Evidence-Based Practice in physiotherapy: a systematic review of barriers, enablers and interventions
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copy is furnished to the author for internal non-commercial research
and education use, including for instruction at the authors institution
and sharing with colleagues.
Other uses, including reproduction and distribution, or selling or
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websites are prohibited.
In most cases authors are permitted to post their version of the
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Author's personal copyPhysiotherapy 100 (2014) 208–219
Systematic review
Evidence-Based Practice in physiotherapy: a systematic
review of barriers, enablers and interventions
Laura Scurlock-Evans a,∗, Penney Upton b , Dominic Upton c
a Psychological Sciences, Institute of Health and Society, University of Worcester, Henwick Grove, Worcester WR2 6AJ, UK
b Institute of Health and Society, University of Worcester, Henwick Grove, Worcester WR2 6AJ, UK
c Faculty of Health, University of Canberra, University Dr, Bruce ACT 2617, Australia
Abstract
Background Despite clear benefits of the Evidence-Based Practice (EBP) approach to ensuring quality and consistency of care, its uptake
within physiotherapy has been inconsistent.
Objectives Synthesise the findings of research into EBP barriers, facilitators and interventions in physiotherapy and identify methods of
enhancing adoption and implementation.
Data sources Literature concerning physiotherapists’ practice between 2000 and 2012 was systematically searched using: Academic Search
Complete, Cumulative Index of Nursing and Allied Health Literature Plus, American Psychological Association databases, Medline, Journal
Storage, and Science Direct. Reference lists were searched to identify additional studies.
Study selection Thirty-two studies, focusing either on physiotherapists’ EBP knowledge, attitudes or implementation, or EBP interventions
in physiotherapy were included.
Data extraction and synthesis One author undertook all data extraction and a second author reviewed to ensure consistency and rigour.
Synthesis was organised around the themes of EBP barriers/enablers, attitudes, knowledge/skills, use and interventions.
Results Many physiotherapists hold positive attitudes towards EBP. However, this does not necessarily translate into consistent, high-quality
EBP. Many barriers to EBP implementation are apparent, including: lack of time and skills, and misperceptions of EBP.
Limitations Only studies published in the English language, in peer-reviewed journals were included, thereby introducing possible publication
bias. Furthermore, narrative synthesis may be subject to greater confirmation bias.
Conclusion and implications There is no “one-size fits all” approach to enhancing EBP implementation; assessing organisational culture
prior to designing interventions is crucial. Although some interventions appear promising, further research is required to explore the most
effective methods of supporting physiotherapists’ adoption of EBP.
© 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Keywords: Evidence-Based Practice; Physiotherapists; Best Practices; Review; Decision Making; Practice-Research Gap
Background
Evidence-Based Practice (EBP) is a 5 step process
whereby clinicians integrate best research evidence with clin-
ical expertise and client preferences, producing the most
appropriate and effective service [1,2]. As a result there has
been growing pressure on physiotherapy to embrace EBP
[3]. Engaging with both research and clinical findings can
enhance the proficiency of physiotherapists’ clinical practice
∗ Corresponding author.
E-mail address: l.scurlock-evans@worc.ac.uk (L. Scurlock-Evans).
[2] and help prevent the misuse, overuse and underuse of
healthcare services [4]. In an era of growing accountability
of healthcare practitioners, this may provide a useful frame-
work within which to work. Indeed, this has led some to argue
that there is a moral obligation to base decision-making on
research findings [3].
Despite the clear benefits of EBP, its uptake within phys-
iotherapy (and other healthcare domains) has been patchy
and inconsistent in quality [5]. Concerns over the compat-
ibility of aspects of EBP and lack of clinically relevant
research [3,6], have been raised by researchers and clinicians
alike.
http://dx.doi.org/10.1016/j.physio.2014.03.001
0031-9406/© 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Systematic review
Evidence-Based Practice in physiotherapy: a systematic
review of barriers, enablers and interventions
Laura Scurlock-Evans a,∗, Penney Upton b , Dominic Upton c
a Psychological Sciences, Institute of Health and Society, University of Worcester, Henwick Grove, Worcester WR2 6AJ, UK
b Institute of Health and Society, University of Worcester, Henwick Grove, Worcester WR2 6AJ, UK
c Faculty of Health, University of Canberra, University Dr, Bruce ACT 2617, Australia
Abstract
Background Despite clear benefits of the Evidence-Based Practice (EBP) approach to ensuring quality and consistency of care, its uptake
within physiotherapy has been inconsistent.
