Table 3
Percentage (median and IQR) of physical therapy treatment choices that involved treatments that were recommended, not recommended or had no recommendation across different conditions
| Musculoskeletal | |||||||||
| Acute low back pain | |||||||||
| Assessed by surveys of physical therapists | Assessed by clinical notes | ||||||||
| Recommended | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Must provide | |||||||||
| Advice to keep active | 32 | 13 | 55 | 7 | 70 | 1 | |||
| Reassurance | 3 | 1 | – | ||||||
| Consider providing | |||||||||
| Group exercise | 14 | 7 | 20 | 2 | – | ||||
| Combination of two or more of 1–3 | 39 | 35 | 60 | 9 | 50 | 47 | 52 | 6 | |
| 1. Manual therapy1 | 45 | 39 | 68 | 9 | 60 | 47 | 78 | 6 | |
| 2. Exercise | 72 | 44 | 78 | 10 | 65 | 51 | 82 | 6 | |
| 3. CBT | – | – | |||||||
| Superficial heat | 33 | 31 | 42 | 5 | 13 | 9 | 43 | 3 | |
| Not recommended | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Paracetamol | 39 | 1 | – | ||||||
| McKenzie | 36 | 24 | 37 | 6 | 53 | 1 | |||
| US, ES, TENS, IF | 34 | 29 | 49 | 7 | 16 | 13 | 29 | 4 | |
| Poor advice2 | 9 | 2 | 28 | 8 | – | ||||
| Acupuncture | 6 | 3 | 16 | 7 | – | ||||
| Traction | 5 | 4 | 28 | 9 | 16 | 1 | |||
| External support3 | 2 | 2 | 16 | 5 | – | ||||
| No recommendation | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Other advice4 | 70 | 54 | 75 | 11 | 49 | 34 | 62 | 5 | |
| Cold therapy5 | 29 | 27 | 44 | 5 | 33 | 32 | 34 | 2 | |
| Other electrophysical agents6 | 16 | 5 | 27 | 5 | 14 | 12 | 20 | 3 | |
| Work-related/ergonomic interventions | 16 | 10 | 28 | 7 | – | ||||
| Back schools | 11 | 7 | 18 | 5 | – | ||||
| Other manual therapy7 | 8 | 8 | 20 | 3 | 7 | 7 | 9 | 3 | |
| Biofeedback | 1 | 0 | 1 | 3 | – | ||||
| Subacute or chronic low back pain | |||||||||
| Assessed by surveys of physical therapists | Assessed by clinical notes | ||||||||
| Recommended | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Must provide | |||||||||
| Advice to keep active | 56 | 35 | 76 | 4 | – | ||||
| Consider providing | |||||||||
| Group exercise | 27 | 14 | 40 | 2 | – | ||||
| Combination of two or more of 1–3 | 41 | 28 | 51 | 9 | 32 | 20 | 43 | 5 | |
| 1. Manual therapy1 | 49 | 30 | 51 | 9 | 58 | 25 | 74 | 6 | |
| 2. Exercise | 64 | 51 | 78 | 10 | 64 | 32 | 75 | 5 | |
| 3. CBT | 10 | 1 | – | ||||||
| McKenzie | 28 | 19 | 35 | 6 | 32 | 1 | |||
| Not recommended | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| US, ES, TENS, IF | 38 | 23 | 46 | 6 | 18 | 16 | 32 | 5 | |
| Traction | 9 | 4 | 22 | 10 | 6 | 6 | 7 | 2 | |
| Acupuncture | 8 | 5 | 15 | 7 | – | ||||
| External support3 | 2 | 2 | 9 | 5 | 24 | 1 | |||
| Poor advice2 | 1 | 0 | 6 | 7 | – | ||||
| No recommendation | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Other advice4 | 68 | 57 | 86 | 9 | – | ||||
| Superficial heat | 38 | 27 | 47 | 4 | 51 | 38 | 55 | 3 | |
| Cold therapy5 | 24 | 14 | 34 | 6 | 32 | 18 | 37 | 3 | |
| Other electrophysical agents6 | 19 | 19 | 42 | 3 | 11 | 9 | 15 | 4 | |
| Work-related/ergonomic interventions | 11 | 6 | 22 | 4 | 1 | 1 | |||
| Other manual therapy7 | 10 | 7 | 20 | 3 | |||||
| Back schools | 6 | 5 | 26 | 5 | |||||
| Biofeedback | 1 | 1 | 1 | 2 | |||||
| Iontophoresis | – | 3 | 1 | ||||||
| Low back pain (duration not specified) | |||||||||
| Assessed by surveys of physical therapists | Assessed by clinical notes | ||||||||
