligible studies prevented us from comparing outcome measures across studies considering this review included multiple KT strategies, professions, targeted behaviours and MSK conditions.

Educational meetings were used across most the included studies. Three studies suggested that single-component interventions had a small, albeit significant effect for improving professional outcomes whether compared to no intervention [48, 50] or another intervention [50].

The majority of the included studies (8/11) used multifaceted KT interventions. This is consistent with other reviews in similar areas [19, 58], possibly because the use of multifaceted interventions was previously encouraged [59]. Seven studies assessed the effectiveness of multifaceted interventions on professional outcomes. Three of these were compared to no interventions showing mixed effects for educational meetings and reminders [47, 56], and no effect for interactive educational meetings delivered by local opinion leaders [53]. Four other studies were compared to single-type interventions, with three showing favorable results [52, 54, 55], and one a non-significant trend toward improvement t [51]. While our findings are consistent with seven prior reviews [19, 29, 30, 57, 58, 60, 61] suggesting multifaceted interventions are more effective than single-component interventions, a recent overview of systematic reviews found that multifaceted interventions are no more effective than single-component interventions [62]. However their findings should be interpreted with caution considering the following limitations: First, the authors limited their search to reviews available on the Rx-for-Change database. Second, they did not search the ‘grey literature’, possibly omitting other relevant work in the field. Third, they did not retrieve data from the original studies that comprised the included reviews, thereby having to rely on the information reported by the review authors. Fourth, they relied on reviews that mainly used non-statistical analyses, so they did not account for the effect sizes of individual studies. Fifth, the included reviews were comprised of different methodological designs (i.e. RCTs, controlled trials, interrupted time series, etc.), whereas this review considered only RCTs.

Finally, four included studies suggested that multifaceted interventions delivered to professionals were ineffective in improving patient outcomes [46, 51, 52, 54]. Similar findings were reported by other reviews targeting physiotherapists [30, 32]. Bekkering et al. (2005) [52] and Rebbeck et al. (2006) [54] attributed the lack of effect of KT interventions on patient outcomes to the high quality care delivered by physiotherapists mitigating further improvement in patient health. Other authors suggested instead this may be due to unmeasured patient’s characteristics (e.g., fear avoidance and depression) moderating the effect on patient outcomes [46], or to the small effect of individual components include in the KT interventions evaluate in these RCTs [51]. For instance adding outreach visits may increase the likelihood of improving outcomes.

About half of the included studies indicated using theoretical frameworks, theories or models to guide the design of the behavior change intervention [49, 50, 52, 53, 56]. Only one of the studies provided a rationale for choosing a specific theory and a description of how using such theories informed intervention design [56]. This is in part because KT frameworks had not been developed when some of the primary RCTs were designed.

Findings from this review suggest that multifaceted educational interventions appear to be effective for improving professional outcomes. However, several elements ought to be improved in future trials to increase our confidence regarding the effect of multifaceted interventions, including: better reporting of providers’ characteristics and level of training; theoretical framework used to support behavior change; intervention components; and the implementation fidelity. Larger sample sizes and a clear rationale for selecting each component of the KT intervention are also needed [33].

Because of the nature and the scope of practice of each MSK profession, the success of specific KT interventions for one profession may not necessarily be successfully replicated among other health professions [19]. Improving the reporting of intervention elements may help explain why certain KT interventions are effective or ineffective, in particular with respect to multifaceted components, and whether more effective interventions are likely to also work with other MSK professionals or for other disorders [59]. Mapping behavior change techniques to previously identified barriers when designing KT interventions may improve the likelihood of successful professional behaviour change and improve patient health outcomes [63‐66].

The strength of this review stemmed from the rigorous search strategy it employed. It captured more studies than antecedent reviews [19, 29, 57, 58] within relevant areas over similar periods. The search strategy we used was recently validated and recommended by Cochrane and Rx for change, helping capture studies other reviews did not identify [48, 49]. Moreover, the present study covered a wide spectrum of MSK disorders and health care professionals. To our knowledge, this is the first review to report on the use of single-component interventions from RCTs for MSK disorders. Other reviews reported on the use of single-component interventions in non-RCT designs [19, 29, 57, 58]. Furthermore, other reviews had not reported the intervention details, for instance, Ospina et al. (2013) [57] classified both Bekkering et al. (2005) [52] and Stevenson et al. (2006) [53] under single-component strategies when in fact, these should be classified under multifaceted strategies as also reported in other reviews [19, 29, 58]. The authors may have overestimated the effect of multifaceted interventions in those reviews.

This review is one of the first to summarize studies on the effectiveness of KT interventions to improve the uptake and application of clinical practice guidelines and best practices specific to MSK disorders among a wide range of MSK professionals. The findings showed that primary trials use a variety of educational approaches with favorable but inconsistent impact on professional outcomes. Very few studies reported the effect on patient outcomes and results tended to be negative. The overall quality of included RCTs was poor. There was poor reporting of the interventions and a lack of reporting the way theoretical frameworks were implemented in the included trials.