Objectives Synthesise the findings of research into EBP barriers, facilitators and interventions in physiotherapy and identify methods of
enhancing adoption and implementation.
Data sources Literature concerning physiotherapists’ practice between 2000 and 2012 was systematically searched using: Academic Search
Complete, Cumulative Index of Nursing and Allied Health Literature Plus, American Psychological Association databases, Medline, Journal
Storage, and Science Direct. Reference lists were searched to identify additional studies.
Study selection Thirty-two studies, focusing either on physiotherapists’ EBP knowledge, attitudes or implementation, or EBP interventions
in physiotherapy were included.
Data extraction and synthesis One author undertook all data extraction and a second author reviewed to ensure consistency and rigour.
Synthesis was organised around the themes of EBP barriers/enablers, attitudes, knowledge/skills, use and interventions.
Results Many physiotherapists hold positive attitudes towards EBP. However, this does not necessarily translate into consistent, high-quality
EBP. Many barriers to EBP implementation are apparent, including: lack of time and skills, and misperceptions of EBP.
Limitations Only studies published in the English language, in peer-reviewed journals were included, thereby introducing possible publication
bias. Furthermore, narrative synthesis may be subject to greater confirmation bias.
Conclusion and implications There is no “one-size fits all” approach to enhancing EBP implementation; assessing organisational culture
prior to designing interventions is crucial. Although some interventions appear promising, further research is required to explore the most
effective methods of supporting physiotherapists’ adoption of EBP.
© 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Keywords: Evidence-Based Practice; Physiotherapists; Best Practices; Review; Decision Making; Practice-Research Gap
Background
Evidence-Based Practice (EBP) is a 5 step process
whereby clinicians integrate best research evidence with clin-
ical expertise and client preferences, producing the most
appropriate and effective service [1,2]. As a result there has
been growing pressure on physiotherapy to embrace EBP
[3]. Engaging with both research and clinical findings can
enhance the proficiency of physiotherapists’ clinical practice
∗ Corresponding author.
E-mail address: l.scurlock-evans@worc.ac.uk (L. Scurlock-Evans).
[2] and help prevent the misuse, overuse and underuse of
healthcare services [4]. In an era of growing accountability
of healthcare practitioners, this may provide a useful frame-
work within which to work. Indeed, this has led some to argue
that there is a moral obligation to base decision-making on
research findings [3].
Despite the clear benefits of EBP, its uptake within phys-
iotherapy (and other healthcare domains) has been patchy
and inconsistent in quality [5]. Concerns over the compat-
ibility of aspects of EBP and lack of clinically relevant
research [3,6], have been raised by researchers and clinicians
alike.
http://dx.doi.org/10.1016/j.physio.2014.03.001
0031-9406/© 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
Author's personal copyL. Scurlock-Evans et al. / Physiotherapy 100 (2014) 208–219 209
Objectives
Research has identified a number of challenges phy-
siotherapists face when implementing EBP [6], which are
sometimes inconsistent. This review aimed to synthesise
research findings regarding barriers and enablers of EBP, and
the effectiveness of current EBP interventions in physiother-
apy, to help identify methods of increasing the consistency
and quality of EBP implementation.
Method
The review followed the PRISMA guidelines [7] for
reporting systematic reviews. A narrative analysis approach
was adopted, whereby text is used to summarise and explain
review synthesis findings, as it is suitably flexible to allow
for the inclusion of diverse methodologies.
Data sources
Literature concerning physiotherapists’ practice between
2000 and 2012 was systematically searched using free-text
keywords and MeSH or equivalent terms in combination (see
Table S1). Reference lists were searched to identify additional
studies.