| Recommended | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Must provide | |||||||||
| Advice to keep active | 35 | 1 | 50 | 30 | 56 | 3 | |||
| Advice and education to support self-management | 26 | 22 | 31 | 2 | 21 | 16 | 27 | 2 | |
| Reassurance | 16 | 1 | – | ||||||
| Consider providing | |||||||||
| Group exercise | – | 76 | 1 | ||||||
| Combination of two or more of 1–3 | 59 | 46 | 86 | 8 | 34 | 24 | 46 | 12 | |
| 1. Manual therapy1 | 60 | 57 | 87 | 9 | 34 | 23 | 44 | 12 | |
| 2. Exercise | 89 | 52 | 91 | 8 | 69 | 61 | 81 | 13 | |
| 3. CBT | – | 47 | 1 | ||||||
| McKenzie | 47 | 36 | 56 | 7 | 58 | 11 | 71 | 5 | |
| Superficial heat | 39 | 28 | 55 | 7 | 16 | 10 | 34 | 4 | |
| Not recommended | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| US, ES, TENS, IF | 67 | 37 | 75 | 8 | 14 | 8 | 30 | 5 | |
| Acupuncture | 45 | 1 | 6 | 4 | 8 | 4 | |||
| Traction | 45 | 15 | 61 | 8 | 8 | 3 | 10 | 6 | |
| Poor advice2 | 26 | 6 | 57 | 4 | 23 | 12 | 33 | 3 | |
| External support3 | 23 | 14 | 31 | 2 | 2 | 2 | 2 | 4 | |
| No recommendation | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Other advice4 | 89 | 77 | 93 | 4 | 68 | 33 | 91 | 9 | |
| Work-related/ergonomic interventions | 71 | 52 | 87 | 4 | 26 | 23 | 29 | 2 | |
| Other manual therapy7 | 19 | 10 | 43 | 7 | 10 | 6 | 17 | 7 | |
| Other electrophysical agents6 | 15 | 9 | 41 | 8 | 23 | 17 | 40 | 8 | |
| Cold therapy5 | 7 | 5 | 17 | 4 | 13 | 6 | 49 | 3 | |
| Relaxation therapy | 7 | 1 | 12 | 1 | |||||
| Back schools | – | 45 | 1 | ||||||
| Iontophoresis | – | 3 | 1 | ||||||
| Neck pain8 | |||||||||
| Assessed by surveys of physical therapists9 | Assessed by clinical notes | ||||||||
| Recommended | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Should provide | |||||||||
| Importance of maintaining activity and movement | 93 | 89 | 96 | 2 | – | ||||
| Consider structured education10 in combination with 1, 2, 3 or 4 | |||||||||
| 1. Multimodal care11 | 51 | 1 | 65 | 57 | 73 | 2 | |||
| 2. Range of motion/flexibility and strengthening exercises | 89 (range of motion or flexibility only) | 84 | 93 | 2 | 55 | 54 | 56 | 2 | |
| 3. Clinical massage | 11 | 1 | 64 | 57 | 72 | 2 | |||
| 4. Laser | 6 | 1 | 4 | 1 | |||||
| Not recommended | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Relaxation therapy | 67 | 1 | 13 | 1 | |||||
| US, ES, TENS, SWD | 27 | 23 | 31 | 2 | 32 | 25 | 39 | 3 | |
| Strengthening alone12 | 31 | 1 | 55 | 54 | 56 | 2 | |||
| Heat or cold therapy | 25 | 1 | 79 | 66 | 89 | 4 | |||
| Poor advice2 | 12 | 1 | – | ||||||
| CBT | 8 | 1 | – | ||||||
| No recommendation | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Advice on posture | 96 | 1 | 2 | 1 | |||||
| Other exercise13 | 82 | 73 | 90 | 2 | 59 | 44 | 73 | 2 | |
| Acupuncture | 40 | 38 | 42 | 2 | – | ||||
| McKenzie | 35 | 1 | – | ||||||
| Manual therapy alone14 | 31 | 20 | 41 | 2 | 86 | 74 | 90 | 4 | |
| Neural mobilisation | 22 | 1 | – | ||||||
| Traction | 20 | 1 | 33 | 24 | 43 | 2 | |||
| Magnetic field therapy | – | 2 | 1 | ||||||
| Collar | – | 1 | 1 | ||||||
| Biofeedback | |||||||||
| Acute whiplash | |||||||||
| Assessed by surveys of physical therapists | Assessed by clinical notes | ||||||||
| Recommended | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Should provide | |||||||||
| Importance of maintaining activity and movement | 81 | 44 | 87 | 3 | – | ||||
