Weekly Pulse: Bridging the Evidence-Practice Gap in Physical Therapy

Evidence-based practice isn’t just a theoretical ideal, it’s the cornerstone of high-quality healthcare. Yet despite decades of progress, the gap between research and real-world clinical care remains wide, impacting patient outcomes and challenging the credibility of our profession.

In this week’s literature roundup, we explore five key perspectives that shed light on why this gap persists, and, more importantly, what can be done to close it. Whether it’s through stronger measurement tools, better implementation strategies, or addressing system-wide barriers, one thing is clear: lasting change requires more than individual effort, it demands coordinated, structural solutions.

Monday: The Hidden Flaws in Our Favorite Outcome Measure

📖 Measurement Properties of the Patient-Specific Functional Scale and Its Current Uses: An Updated Systematic Review of 57 Studies Using COSMIN Guidelines
Pathak et al., 2022
👉 Read it here

The Patient-Specific Functional Scale (PSFS) is everywhere in physical therapy. Quick to administer, patient-centered, and seemingly responsive, it checks all the boxes for modern healthcare. But this comprehensive systematic review reveals a troubling truth: we may not understand what we're actually measuring.

Pathak and colleagues analyzed 57 studies using rigorous COSMIN guidelines and found that while the PSFS shows solid reliability and responsiveness in musculoskeletal conditions, its construct validity as a measure of physical function is insufficient. Translation? The PSFS might be measuring something entirely different than what we think.

The deeper issue: We've been so focused on patient-reported outcomes that we've forgotten to validate what those outcomes actually represent. The PSFS captures unique constructs not found in traditional measures, but without clear construct validity, we're flying blind.

Clinical reality check: The PSFS remains useful for tracking individual progress, but using it as a standalone measure of physical function, especially in non-musculoskeletal populations, is scientifically questionable. We need better tools, not just convenient ones.

Tuesday: Why One Question Might Not Be Enough

📖 Net Promoter Score: A Prospective, Single-Centre Observational Study Assessing if a Single Question Determines Treatment Success After Primary or Revision Hip Arthroplasty
Osmanski-Zenk et al., 2023
👉 Read it here

In our quest for efficiency, healthcare has embraced the Net Promoter Score (NPS), a single question that promises to capture treatment success. "Would you recommend this treatment to a friend?" Sounds simple, right? This study of 1,243 hip arthroplasty patients suggests it's not that straightforward.

While high patient-reported outcomes correlated with promoter status, the NPS showed limited value at 3 months for identifying patients needing additional care. More concerning, satisfaction required extraordinarily high functional scores, especially for revision patients. Pain relief emerged as the most sensitive predictor, not functional improvement.

The paradox: We're using single-question measures in an era of personalized medicine. The NPS might capture the "what" of satisfaction, but it misses the "why" and "how" that drive clinical decisions.

Strategic implication: Quick satisfaction metrics are useful for administrative purposes, but they're insufficient for clinical care. We need nuanced assessment tools that match the complexity of human recovery.

Wednesday: The Uncomfortable Truth About Our Evidence-Based Practice

📖 Do Physical Therapists Follow Evidence-Based Guidelines When Managing Musculoskeletal Conditions?
Zadro, O'Keeffe, & Maher, 2019
👉 Read it here

This systematic review delivers a sobering reality check: we're not as evidence-based as we think. Only 54% of physical therapists choose recommended treatments according to surveys, while 43% select treatments that guidelines explicitly advise against. Clinical audits paint a slightly better picture, but still reveal that 27% of patients receive non-recommended care.

The pattern is revealing:

• Low back pain: Only 35% receive recommended care

• Shoulder pain: 93% compliance with recommendations, but 90% also receive non-evidence-based treatments

• Knee osteoarthritis: Moderate compliance at 58%

The deeper problem: We're not just failing to follow guidelines, we're actively contradicting them while simultaneously claiming to practice evidence-based care. This isn't about knowledge gaps; it's about professional integrity.

Call to action: The profession needs accountability mechanisms, not just more education. When nearly half of our interventions contradict evidence, we have a crisis of credibility.