Study selection
Articles were initially reviewed according to the following
inclusion criteria;
• Published in a peer-reviewed journal in English;
• Published between 2002 and 2012;
• Primary research conducted with qualified physiothera-
pists;
• Focused on at least one of the following;
- Physiotherapists’ knowledge/understanding of EBP
- Physiotherapists’ attitudes towards EBP
- Physiotherapists’ practice/implementation of EBP.
- EBP interventions in Physiotherapy.
To enhance comparability of researching findings, only
studies from the following Western cultures/regions were
included: UK, Ireland, Europe, USA, Canada, Australia and
New Zealand.
In total, 32 articles were retrieved that met the criteria; 27
used a quantitative method, 3 used a qualitative method and 2
used mixed-methods designs. A flow chart of study retrieval
and selection is presented in Fig. S1.
Data extraction and synthesis
One author undertook all data extraction using a
pre-defined template, and a second reviewed to ensure
consistency and rigour. Synthesis was organised around the
themes of EBP barriers/enablers, attitudes, knowledge/skills,
use and interventions.
Quality appraisal
Quantitative articles were assessed using the Effective
Public Health Practice Project (EPHPP; [8]) tool: each study
was rated as strong, moderate or weak (see Table 1). Quali-
tative articles were appraised using the consolidated criteria
for reporting qualitative research (COREQ; [9]), modified
to rate articles as strong, moderate or weak. Mixed-methods
research was evaluated using both tools.
Results
Despite known variations between countries’ healthcare
provision a number of key themes were evident, suggesting
they represent factors common to the practice of physiother-
apy across contexts; as there were no obvious systematic
differences in the characteristics of the research across
regions or publication date, the results were structured around
these themes. However, to aid with interpretation Table 1
presents studies’ characteristics and findings by region and
date.
Practice of EBP
Some studies compared physiotherapists’ practice of
EBP with professionals’ from other healthcare domains.
Palfreyman et al. [10] found that although both nurses
and physiotherapists had access to a broad range of EBP
knowledge sources, physiotherapists used such sources and
implemented EBP more frequently. However, both pro-
fessions relied significantly on patients and colleagues as
knowledge sources.
In a study comparing Swedish physiotherapists, dieti-
cians and occupational therapists, physiotherapists read and
reviewed research more often and were more likely to say
EBP helped them with decision-making [11]. Complex dif-
ferences between physiotherapists’ and other allied health
professionals’ (AHPs) were identified in a UK sample [12];
physiotherapists outperformed on some aspects, such as iden-
tifying relevant research, but performed less well on others,
such as identifying knowledge-gaps. However, other research
with UK-based AHPs (physiotherapists, speech and language
therapists, occupational therapists, dieticians, radiographers
and podiatrists) found no statistically significant differences
in EBP implementation, attitudes, or knowledge and skills
[13]. These discrepancies may be explained by differences
in level of academic preparation and access to educational
initiatives (e.g. all professionals in [13]’s study had
access to a professional development programme, poten-
tially increasing consistency in EBP), and changes to EBP
teaching.
Objectives
Research has identified a number of challenges phy-
siotherapists face when implementing EBP [6], which are
sometimes inconsistent. This review aimed to synthesise
research findings regarding barriers and enablers of EBP, and
the effectiveness of current EBP interventions in physiother-
apy, to help identify methods of increasing the consistency
and quality of EBP implementation.
Method
The review followed the PRISMA guidelines [7] for
reporting systematic reviews. A narrative analysis approach
was adopted, whereby text is used to summarise and explain
review synthesis findings, as it is suitably flexible to allow
for the inclusion of diverse methodologies.
Data sources
Literature concerning physiotherapists’ practice between
2000 and 2012 was systematically searched using free-text
keywords and MeSH or equivalent terms in combination (see
Table S1). Reference lists were searched to identify additional
studies.
Study selection
Articles were initially reviewed according to the following
inclusion criteria;
• Published in a peer-reviewed journal in English;
• Published between 2002 and 2012;
• Primary research conducted with qualified physiothera-
pists;
• Focused on at least one of the following;
- Physiotherapists’ knowledge/understanding of EBP
- Physiotherapists’ attitudes towards EBP
- Physiotherapists’ practice/implementation of EBP.
