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. 2019 Oct 7;9(10):e032329. doi: 10.1136/bmjopen-2019-032329

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 physical therapists that report they provide (or would provide) treatments that was recommended, not recommended and had no recommendation for a given condition.

¥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.