Professional interventions for general practitioners on the management of musculoskeletal conditions
Open accessAbstract
BACKGROUND: Musculoskeletal conditions require particular management skills. Identification of interventions which are effective in equipping general practitioners (GPs) with such necessary skills could translate to improved health outcomes for patients and reduced healthcare and societal costs. OBJECTIVES: To determine the effectiveness of professional interventions for GPs that aim to improve the management of musculoskeletal conditions in primary care. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), 2010, Issue 2; MEDLINE, Ovid (1950 - October 2013); EMBASE, Ovid (1980 - Ocotber 2013); CINAHL, EbscoHost (1980 - November 2013), and the EPOC Specialised Register. We conducted cited reference searches using ISI Web of Knowledge and Google Scholar; and handsearched selected issues of Arthritis and Rheumatism and Primary Care-Clinics in Office Practice. The latest search was conducted in November 2013. SELECTION CRITERIA: We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-and-after studies (CBAs) and interrupted time series (ITS) studies of professional interventions for GPs, taking place in a community setting, aiming to improve the management (including diagnosis and treatment) of musculoskeletal conditions and reporting any objective measure of GP behaviour, patient or economic outcomes. We considered professional interventions of any length, duration, intensity and complexity compared with active or inactive controls. DATA COLLECTION AND ANALYSIS: Two review authors independently abstracted all data. We calculated the risk difference (RD) and risk ratio (RR) of compliance with desired practice for dichotomous outcomes, and the mean difference (MD) and standardised mean difference (SMD) for continuous outcomes. We investigated whether the direction of the targeted behavioural change affects the effectiveness of interventions. MAIN RESULTS: Thirty studies met our inclusion criteria.From 11 studies on osteoporosis, meta-analysis of five studies (high-certainty evidence) showed that a combination of a GP alerting system on a patient's increased risk of osteoporosis and a patient-directed intervention (including patient education and a reminder to see their GP) improves GP behaviour with regard to diagnostic bone mineral density (BMD) testing and osteoporosis medication prescribing (RR 4.44; (95% confidence interval (CI) 3.54 to 5.55; 3 studies; 3,386 participants)) for BMD and RR 1.71 (95% CI 1.50 to 1.94; 5 studies; 4,223 participants) for osteoporosis medication. Meta-analysis of two studies showed that GP alerting on its own also probably improves osteoporosis guideline-consistent GP behaviour (RR 4.75 (95% CI 3.62 to 6.24; 3,047 participants)) for BMD and RR 1.52 (95% CI 1.26 to 1.84; 3.047 participants) for osteoporosis medication) and that adding the patient-directed component probably does not lead to a greater effect (RR 0.94 (95% CI 0.81 to 1.09; 2,995 participants)) for BMD and RR 0.93 (95% CI 0.79 to 1.10; 2,995 participants) for osteoporosis medication.Of the 10 studies on low back pain, seven showed that guideline dissemination and educational opportunities for GPs may lead to little or no improvement with regard to guideline-consistent GP behaviour. Two studies showed that the combination of guidelines and GP feedback on the total number of investigations requested may have an effect on GP behaviour and result in a slight reduction in the number of tests, while one of these studies showed that the combination of guidelines and GP reminders attached to radiology reports may result in a small but sustained reduction in the number of investigation requests.Of the four studies on osteoarthritis, one study showed that using educationally influential physicians may result in improvement in guideline-consistent GP behaviour. Another study showed slight improvements in patient outcomes (pain control) after training GPs on pain management.Of three studies on shoulder pain, one study reported that there may be little or no improvement in patient outcomes (functional capacity) after GP education on shoulder pain and injection training.Of two studies on other musculoskeletal conditions, one study on pain management showed that there may be worse patient outcomes (pain control) after GP training on the use of validated assessment scales.The 12 remaining studies across all musculoskeletal conditions showed little or no improvement in GP behaviour and patient outcomes.The direction of the targeted behaviour (i.e. increasing or decreasing a behaviour) does not seem to affect the effectiveness of an intervention. The majority of the studies did not investigate the potential adverse effects of the interventions and only three studies included a cost-effectiveness analysis.Overall, there were important methodological limitations in the body of evidence, with just a third of the studies reporting adequate allocation
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Targeted GP education and training interventions to build motivation and confidence were potential facilitators to clinical guideline adherence identified by the GPs in this study and other studies.
“Targeted GP education and training interventions to build motivation and confidence were potential facilitators to clinical guideline adherence identified by the GPs in ours and other studies [54,55].”