- EBP interventions in Physiotherapy.
To enhance comparability of researching findings, only
studies from the following Western cultures/regions were
included: UK, Ireland, Europe, USA, Canada, Australia and
New Zealand.
In total, 32 articles were retrieved that met the criteria; 27
used a quantitative method, 3 used a qualitative method and 2
used mixed-methods designs. A flow chart of study retrieval
and selection is presented in Fig. S1.
Data extraction and synthesis
One author undertook all data extraction using a
pre-defined template, and a second reviewed to ensure
consistency and rigour. Synthesis was organised around the
themes of EBP barriers/enablers, attitudes, knowledge/skills,
use and interventions.
Quality appraisal
Quantitative articles were assessed using the Effective
Public Health Practice Project (EPHPP; [8]) tool: each study
was rated as strong, moderate or weak (see Table 1). Quali-
tative articles were appraised using the consolidated criteria
for reporting qualitative research (COREQ; [9]), modified
to rate articles as strong, moderate or weak. Mixed-methods
research was evaluated using both tools.
Results
Despite known variations between countries’ healthcare
provision a number of key themes were evident, suggesting
they represent factors common to the practice of physiother-
apy across contexts; as there were no obvious systematic
differences in the characteristics of the research across
regions or publication date, the results were structured around
these themes. However, to aid with interpretation Table 1
presents studies’ characteristics and findings by region and
date.
Practice of EBP
Some studies compared physiotherapists’ practice of
EBP with professionals’ from other healthcare domains.
Palfreyman et al. [10] found that although both nurses
and physiotherapists had access to a broad range of EBP
knowledge sources, physiotherapists used such sources and
implemented EBP more frequently. However, both pro-
fessions relied significantly on patients and colleagues as
knowledge sources.
In a study comparing Swedish physiotherapists, dieti-
cians and occupational therapists, physiotherapists read and
reviewed research more often and were more likely to say
EBP helped them with decision-making [11]. Complex dif-
ferences between physiotherapists’ and other allied health
professionals’ (AHPs) were identified in a UK sample [12];
physiotherapists outperformed on some aspects, such as iden-
tifying relevant research, but performed less well on others,
such as identifying knowledge-gaps. However, other research
with UK-based AHPs (physiotherapists, speech and language
therapists, occupational therapists, dieticians, radiographers
and podiatrists) found no statistically significant differences
in EBP implementation, attitudes, or knowledge and skills
[13]. These discrepancies may be explained by differences
in level of academic preparation and access to educational
initiatives (e.g. all professionals in [13]’s study had
access to a professional development programme, poten-
tially increasing consistency in EBP), and changes to EBP
teaching.
Author's personal copy210 L. Scurlock-Evans et al. / Physiotherapy 100 (2014) 208–219
Table 1
Summary of characteristics and findings of studies, arranged according region.
Ref Sample Design Purpose Findings Quality score
UK research
Upton 2012 [13] Opportunistic sample,
154 newly qualified
AHPs (response
rate = 27%)
Descriptive,
cross-sectional survey
Assess and
characterise adoption
of EBP within newly
qualified AHPs’
clinical practice
• No statistically significant differences on EBP Use,
Attitudes or knowledge/skills between allied health
professions.
• Changes to education/training in recent years have
increased adoption and implementation of EBP
among newly qualified AHPs
• Adoption and implementation of EBP may be
influenced by education and support in tertiary
settings.
Weak
Bourne 2007 [36] Random sample, 134
community
physiotherapists from
Community Trusts
(response rate 67%).
Questionnaire
development and
descriptive,
cross-sectional survey
Identify perceived
professional,
educational and
personal needs of
community
physiotherapists, and
determine good
practice in meeting
these needs
• 51% of participants had no specific continuing
professional development learning objectives.
• Barriers to EBP: access to library resources within
reasonable travelling distance, skills to use library
facilities effectively, confidence to critically appraise
literature, training opportunities to develop skills,
opportunity to discuss research evidence with
colleagues., computer access, and time and skills to
use computer resources.