| Information on nature, management and course | 56 | 41 | 70 | 2 | – | ||||
| Consider structured education10 in combination with 1 or 2 | |||||||||
| 1. Multimodal care11 | 81 | 79 | 84 | 2 | – | ||||
| 2. Range of motion/flexibility exercises | 90 | 86 | 94 | 2 | – | ||||
| Not recommended | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Heat or cold therapy | 53 | 46 | 61 | 2 | – | ||||
| Poor advice2 | 11 | 5 | 16 | 2 | – | ||||
| Collar | 7 | 4 | 10 | 2 | – | ||||
| US, ES | 4 | 2 | 7 | 2 | – | ||||
| No recommendation | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Other exercise13 | 96 | 91 | 97 | 3 | – | ||||
| Clinical massage | 86 | 1 | – | ||||||
| Manual therapy alone14 | 83 | 79 | 86 | 2 | – | ||||
| Advice on posture or analgesics | 53 | 32 | 74 | 2 | – | ||||
| Work-related/ergonomic interventions | 39 | 2 | – | ||||||
| Traction | 30 | 1 | – | ||||||
| Laser, IF | 24 | 18 | 30 | 2 | – | ||||
| McKenzie | 9 | 1 | – | ||||||
| Chronic whiplash | |||||||||
| Assessed by surveys of physical therapists | Assessed by clinical notes | ||||||||
| Recommended | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Should provide | |||||||||
| Importance of maintaining activity and movement | 80 | 79 | 80 | 2 | – | ||||
| Information on nature, management and course | 60 | 1 | – | ||||||
| Consider structured education10 in combination with 1, 2 or 3 | |||||||||
| 1. Multimodal care11 | 72 | 1 | – | ||||||
| 2. Range of motion/flexibility and strengthening exercises | 56 | 1 | – | ||||||
| 3. Clinical massage | 86 | 1 | – | ||||||
| Not recommended | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Strengthening alone12 | 56 | 1 | – | ||||||
| Heat or cold therapy | 43 | 38 | 48 | 2 | – | ||||
| US, ES, TENS, SWD | 30 | 30 | 30 | 2 | – | ||||
| Poor advice2 | 10 | 5 | 15 | 2 | – | ||||
| No recommendation | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Advice on posture | 95 | 1 | – | ||||||
| Other exercise13 | 94 | 93 | 95 | 2 | – | ||||
| Work-related/ergonomic interventions | 74 | 71 | 78 | 2 | – | ||||
| Manual therapy alone1 4 | 68 | 59 | 77 | 2 | – | ||||
| McKenzie | 10 | 1 | – | ||||||
| Collar | 1 | 1 | 2 | 2 | – | ||||
| Subacromial pain (surveys) or shoulder pain15 (clinical notes) | |||||||||
| Assessed by surveys of physical therapists | Assessed by clinical notes | ||||||||
| Recommended16 | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Likely to be beneficial | |||||||||
| Exercise | 89 | 85 | 92 | 4 | 72 | 67 | 76 | 2 | |
| Manual therapy1 | 49 | 20 | 80 | 4 | 61 | 59 | 68 | 3 | |
| Laser | 36 | 20 | 52 | 2 | 23 | 18 | 27 | 2 | |
| Not recommended | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| IF, magnetic field therapy | 90 | 1 | 8 | 1 | |||||
| No recommendation | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Any advice17 | 79 | 77 | 82 | 2 | 91 | 1 | |||
| Tape | 59 | 54 | 64 | 2 | 15 | 1 | |||
| Acupuncture | 53 | 51 | 54 | 2 | – | ||||
| Shockwave, ES, US, SWD, TENS, microwave current | 44 | 33 | 65 | 4 | 26 | 13 | 39 | 3 | |
| Heat or cold therapy | 38 | 24 | 55 | 4 | 47 | 39 | 54 | 2 | |
| Body awareness | 11 | 1 | – | ||||||
| CBT | 4 | 1 | – | ||||||
| Iontophoresis | – | 15 | 1 | ||||||
| Knee osteoarthritis (surveys)18 and knee pain (clinical notes)19 | |||||||||
| Assessed by surveys of physical therapists | Assessed by clinical notes | ||||||||