Thursday: Why the System Is Broken, Not the People

📖 Factors Affecting Implementation of Evidence-Based Practices in Public Health Preparedness and Response
Kennedy et al., 2020
👉 Read it here

This study of 228 U.S. public health agencies reveals why individual behavior change approaches fail. The barriers to evidence-based practice are systemic, not personal. Insufficient funding tops the list at 74.3%, followed by lack of clarity on what constitutes evidence-based practice (60.3%) and absence of available evidence-based practices (54.6%).

The multilevel reality:

• System barriers: Funding, unclear evidence, missing protocols

• Organizational barriers: Insufficient staffing (69.1%), inadequate leadership support

• Individual barriers: Minimal, mostly skills gaps and preference for experience over evidence

The revelation: We've been solving the wrong problem. While 81.4% of agencies value evidence-based practice and 65.2% have internal champions, system-level "push" factors remain underdeveloped.

Strategic insight: Change requires coordinated intervention across all levels. Fixing individual knowledge while ignoring funding and organizational support is like treating symptoms while ignoring the disease.

Friday: Are We Getting Worse, Not Better?

📖 Has Physical Therapists' Management of Musculoskeletal Conditions Improved Over Time?
Zadro & Ferreira, 2020
👉 Read it here

This longitudinal analysis from 1990 to 2018 delivers the most disturbing finding of the week: we're not improving. In fact, we might be getting worse. The use of treatments with unknown value has skyrocketed from 41% in the 1990s to 70% by 2018, while recommended care has stagnated.

The timeline tells the story:

• 1990-1999: 40% recommended, 41% non-recommended, 41% unknown

• 2000-2009: 50% recommended, 28% non-recommended, 55% unknown

• 2010-2018: 35% recommended, 39% non-recommended, 70% unknown

Possible explanations:

• Innovation pressure in the absence of evidence

• Information overload making it harder to discern quality research

• Social media amplifying unverified treatments

• Growing skepticism of research relevance

The wake-up call: Simply producing more research isn't working. We need better mechanisms for translating evidence into practice, not just generating more studies.

Final Thoughts: A Weekly Reflection

Across these five studies, a shared truth emerges: the evidence-practice gap isn't closing, it's widening. Despite decades of emphasis on evidence-based practice, we're using more treatments of unknown value while struggling to implement proven interventions.

To bridge this gap, the profession must evolve:

From individual education to systems change

From knowledge transfer to implementation science

From more research to better translation

From measurement for measurement's sake to meaningful outcome assessment

In a healthcare system increasingly driven by metrics and efficiency, we must defend what makes physical therapy uniquely valuable: the ability to deliver evidence-informed, patient-centered care that adapts to complexity rather than avoids it.

As we look ahead, let this be a rallying point, not only for clinical care, but for how we design education, implement technology, and define our profession's future. The evidence is clear, now we need the courage to act on it.

References

Pathak, A., Wilson, R., Sharma, S., Pryymachenko, Y., Ribeiro, D. C., Chua, J., & Abbott, J. H. (2022). Measurement properties of the Patient-Specific Functional Scale and its current uses: An updated systematic review of 57 studies using COSMIN guidelines. Journal of Orthopaedic & Sports Physical Therapy, 52(5), 262–275. https://doi.org/10.2519/jospt.2022.10727

Osmanski-Zenk, K., Ellenrieder, M., Mittelmeier, W., & Klinder, A. (2023). Net Promoter Score: A prospective, single-centre observational study assessing if a single question determined treatment success after primary or revision hip arthroplasty. BMC Musculoskeletal Disorders, 24, 849. https://doi.org/10.1186/s12891-023-06981-y

Zadro, J., O'Keeffe, M., & Maher, C. (2019). Do physical therapists follow evidence-based guidelines when managing musculoskeletal conditions? BMJ Open, 9(10), e032329. https://doi.org/10.1136/bmjopen-2019-032329

Kennedy, M., Carbone, E. G., Siegfried, A. L., Backman, D., Henson, J. D., Sheridan, J., Meit, M. B., & Thomas, E. V. (2020). Factors affecting implementation of evidence-based practices in public health preparedness and response. Journal of Public Health Management and Practice, 26(5), 434–442. https://doi.org/10.1097/PHH.0000000000001178

Zadro, J. R., & Ferreira, G. (2020). Has physical therapists' management of musculoskeletal conditions improved over time? Brazilian Journal of Physical Therapy, 24(5), 458–462. https://doi.org/10.1016/j.bjpt.2020.04.002