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Hulshof, C. T. J., Colosio, C., Daams, J. G., Ivanov, I. D., Prakash, K. C., Kuijer, P., Leppink, N., Mandić‐Rajčević, S., Masci, F., van der Molen, H. F., et al. (2018) · Environment International · doi:10.1016/j.envint.2018.09.053 · Cited by 95 · see citing works
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Haas, R., Gorelik, A., Busija, L., O’Connor, D. A., Pearce, C. M., Mazza, D., & Buchbinder, R. (2023) · BMC Family Practice · doi:10.1186/s12875-023-01976-z · Cited by 66 · see citing works
Sajid, I. M., Parkunan, A., & Frost, K. (2021) · BMJ Open Quality · doi:10.1136/bmjoq-2020-001287 · Cited by 64 · see citing works
Speerin, R., Needs, C., Chua, J., Woodhouse, L. J., Nordin, M. C., McGlasson, R. A., & Briggs, A. M. (2020) · Best Practice & Research Clinical Rheumatology · doi:10.1016/j.berh.2020.101548 · Cited by 62 · see citing works
Martel‐Pelletier, J., Maheu, E., Pelletier, J., Alekseeva, L., Mkinsi, O., Branco, J., Monod, P., Planta, F., Reginster, J., & Rannou, F. (2018) · Aging Clinical and Experimental Research · doi:10.1007/s40520-018-1077-8 · Cited by 59 · see citing works
“A Cochrane systematic review suggested that interventions such as improving general practitioner (GP) training regarding OA pain and use of influential physicians may increase guideline-consistent behaviour and improve patient outcomes [20].”
BackgroundPaley, C. A., Wittkopf, P. G., Jones, G., & Johnson, M. I. (2021) · Medicina · doi:10.3390/medicina57101060 · Cited by 55 · see citing works
Otete, H. E., Deleuran, T., Fleming, K. M., Card, T. R., Aithal, G. P., Jepsen, P., & West, J. (2018) · Journal of Hepatology · doi:10.1016/j.jhep.2018.04.002 · Cited by 54 · see citing works
Low‐value care in musculoskeletal health care: Is there a way forward?
Hartvigsen, J., Kamper, S. J., & French, S. D. (2022) · Pain Practice · doi:10.1111/papr.13142 · Cited by 51 · see citing works
Hodder, R. K., Wolfenden, L., Kamper, S. J., Lee, H., Williams, A. J., O’Brien, K. M., & Williams, C. M. (2016) · Best Practice & Research Clinical Rheumatology · doi:10.1016/j.berh.2017.05.002 · Cited by 44 · see citing works
Bandong, A. N., Leaver, A. M., Mackey, M., Ingram, R., Shearman, S., Chan, C., Cameron, I. D., Moloney, N. A., Mitchell, R. J., Doyle, E., et al. (2018) · BMC Health Services Research · doi:10.1186/s12913-018-3439-5 · Cited by 43 · see citing works
Darlow, B. J. S., Stanley, J., Dean, S. G., Abbott, J. H., Garrett, S., Wilson, R., Mathieson, F. M., & Dowell, A. C. (2019) · PLoS Medicine · doi:10.1371/journal.pmed.1002897 · Cited by 36 · see citing works
Digital health interventions for osteoporosis and post-fragility fracture care
Gupta, A., Maslen, C., Vindlacheruvu, M., Abel, R. L., Bhattacharya, P., Bromiley, P. A., Clark, E., Compston, J. E., Crabtree, N. J., Gregory, J. S., et al. (2022) · Therapeutic Advances in Musculoskeletal Disease · doi:10.1177/1759720x221083523 · Cited by 38 · see citing works
“29 Despite this, there is a lack of robust evidence on what types of alerts, reminders and prompts should be used and how they should be deployed to most positively impact practitioner practice and improve patient outcomes.”
BackgroundAbbott, A. D., Schröder, K., Enthoven, P., Nilsén, P., & Öberg, B. E. (2018) · BMJ Open · doi:10.1136/bmjopen-2017-019906 · Cited by 28 · see citing works
Goertz, C., Long, C. R., English, C., Meeker, W. C., & Marchiori, D. M. (2021) · The Journal of Alternative and Complementary Medicine · doi:10.1089/acm.2020.0392 · Cited by 25 · see citing works
“AlthoughadoptionofpreviousLBPguidelineshasbeen low, 9–11 it is possible that increased efforts to disseminate information to both physicians and the public about the risks associated with opioid use have accelerated implementation of the more recent ACP recommendations.”