| Recommended | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Must provide | |||||||||
| Advice to stay active | 89 | 78 | 92 | 3 | – | ||||
| Self-management strategies20 | 82 | 74 | 91 | 3 | – | ||||
| Aerobic and strengthening | 66 | 47 | 72 | 3 | 65 | 65 | 66 | 2 | |
| Advice on footwear | 57 | 1 | – | ||||||
| Weight loss interventions | 54 | 51 | 56 | 3 | – | ||||
| Advice on weight loss | 49 | 1 | – | ||||||
| Consider providing | |||||||||
| Heat or cold therapy | 62 | 15 | 73 | 5 | 69 | 63 | 74 | 2 | |
| Manual therapy1, traction or stretching | 60 | 54 | 76 | 5 | 79 | 78 | 79 | 2 | |
| TENS | 52 | 32 | 54 | 3 | 21 | 21 | 21 | 1 | |
| Walking aids | 8 | 5 | 38 | 3 | – | ||||
| CBT | 3 | 1 | – | ||||||
| Not recommended | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| ES, US, Laser, IF, SWD | 43 | 20 | 55 | 6 | 21 | 1 | |||
| Poor advice2 | 23 | 15 | 31 | 2 | – | ||||
| Acupuncture | 22 | 20 | 34 | 5 | – | ||||
| No recommendation | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Other exercise21 | 98 | 88 | 100 | 5 | 75 | 1 | |||
| Balneotherapy22 | 16 | 1 | – | ||||||
| Iontophoresis | – | 8 | 1 | ||||||
| Acutelateral ankle sprains | |||||||||
| Assessed by surveys of physical therapists | Assessed by clinical notes | ||||||||
| Recommended | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Should provide | |||||||||
| Exercise | 39 | 31 | 46 | 2 | – | ||||
| Consider providing | |||||||||
| Rest, ice, compression and elevation23 | 12 | 1 | – | ||||||
| External support24 | 34 | 1 | – | ||||||
| Not recommended | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| US, ES, Laser | 14 | 1 | – | ||||||
| Joint mobilisation | 3 | 1 | – | ||||||
| Heat or cold therapy | 1 | 1 | – | ||||||
| No recommendation | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Advice or education | 22 | 12 | 33 | 2 | – | ||||
| IF, SWD, Diadynamic current | 7 | 1 | 45 | 1 | |||||
| Plantar fascitis | |||||||||
| Assessed by surveys of physical therapists | Assessed by clinical notes | ||||||||
| Recommended | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Should provide | |||||||||
| Stretching | 100 | 1 | – | ||||||
| Manual therapy1 | 81 | 1 | 87 | 1 | |||||
| Night splints | 29 | 1 | |||||||
| May provide | |||||||||
| Strengthening exercises and movement training | 94 | 1 | – | ||||||
| Education and counselling for weight loss | 89 | 1 | – | ||||||
| Laser, US, ES | 43 | 1 | – | ||||||
| Not recommended | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Acupuncture | 31 | 1 | – | ||||||
| No recommendation | Median (%€) | Q1 | Q3 | N | Median (%¥) | Q1 | Q3 | N | |
| Shockwave | 10 | 1 | – | ||||||
| Heat or cold therapy | 79 | 1 | – | ||||||
| Other exercise25 | 96 | 1 | 90 | 1 | |||||
| Other advice26 | 98 | 1 | – | ||||||
| Prefabricated orthotics27 | 70 | 1 | |||||||
| Orthopaedics | |||||||||
| Knee or hip arthroplasty (surveys of physical therapists or physical therapy departments)28 | |||||||||
| Inpatients | Outpatients29 | ||||||||
| Recommended | Median (%€) | Q1 | Q3 | N | Median (%€) | Q1 | Q3 | N | |
| Exercise | 94 | 94 | 95 | 2 | 76 | 66 | 86 | 4 | |
| Not recommended | Median (%€) | Q1 | Q3 | N | Median (%€) | Q1 | Q3 | N | |
| Passive range of motion | 69 | 57 | 81 | 2 | 1 | 1 | |||
| Cold therapy | 28 | 25 | 30 | 2 | 20 | 16 | 25 | 2 | |
| No recommendation | Median (%€) | Q1 | Q3 | N | Median (%€) | Q1 | Q3 | N | |