• Participants who had access to and taken up support
(e.g. mentorship and journal clubs) had more positive
EBP attitudes.
Weak
Caldwell 2007 [5] Random sample,
recent graduates from
3 London Universities
(response rate = 43%);
Social workers
(N = 26),
Occupational
Therapists (N = 29),
Physiotherapists
(N = 10), and Nurses
(N = 1)
Descriptive,
cross-sectional postal
questionnaire
Explore relevance of
initial professional
training on EBP and
explore practitioners’
confidence in
engaging with EBP
• 76% stated that they had received training in
conducting literature searches
• Positive attitudes held towards EBP and research;
implementation of EBP by practitioners is infrequent
with limited use of research resources.
• Despite 72% agreeing that EBP is favoured among
colleagues, 58% agreed that there was a lack of time
for EBP.
Moderate
Stevenson 2006 [39] Census of a
Community Trust in
North Staffordshire
(N = 30)
Intervention design
with random
assignment;
intervention group
(n = 17), control group
(n = 13) Questionnaire
survey.
Explore community
physiotherapists’
change in clinical
management of
patients with low back
pain (LBP) following
an educational
intervention, using
local opinion leaders
• Physiotherapists may have already been using
aspects of psychosocial management (the intervention
focus) for patients prior to the intervention.
• Little change was identified for the intervention
group in what participants perceived to be important
to patient recovery, actual clinical practice following
the intervention, and treatment options used.
Strong
Table 1
Summary of characteristics and findings of studies, arranged according region.
Ref Sample Design Purpose Findings Quality score
UK research
Upton 2012 [13] Opportunistic sample,
154 newly qualified
AHPs (response
rate = 27%)
Descriptive,
cross-sectional survey
Assess and
characterise adoption
of EBP within newly
qualified AHPs’
clinical practice
• No statistically significant differences on EBP Use,
Attitudes or knowledge/skills between allied health
professions.
• Changes to education/training in recent years have
increased adoption and implementation of EBP
among newly qualified AHPs
• Adoption and implementation of EBP may be
influenced by education and support in tertiary
settings.
Weak
Bourne 2007 [36] Random sample, 134
community
physiotherapists from
Community Trusts
(response rate 67%).
Questionnaire
development and
descriptive,
cross-sectional survey
Identify perceived
professional,
educational and
personal needs of
community
physiotherapists, and
determine good
practice in meeting
these needs
• 51% of participants had no specific continuing
professional development learning objectives.
• Barriers to EBP: access to library resources within
reasonable travelling distance, skills to use library
facilities effectively, confidence to critically appraise
literature, training opportunities to develop skills,
opportunity to discuss research evidence with
colleagues., computer access, and time and skills to
use computer resources.
• Participants who had access to and taken up support
(e.g. mentorship and journal clubs) had more positive
EBP attitudes.
Weak
Caldwell 2007 [5] Random sample,
recent graduates from
3 London Universities
(response rate = 43%);
Social workers
(N = 26),
Occupational
Therapists (N = 29),
Physiotherapists
(N = 10), and Nurses
(N = 1)
Descriptive,
cross-sectional postal
questionnaire
Explore relevance of
initial professional
training on EBP and
explore practitioners’
confidence in
engaging with EBP
• 76% stated that they had received training in
conducting literature searches
• Positive attitudes held towards EBP and research;
implementation of EBP by practitioners is infrequent
with limited use of research resources.
• Despite 72% agreeing that EBP is favoured among
colleagues, 58% agreed that there was a lack of time
for EBP.
Moderate
Stevenson 2006 [39] Census of a
Community Trust in
North Staffordshire
(N = 30)
Intervention design
with random
assignment;
intervention group
(n = 17), control group
(n = 13) Questionnaire
survey.
Explore community
physiotherapists’
change in clinical
management of
patients with low back
pain (LBP) following
an educational
intervention, using
local opinion leaders
• Physiotherapists may have already been using
aspects of psychosocial management (the intervention
focus) for patients prior to the intervention.
• Little change was identified for the intervention
group in what participants perceived to be important
to patient recovery, actual clinical practice following
the intervention, and treatment options used.
Strong
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