BackgroundHall, A. M., Richmond, H., Pike, A. E., Lawrence, R., Etchegary, H., Swab, M., Thompson, J., Albury, C., Hayden, J. A., Patey, A. M., et al. (2021) · Implementation Science · doi:10.1186/s13012-021-01136-w · Cited by 19 · see citing works
Pain Management in Patients with Heart Failure: A Survey of Nurses’ Perception
Chen, J., Walsh, S. J., Delaney, C., & Cong, X. S. (2019) · Pain Management Nursing · doi:10.1016/j.pmn.2019.09.004 · Cited by 16 · see citing works
French, S. D., O’Connor, D. A., Green, S., Page, M. J., Mortimer, D., Turner, S., Walker, B. F., Keating, J. L., Grimshaw, J., Michie, S., et al. (2022) · Trials · doi:10.1186/s13063-022-06053-x · Cited by 16 · see citing works
Bounabe, A., Ammare, S. E., Janani, S., Ouabich, R., & Elarrachi, I. (2024) · Seminars in Arthritis and Rheumatism · doi:10.1016/j.semarthrit.2024.152569 · Cited by 13 · see citing works
Chagnas, M.-O., Poiraudeau, S., Lefèvre‐Colau, M., Rannou, F., & Nguyen, C. (2019) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-019-2782-y · Cited by 13 · see citing works
“As a result, many lack confidence in the management of musculoskeletal disorders in daily practice [8].”
BackgroundKechichian, A., Desmeules, F., Girard, P., & Pinsault, N. (2022) · Family Medicine and Community Health · doi:10.1136/fmch-2022-001644 · Cited by 12 · see citing works
Voigt-Radloff, S., Schöpf, A. C., Boeker, M., Frank, L., Farin‐Glattacker, E., Kaier, K., Körner, M., Wollmann, K., Lang, B., Meerpohl, J. J., et al. (2019) · BMC Family Practice · doi:10.1186/s12875-019-0925-8 · Cited by 12 · see citing works
“• A review on professional interventions for general practitioners on the management of musculoskeletal conditions analysed 10 trials on back pain [29].”
BackgroundQuality Measures and Quality Improvement Initiatives in Osteoporosis—an Update
French, S., Choden, S., & Schmajuk, G. (2019) · Current Osteoporosis Reports · doi:10.1007/s11914-019-00547-5 · Cited by 13 · see citing works
Use of an electronic medical record dashboard to identify gaps in osteoporosis care
Παπαϊωάννου, Α., McCloskey, E. V., Bell, A., Ngui, D., Mehan, U., Tan, M., Goldin, L., & Langer, A. (2021) · Archives of Osteoporosis · doi:10.1007/s11657-021-00919-4 · Cited by 11 · see citing works
“Despite evidence that interventions combining education and EMR-based alerting systems can increase BMD screening and appropriate osteoporosis medication prescribing [29], in this study, there continued to be a significant number of patients at risk who were not screened or treated.”
BackgroundBarnes, R., van Rensburg, A. J., & Raubenheimer, J. (2021) · South African Journal of Physiotherapy · doi:10.4102/sajp.v77i1.1563 · Cited by 10 · see citing works
“A Cochrane review which was conducted in 2016 included 30 studies that assessed a variety of professional interventions by GPs with the intention to improve the management of individuals living with MSD (Tzortziou Brown et al. 2016).”
MethodDoes Every Patient Require an Intrathecal Baclofen Trial Before Pump Placement?
Bilsky, G. S., Saulino, M. F., & O’Dell, M. W. (2016) · PM&R · doi:10.1016/j.pmrj.2016.07.005 · Cited by 9 · see citing works
“My Back Exercise App”—mHealth for Low Back Pain: Development and Usability Testing
Comachio, J., Castrillón, C. I. M., Beckenkamp, P. R., Roberts, K. E., Ho, E. K., Field, R., Nelligan, R. K., Ferreira, M. L., Bennell, K. L., Gordon, C. J., et al. (2024) · Journal of Healthcare Informatics Research · doi:10.1007/s41666-024-00179-0 · Cited by 8 · see citing works
Bonney, A. D., Metusela, C., Mullan, J., Barnett, S., Rhee, J., Kobel, C., & Batterham, M. J. (2021) · Trials · doi:10.1186/s13063-021-05438-8 · Cited by 8 · see citing works
Bone health in rural Australia: a mixed methods study of consumer needs
Jones, A., Garth, B., Haigh, C., Ebeling, P. R., Teede, H. J., & Vincent, A. J. (2023) · Archives of Osteoporosis · doi:10.1007/s11657-023-01333-8 · Cited by 6 · see citing works
“A variety of educational programs targeting GPs have been shown to increase DXA and prescribing rates, including electronic reminders, dissemination of guidelines and academic detailing, although most studies also incorporate a patient-directed component [31, 34].”