| Manual therapy30 | 93 | 1 | 31 | 1 | |||||
| Advice or education | – | 55 | 33 | 77 | 2 | ||||
| TENS, electrotherapy | – | 0 | 1 | ||||||
| Acupuncture | – | 0 | 1 | ||||||
¥The percentage of patients that received treatments from a physical therapist that were recommended, not recommended or had no recommendation 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.
1Includes massage, mobilisation or manipulation.
2Advice promoting bed rest or time off work.
3Corsets, belts, braces, sticks or taping.
4Includes advice on posture, heavy lifting, sitting or standing habits, avoiding painful movements, analgesics.
5Including where heat and cold therapy could not be separated.
6Including laser, infrared therapy, microcurrent therapy, SWD, and so on.
7Includes neural mobilisation, Mulligan, Cyriax, myofascial release, and so on.
8Insufficient data to stratify by symptom duration. We used the guidelines for chronic neck pain from online supplementary table 3 as they classify a greater number of interventions as high and low value.
9Included two studies that combined treatment choices for neck pain and whiplash.
10No study reported structured education so the below interventions are reported in isolation.
11Includes mobilisation or manipulation and range of motion exercises.
12We were unable to determine the percentage of strengthening that was delivered in isolation.
13Any exercise not included in the above categories.
14Includes mobilisation or manipulation, but we were unable to determine the percentage of manual therapy that was delivered in isolation.
15Two studies combined physical therapy treatment choices for a variety of shoulder conditions.
16There is no high-quality evidence supporting a recommended physical therapy intervention for shoulder pain.
17Including advice on posture and advice to rest or reduce activity.
18One study that combined physical therapy treatment choices for knee and hip osteoarthritis was not included in this table (Barten et al 2015) (see online supplementary table 3).
19One study that combined physical therapy treatment choices for acute and chronic knee conditions was not included in this table (van Baar et al 1998) (see online supplementary table 3).
20Includes exercise, weight loss, use of suitable footwear or pacing, but we were unable to assess the content of self-management strategies reported in the included studies.
21Exercise that is neither aerobic nor strengthening.
22Spa bath therapy (separate to hydrotherapy which is included within ‘other exercise’).
23Only compression was mentioned in the included study.
24Includes braces, boots or taping.
25Exercise that is neither strengthening or movement training.
26Includes advice on self-management, pacing,ergonomics, and so on.
27Custom orthotics were provided by 63% of physical therapists.
28One study that reported physical therapy treatment choices as assessed by clinical notes is not included in this table but is represented in the summary table (table 2).
29Includes one study that reported physical therapy treatment choices for knee and hip arthroscopy combined.
30Includes massage or mobilisation.
CBT, cognitive–behavioural therapy; ES, electrical stimulation; IF, interferential current;N, number of studies; Q1, first quartile; Q3, third quartile; SWD, short wave diathermy; TENS, transcutaneous electrical nerve stimulation; US, Ultrasound.