Our search retrieved 7667 citations (Fig. 1). After removing duplicates (n = 1333), we screened 6334 articles. During the phase 1 screening, 6192 articles were irrelevant, and 142 full text were examined. During the phase 2 screening, 99 articles were excluded for the following reasons: 1) outcomes did not focus on guideline utilization (n = 79); 2) MSDs were not the only condition studied and the results were not stratified by disorders (n = 13); 3) publication type was not eligible (commentaries) (n = 6); 4) full-text article was not available (n = 1). Therefore, our synthesis included 43 articles (Table 1) (3, 23–58).
Most articles (67%, 29/43) were published after 2009, 30% (n = 12) between 2001 and 2009, and 3% (n = 2) were published before 2001 (Table 1). Studies were mainly conducted in Europe (51%, n = 22), and North America (35%, n = 15), with a lower proportion elsewhere (7% in New Zealand or Australia (n = 3), 5% in Israel (n = 2) and 2% in Africa (n = 1)). Low back pain was the most studied disorder (81%, n = 35), followed by neck pain and associated disorders (12%, n = 5), lower limb disorders (n = 1), and two articles evaluated mixed MSDs. Most studies (63%, n = 27) used epidemiological designs, 30% (n = 13) used qualitative designs and 7% (n = 3) used mixed methods. Most epidemiological studies were cross-sectional (85%, n = 23), 11% (n = 3) were cohorts, and one was a randomized controlled trial. Forty percent of studies (n = 17) investigated physiotherapists; 30% (n = 13) medical doctors; 9% (n = 4) doctors of chiropractic; 2% (n = 1) occupational therapists; 2% (n = 1) doctors of osteopathy; and 16% (n = 7) investigated multiple professions.
Regarding methodological quality, 42% (n = 18), 30% (n = 12) and 30%(n = 13) were of low, medium and high-quality level, respectively.
Finally, we found no difference between determinants related to internal validity, country, type of healthcare providers or MSDs.
Barriers to guidelines’ utilization
Barriers to guidelines’ utilization are reported in Fig. 2 according to their frequency of citation in the literature and detailed below according to the planned behavior theory.
Barriers linked to clinicians’ attitudes towards their behavior
Clinicians who feel frustrated, anxious or a perceived loss of autonomy when using guidelines were less likely to use them (3, 40, 47, 49, 53, 57, 59–61). Furthermore, being afraid of missing information such as clinical signs or patient information, was also perceived as a barrier to use guidelines (3, 49, 53, 54). The perception of a gap between the biopsychosocial model of care recommended by guidelines and their current practice (for example biomedical approach)(33, 51, 53, 56, 60, 61), a culture of suspicion about guidelines (45), and a skeptical view of medicine or evidence-based practice (30, 62) were identified as barriers of guideline utilization.
Barriers included in subjective norms
We identified barriers related to clinicians’ judgment and perception of their own behavior by other people. Health care providers reported to be influenced by non-compliance of their instructors during their training (3, 62), non-compliance of colleagues or other professionals in their practice (3, 27, 29, 39, 45, 49, 53, 59). For example, when they had experienced the feeling of being in competition with other practitioners (45, 62). Moreover, authorities and public health policies could have an impact on clinicians perceiving guidelines as mandatory (45). Finally, long-term patients could also have an impact on guidelines’ utilization; clinicians could be afraid to lose these patients if they do not satisfy their expectations (26, 27, 60–63).
Barriers involved in clinicians perceived behavioral control
Barriers were related to clinicians’ perception of how they control their behavior. Guidelines may be perceived as non-practical for current practice (28, 39, 44, 49, 52–54, 60, 63–65) or reported to be too restrictive, theoretical, long, cumbersome (3, 30, 31, 46, 47, 57, 59–61, 65) or outdated (59, 62). The number of available guidelines may be viewed as too large for practitioners (45, 47), with a lack of consistency in their methodology (3, 39, 42, 47, 53, 59, 65). Consequently, clinicians may be confused when selecting a guideline. Furthermore, terminology used is sometimes perceived to be unclear, particularly regarding the term “non-specific” used to describe some MSDs such as neck or low back pain (23, 30, 39, 40, 46, 47, 49, 64).
In addition, some clinicians reported that they are not sufficiently trained to use guideline recommendations. For example, clinicians who are not trained to use yellow flags, or the biopsychosocial approach would be challenged with using them to manage patients (27, 37–39, 41, 42, 46, 55, 59–61). Barriers to compliance also include the ability to provide recommended multimodal care, and accessibility and reimbursement for healthcare services (26–28, 30, 39, 42, 49, 59, 65). For these reasons, some practitioners perceived guidelines as not adapted to the needs of their patients, limiting the interest in using guidelines to inform care for individual cases.
Facilitators to guidelines’ utilization
All facilitators to guideline utilization are reported in Fig. 2.
Facilitators linked to clinicians’ attitudes towards their behavior
A practitioner’s motivation to provide good clinical care, positive behaviors toward using guidelines and professionalism were frequently associated with compliance (3, 26, 53). Providers interested in scientific literature used guidelines more frequently (3, 25, 30, 42, 45, 49, 59). Clinicians who are interested in evidence-based practice are more likely to use recommendations from guidelines (23, 25, 36). Furthermore, clinicians practicing in a hospital or a clinic with a large volume of MSDs patients reported using guidelines more often (24, 34, 44).
Facilitators included in subjective norms
These determinants involved how clinicians practice and interact with others (64). Relationships and social interactions with colleagues, superiors, and public health authorities can influence guideline utilization (29, 31, 39, 48, 61, 65). Moreover, clinicians who use recommendations prefer to perceive that the guidelines are commonly used in practice by others in their field (42, 46). Having good experiences with recommended multidisciplinary approaches (64) encourages clinicians to maintain this behavior in practice. In this way, they use guidelines as a common and shared language between different professions (42, 47, 48, 62). Clinicians who want to legitimize their own practice in front of others (62) use guidelines in practice. Finally, it is reported that clinicians need to trust those who developed guidelines (3, 47) and must have financial resources supported by authorities to work in accordance with guidelines (47, 48, 61).
Facilitators involved in clinicians’ perceived behavioral control
Determinants may be linked to clinicians’ perception of control about their ability to use guidelines. Recommendations must be perceived as accessible, concise, clear, adapted to daily practice, useful and relevant for use by clinicians (42, 46, 48, 49, 59, 61).
Providers who aim to improve their practice tend to use more guidelines. Practice improvement occurs when providers view guidelines s tools to help form clinical judgments, inform patient communication, improve patients’ triage, and be more efficient (26, 28–30, 39, 48, 61). Some clinicians expressed the need to be trained by having access to education sessions about guidelines utilization (52, 65).