BackgroundBurton, W. M., Salsbury, S. A., & Goertz, C. (2024) · BMC Health Services Research · doi:10.1186/s12913-024-10578-z · Cited by 8 · see citing works
Zaina, F., & Négrini, S. (2008) · PubMed · Cited by 5 · see citing works
Metusela, C., Mullan, J., Kobel, C., Rhee, J., Batterham, M. J., Barnett, S., & Bonney, A. D. (2023) · BMC Health Services Research · doi:10.1186/s12913-023-10374-1 · Cited by 4 · see citing works
“GP alerting systems combined with practitioner education, including online tools and feedback have been shown to be beneficial in changing test ordering practices [21].”
BackgroundAyorinde, A., Williams, I., Mannion, R., Song, F., Skrybant, M., Lilford, R. J., & Chen, Y. (2020) · Health Services and Delivery Research · doi:10.3310/hsdr08330 · Cited by 4 · see citing works
Lowry, V., Desmeules, F., Lavigne, P., Décary, S., Tousignant‐Laflamme, Y., Martel, M., Roy, J., Perreault, K., Lefebvre, M.-C., Kilpatrick, K., et al. (2024) · Physical Therapy · doi:10.1093/ptj/pzae160 · Cited by 2 · see citing works
The Changing Role of Patient Education in Osteoporosis
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“It is not possible to provide a detailed review of prior studies in this editorial but readers are referred to the recent Cochrane review[6].”
BackgroundBurch, J., & Tort, S. (2017) · Cochrane Clinical Answers · doi:10.1002/cca.1674 · Cited by 2 · see citing works
Gidlow, C. J., Mankoo, A. S., Jolly, K. B., & Retzer, A. (2025) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph22060851 · Cited by 2 · see citing works
Nattabi, B., Gudka, S., Ward, J. S., & Rumbold, A. R. (2016) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd012374 · Cited by 1 · see citing works
Integrated care for adults with chronic musculoskeletal disorders: a scoping review protocol
Chala, M. B., Elliott, J. B., Baker, G. R., Walton, D. M., Steele, M., & Schabrun, S. M. (2024) · JBI Evidence Synthesis · doi:10.11124/jbies-23-00534 · Cited by 1 · see citing works
Hickey, S., Saywell, N. L., Adams, T. M., & Hill, J. (2025) · Musculoskeletal Care · doi:10.1002/msc.70086 · Cited by 1 · see citing works
A scoping review characterising the activities and landscape around implementing NICE guidance
Kneale, D., Goldman, R., & Thomas, J. (2016) · UCL Discovery (University College London) · Cited by 1 · see citing works
Burch, J., & Tort, S. (2017) · Cochrane Clinical Answers · doi:10.1002/cca.1672 · Cited by 1 · see citing works
Burch, J., & Tort, S. (2017) · Cochrane Clinical Answers · doi:10.1002/cca.1673 · Cited by 1 · see citing works
Treatment of Osteoporosis and the Use of Digital Health Intervention
Malviya, R., Rajput, S., & Vaidya, M. (2024) · doi:10.1002/9781394230914.ch4 · Cited by 1 · see citing works
Interventional methods in musculoskeletal system
Monteros, R. E. D. L., & Antônio, J. (2018)
Aplicación móvil en el diagnóstico de dolor de hombro para médicos generales
Marsalli, M., Sepúlveda, O., & Paz, J. D. L. (2020) · Revista Chilena de Ortopedia y Traumatología · doi:10.1055/s-0040-1713797
To Determine Preference of Shoulder Pain Management by General Physicians in Lahore
Saeed, T. D., & Khalid, H. A. (2021) · American Journal of Surgery and Clinical Case Reports · doi:10.47829/ajsccr.2021.2503
“Three studies were conducted on the management of shoulder pain and out of these three studies the results of one study revealed that there was a low rate or no improvement in the patient complaints (functional outcomes) after the physician diagnosis and counseling on the management of shoulder pain [6].”
ResultTo Determine Preference of Shoulder Pain Management by General Physicians in Lahore
(2021) · Journal of Medical Clinical Case Reports · doi:10.47485/2767-5416.1021
Shaping Tomorrow's Surgeons: The Need for Orthopaedic Reform at United Kingdom Medical Schools
Koshy, D. I., Koshy, D., Joseph, K. V., Ishaku, Z., & Varathan, K. (2025) · Cureus · doi:10.7759/cureus.84298
“However, the review also noted that the overall quality of evidence was variable, and more research is needed to determine the most effective strategies for other musculoskeletal conditions [28].”
Metusela, C., Mullan, J., Kobel, C., Rhee, J., Batterham, M. J., Barnett, S., & Bonney, A. D. (2024) · Figshare · doi:10.6084/m9.figshare.26648832
Metusela, C., Mullan, J., Kobel, C., Rhee, J., Batterham, M. J., Barnett, S., & Bonney, A. D. (2024) · Figshare · doi:10.6084/m9.figshare.26648829
Cortet, B., Chelbani, L., Garot, T., Samama, P., & Lespessailles, É. (2026) · Archives of Osteoporosis · doi:10.1007/s11657-026-01663-3
“While GPs play a central role in the management of PMO, there are widely recognized disparities between clinical practice and evidence-based guidelines [11–13].”
Marks, D., Todd, J., Thomas, M., Stern, S., Mickan, S. M., & Hing, W. (2026) · Australian Health Review · doi:10.1071/ah26058
Christe, G., Darlow, B., Hartvigsen, J., Stanic, J., Rosa, M., Virdee, J., Martel, M., Lötscher-Stamm, M., Wieser, S., Schaller, D., et al. (2026) · Contemporary Clinical Trials Communications · doi:10.1016/j.conctc.2026.101679
“Core components of PRIME include (1) training for GPs to support evidence-based assessment, reassurance, and risk-stratified care [23, 33]; (2) training for physiotherapists to deliver biopsychosocial, guideline-concordant rehabilitation that target risk factors of chronicity [36 – 38]; (3)…”
Daniels, C. J., Maiers, M., Schielke, A. L., Trager, R. J., Salsbury, S. A., Price, M. R., Farabaugh, R. J., Whalen, W. M., Stevans, J. M., Shastri, V., et al. (2026) · Research Square · doi:10.21203/rs.3.rs-11117609/v1
- Authors
- Tzortziou Brown, V., Underwood, M., Mohamed, N., Westwood, O., & Morrissey, D.
- Affiliations
- Blizard Institute, Barts and The London School of Medicine and Dentistry.; Centre for Primary Care and Public Health; London UK
- University of Warwick (GB)
- Croydon University Hospital (GB)
- Queen Mary University of London (GB)
- Venue
- Cochrane Database of Systematic Reviews
- Publisher
- Wiley
- Published
- 2016-05-06
- Volume
- 2016
- Issue
- 5
- Pages
- CD007495-CD007495
- ISSN
- 1361-6137 (ISSN-L)
- 1465-1858
- PMC
- PMC10523188
- OpenAlex
- W2143249121
- Cited by
- 62
- References
- 79
- Citations by year
- 2026: 4 · 2025: 4 · 2024: 8 · 2023: 3 · 2022: 4 · 2021: 9 · 2020: 4 · 2019: 6 · 2018: 9 · 2017: 4 · 2016: 6
- FWCI
- 1.06
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Cochrane Database of Systematic Reviews (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Warwick Research Archive Portal (University of Warwick) (acceptedVersion)
- Queen Mary Research Online (Queen Mary University of London) (submittedVersion)
- Funders
- Queen Mary University of London
- National Institute for Health and Care Research (CAT SCL-2013-04-003, NF-SI-0512-10103, CL-2015-19-004)
- University of Oxford
- University of Bath
- Topics
- Health Sciences › Medicine › Rehabilitation › Musculoskeletal Disorders and Rehabilitation
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Keywords
- musculoskeletal disorders, general practitioners, professional intervention, osteoporosis, bone densitometry, patient education, primary care
- MeSH terms
- Back Pain, Humans, Musculoskeletal Diseases, Osteoarthritis, Osteoporosis, Bone Density, Randomized Controlled Trials as Topic, Reminder Systems, Guideline Adherence, Shoulder Pain, Bone Density Conservation Agents, General Practitioners, Interrupted Time Series Analysis, Controlled Before-After Studies
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